List of Differentials

8/9/2019 List of Differentials

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U N

I T E D

S T A T

ES C O A S T G

U A R D

H E A L T H

S E R V I CE S

T E C H

N I C

I A N


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TABLE OF CONTENTS


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1– CONDITIONS

DERM EENT CV RESP GI GU GYN MUS/SKEL NEURO MH

Erythema Red EyeCardiac Chest

Pain Acu te Cough Abdomi nal Pain STD Menses Neck Pain

Alt ered MentalStatus

MoodDisorders

• Anthrax(cutaneous)

• Cellulitis

• DrugReaction

• Furuncle

• Urticaria

• Viral

Exanthemas(measles,mumps,rubella)

• Blepharitis

• Chalazion

• Chemical Burn

• Conjunctivitis,allergic/infectious

• Corneal Abrasion

• Foreign Body

•

Glaucoma• Hordeolum

• Hyphema

• Pinguecula

• Pterygium

• Retinaldetachment

• SubconjunctivalHemorrhage

•

Uveitis

• Acute CoronarySyndrome

• Angina Pectoris

• Pericarditis

• Bronchitis,Mycoplasm

• Bronchitis– Viral

• Influenza

• Pneumonia,Bacterial

• Pneumonia,

Mycoplasma• Pneumonia,

Viral

• Appendicitis

• Cholecystitis

• Constipation

• Diarrhea

• Diverticulitis

• Food Poisoning

• Gastroenteritis,

Acute• GERD

• Hepatitis

• Hernia, Abdominal

• Irritable BowlSyndrome

• Pancreatitis, Acute

• PUD

• Chancroid

• Chlamydia

• Condyloma Acuminata

• Gonorrhea

• HIV

• HSV II

•

Lymphogran-ulomaVenereum

• Pediculosis

• Syphilis

• Trichomoni-asis

• Cervical Disk(HNP)

• MuscleStrain,Cervical

• Alcohol Abuse

• CVA

• Seizure

Growths Earache Non-Cardiac

Pain ChronicCough

Female Specific Abdomi nal Pain

MaleComplaint

Shoulder Pain Headache,Emergent

• MolluscumContagiosum

• Wart,Common

• Barotrauma

• CerumenImpaction

• Eustachian TubeDysfunction

• Mastoiditis

• Otitis Externa

• Otitis Media

• Perforation ofTympanicMembrane

• Serous OtitisMedia

• Temporomandibular Joint (TMJ)Syndrome

• Anxiety

• Costochondritis

• GERD

• Pleuritis

• COPD

• GERD

• Tuberculosis

• EctopicPregnancy

• Endometriosis

• Ovarian Cyst

• Epididymitis

• Hydrocele, Acute

• InguinalHernia

• Prostatitis,

Acute• Testicular

Torsion

• UTI

• Varicocele

• DysfunctionalUterineBleeding

• Dysmenorrhea,Primary

END

• BicipitalRupture,Proximal

• BicipitalTendonitis

• Bursitis,Subacromial

• ImpingementSyndrome

• Rotator CuffTear

• Hemorrhage,Subarachnoid

• HypertensionEmergency

• Meningitis

• AdjustmentDisorder

• Anxiety

• Depression

• SuicidalIdeation

END

Continued on Next Page


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2– CONDITIONS

DERM EENT CV RESP GI GU MUS/SKEL NEURO

Inflammatory Stuffy Nose SyncopeDifficult

BreathingRectal

Pain/BleedingFemale Complaint Elbow Pain

Headache,

Non-emergent

• Acne Vulgaris

• Insect Bite/Sting(non-venomous)

• Miliaria

• PseudofolliculitisBarbae

• Scabies

• Allergic Rhinitis

• Common Cold

• Epistaxis

• Sinusitis

• Arrhythmia

• OrthostaticHypotension

• Seizure

• Bacterial Vaginosis

• Bartholin’s Cyst

• Candidiasis,Volvovaginal

• UTI

• Bursitis, Olecranon

• Epicondylitis

• Cluster

• Sinusitis

• Tension

• Vascular

Scaly

Sore

Mouth/Throat Vascular Hematuria Wrist pain Vertigo

• Carpal TunnelSyndrome

• Ganglion Cyst

• Scaphoid Fracture

Finger pain

• Candidiasis(oral)

• Pityriasis Rosea

• Psoriasis

• SeborrheicDermatitis

• Tinea Capitis

• Tinea Corporis

• Tinea Cruris

• Tinea Pedis

• Tinea Unguium

• Tinea Versicolor

• Aphthous Ulcer

• Epiglottitis

• Herpes SimplexVirus

• Laryngitis

• Mononucleosis

• Peritonsillarabscess

• Pharyngitis,Bacterial

• Pharyngitis,Viral

• Salivary Stone

END

• Deep VeinThrombosis

• Raynaud’sDisease

• VaricoseVeins

END

• Anaphylaxis

• Asthma

• Pneumothorax,Spontaneous

END

• Colorectal Cancer

• Hemorrhoid

• Pilonidal Cyst

• Ulcerative Colitis

END

• Glomerulonephritis

• Pyelonephritis, Acute

• Renal Calculi

END

• Paronychia

• Labyrinthitis

• Meniere’s Disease

• Motion Sickness

• Vertigo, BenignPositional

Continued on Next Page


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3– CONDITIONS

DERM MUS/SKEL NEURO

Vesicular Lower Back Pain Facial Neuropathy

•

Mechanical, Muscular Strain• Neurological, Herniated Disk

• Prostatitis

• Pyelonephritis

• Renal Calculi

Knee Pain

• Bursitis, Patellar

• Collateral Ligament Tear

•

Cruciate Ligament Tear• Meniscal Tear

• Patellofemoral Syndrome

• Popliteal Cyst

Ank le Pain

• Achilles Tendon Rupture

• Ankle Sprain

Foot Pain

• Fifth Metatarsal Fracture

• Heel Spur

• Plantar Fasciitis

Toe Pain

• Ingrown Toenail

Leg Pain

•

Atopic Dermatitis• Contact Dermatitis

• Eczematous Dermatitis/Dyshidrosis

• Herpes Simplex Virus

• Herpes Zoster

• Impetigo

• Smallpox

• Varicella (Chickenpox)

END

• Shin Splints

END

•

Bell’s Palsy• Cerebrovascular accident

(CVA)

• Trigeminal Neuralgia

END

END


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4 – GUIDE TO SCOPE OF PRACTICE FOR HS TECHNICIANS

GUIDE TO SCOPE OF PRACTICE FOR HS TECHNICIANS

A Health Services Technician (HS) provides supportive services to medical officers and basic primary health care in

their absence. Each HS who provides medical treatment to patients at a Coast Guard clinic shall have an assignedDesignated Supervising Medical Officer (DSMO) from that facility. One of the primary goals of the HS is to eventuallywork independently after completion of the Independent Duty Health Services Technician School.

An Independent Duty Health Services Technician (IDHS) works outside of a clinical setting, and is supervised by aDesignated Medical Officer Advisor (DMOA). The IDHS practices independently, though acts as the ‘eyes, ears andhands’ in consultation with the DMOA or Duty Flight Surgeon when a situation is beyond the scope of technician healthcare.

This job aid captures all of the medical conditions that the HS3 (A for apprentice), HS2 (J for journeyman), and IDHS(M for master) should be familiar with. This job aid is divided into nine categories by body system plus a tenth formental health conditions. The categories are further broken down into patient chief complaints or presenting situation.The chief complaints have a list of conditions with corresponding potential differential diagnosis. Though the condition’spathogenesis is not discussed here, each condition is presented with:

•

A definition• Key features

• Differentiating signs and symptoms

• Differentiating objective findings

• Common diagnostic test considerations

• Proposed treatment

• Recommended follow-up

As you use the following guide to determine if a condition is within your scope of practice, remember that the “A” is for Apprentice and indicates that the HS, in achieving their rank, has included that condition in their scope of practice.


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DERMATOLOGICAL

CHIEFCOMPLAINT

CONDITION HS3 Post‘A’ School

HS2 IDHS ‘C’School

Anthrax (cutaneous) A J M

Cellulitis A J M

Drug Reaction A J M

Furuncle A J M

Urticaria A J M

Erythema

Viral Exanthemas(measles, mumps,rubella)

A M

MolluscumContagiosum

A MGrowths

Wart (common) A J M

Acne Vulgaris A

J M

Insect bite/sting(nonvenomous)

A M

Miliaria A M

Pseudofolliculitis,Barbae

A M

Inflammatory

Scabies A M

Candidiasis(oral) A M

Pityriasis Rosea A M Psoriasis A M

Seborrheic Dermatitis A M

Tinea Capitis A M

Tinea Corporis A J M

Tinea Cruris A J M

Tinea Pedis A J M

Tinea Unguium A M

Scaly

Tinea Versicolor A J M

DERMATOLOGICAL, Continued

CHIEFCOMPLAINT



Atopic Dermatitis A J M

Contact Dermatitis A J M

Eczema (dyshidrosis) A J M

Herpes Simplex Virus A M

Herpes Zoster A J M

Impetigo A M

Smallpox A J M

Vesicular

Varicella (chickenpox) A J M


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EYES, EARS, NOSE, AND THROAT

CHIEFCOMPLAINT



Blepharitis A J M

Chalazion A M

Chemical Burn A M

Conjunctivitis, Allergic A J M

Conjunctivitis, Infectious A J M

Corneal Abrasion A J M

Foreign Body A M

Glaucoma A M

Hordeolum A J M

Hyphema A J M

Pinguecula A M

Pterygium A M

Retinal Detachment A M

SubconjunctivalHemorrhage

A J M

Red Eye

Uveitis A M

Barotrauma A M

Cerumen Impaction A J M

Eustachian Tube

Dysfunction

A J M

Mastoiditis A M

Otitis Externa A J M

Otitis Media A J M

Perforation A J M

Earache

Serous Otitis Media A J M

EYES, EARS, NOSE, AND THROAT, Conti nued

CHIEFCOMPLAINT



Earache,continued

Temporomandibular JointSyndrome

A M

Allergic Rhinitis A J M

Common Cold A J M

Epistaxis A J M

Stuffy Nose

Sinusitis A J M

Aphthous Ulcer A J M

Epiglottitis A M

Herpes Simplex Virus A M

Laryngitis A M

Mononucleosis A M

Peritonsillar Abscess A M

Pharyngitis, Bacterial A J M

Pharyngitis, Viral A J M

Sore Throat

Salivary Stone A M


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CARDIOVASCULAR

CHIEFCOMPLAINT



Acute CoronarySyndrome (ACS)

A J M

Angina Pectoris A J M

Cardiac ChestPain

Pericarditis A M

Anxiety (see Mental

Health–Feeling Downor Worried)

A M

Costochondritis A J M

GastroesophagealReflux Disease(GERD– seeRespiratory–ChronicCough)

A J M

Non-CardiacChest Pain

Pleuritis A

J M

Arrhythmia A M

OrthostaticHypotension

A M Syncope

Seizure (seeNeurological –AlteredMental Status)

A M

Deep Vein Thrombosis A M

Raynaud’s Disease A M Vascular

Varicose Veins A M

RESPIRATORY

CHIEFCOMPLAINT



Bronchitis,Mycoplasma

A M

Bronchitis, Viral A J M

Influenza A J M

Pneumonia, Bacterial A J M

Pneumonia,Mycoplasma

A J M

Acute Cough

Pneumonia, Viral A J M

Chronic ObstructivePulmonary Disease

A M

GastroesophagealReflux Disease

A J M ChronicCough

Tuberculosis A J M

Anaphylaxis A J M

Asthma A J M DifficultBreathing

Pneumothorax,Spontaneous

A M


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GASTROINTESTINAL

CHIEF

COMPLAINT

CONDITION HS3 Post

‘A’ School

HS2 IDHS ‘C’

School

Appendicitis A J M

Cholecystitis A M

Constipation(symptom)

A J M

Diarrhea (symptom) A J M

Diverticulitis A M

Food Poisoning A J M

Gastroenteritis, Acute(viral)

A J M

GastroesophagealReflux Disease

A J M

Hepatitis A M

Hernia, Abdominal A M

Irritable BowelSyndrome

A M

Pancreatitis, Acute A M

Abdominal pain

Peptic Ulcer Disease A M

Ectopic Pregnancy A M

Endometriosis A M Abdominal Pain – Female

Ovarian Cyst A M

Colorectal Cancer A M

Hemorrhoid A M

Pilonidal Cyst(abscess)

A M

RectalPain/Bleeding

Ulcerative Colitis A M

GENITOURINARY

CHIEF

COMPLAINT

CONDITION HS3 Post

‘A’ School

HS2 IDHS

‘C’School

Bacterial Vaginosis A M

Bartholin’s Cyst A M

Candidiasis, Vulvovaginal A J M FemaleComplaint

Urinary Tract Infection A J M

Epididymitis A J M

Hydrocele, Acute A M

Inguinal Hernia A J M

Prostatitis, Acute A J M

Testicular Torsion A J M

Urinary Tract Infection(UTI)

A J M

MaleComplaint

Varicocele A M

Glomerulonephritis A M

Pyelonephritis A J M Hematuria

Renal Calculi A J M

Chancroid A J M

Chlamydia A J M

Condyloma Acuminata A M

Gonorrhea A J M

Herpes Simplex Virus A J M

Human ImmunodeficiencyVirus (HIV)

A J M

LymphogranulomaVenereum

A M

Pediculosis A M

Syphilis A J M

SexuallyTransmittedDisease

Trichomoniasis A M


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GYNECOLOGICAL

CHIEF

COMPLAINT

CONDITION HS3 Post

‘A’ School

HS2 IDHS ‘C’

School

Dysfunctional UterineBleeding

A M Menses

Dysmenorrhea A J M

MUSCULOSKELETAL

CHIEF

COMPLAINT

CONDITION HS3 Post

‘A’ School

HS2 IDHS ‘C’

School

Cervical Muscle Strain A J M

Neck painHerniated Cervical Disk(HNP)

A M

Bicipital TendonRupture, Proximal

A M

Bicipital Tendonitis A J M

Impingement Syndrome A M

Rotator Cuff Tear A M

Shoulder pain

Subacromial Bursitis A J M

Bursitis, Olecranon A J M

Elbow painEpicondylitis A J M

Carpal TunnelSyndrome

A J M

Ganglion Cyst A M Wrist pain

Scaphoid Wrist Fracture A J M

Finger pain Paronychia A M

Continued next page


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MUSCULOSKELETAL, Continued

CHIEF

COMPLAINT

CONDITION HS3 Post

‘A’ School

HS2 IDHS ‘C’

School

Mechanical MuscularStrain

A J M

Neurological, HerniatedDisk

A J M

Prostatitis (see GU– male) A M

Pyelonephritis (see GU–hematuria)

A J M

Lower BackPain

Renal Calculi (see GU–hematuria)

A J M

Bursitis, Patellar A A M

Collateral Ligament Tear A M

Cruciate Ligament Tear A M

Meniscal Tear A M

Patellofemoral Syndrome A M

Knee Pain

Popliteal Cyst A M

Achilles Tendon Rupture A M Ankle Pain

Ankle Sprain A J M

Fifth Metatarsal Fracture A J M

Heel Spur A M Foot Pain

Plantar Fasciitis A M

Toe Pain Ingrown nail A M

Leg Pain Shin splints A J M

NEUROLOGICAL

CHIEF

COMPLAINT

CONDITION HS3 Post

‘A’ School

HS2 IDHS ‘C’

School

Alcohol Abuse A J M

Cerebrovascular Accident (CVA)

A M Altered MentalStatus

Seizure A J M

Hemorrhage,Subarachnoid

A M

HypertensionEmergency

A M EmergentHeadache

Meningitis A J M

Cluster Headache A M

Sinusitis A J M

Tension Headache A J M

Non-Emergent

Headache

Vascular Headache A M

Labyrinthitis A M

Meniere’s Disease A M

Motion Sickness A M Vertigo

Vertigo, BenignPositional

A M

Bell’s Palsy A M

Cerebrovascular Accident

A M FacialNeuropathy

Trigeminal neuralgia A M


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13–DERMATOLOGICAL

CHIEF COMPLAINT: ERYTHEMA

CONDITION &DEFINITION

KEY FEATURES DIFFERENTIATINGSIGNS & SYMPTOMS

DIFFERENTIATINGOBJECTIVEFINDINGS

COMMONDIAGNOSTIC TEST

TREATMENT FOLLOW-UP

Anthrax(cutaneous)

Caused by Bacillusanthracis and istransmitted tohumans by infectedanimals; has alsobeen used forhostile purposes as

a bio- logicalwarfare agent.

• Begins as alocalized, painless,pruritic, red papule1-6 days afterexposure

• May have fever,malaise, myalgia,headache, nausea,vomiting

• Progressiveenlargement withmarked erythema,edema, vesicles,central ulceration,and black pustules

• Exposure Hximportant

• Same as s/s

• Assess localizedlymphadenopathy

• Culture lesion

• Chest radiographand specific testsas indicated

Antibiot ic :

Ciprofloxacin 500 mgpo bid for 60 days

• CONTACT MOand FlightSurgeon

• Notify Command -Disease AlertReport

• Be familiar withthe AVIP

www.anthrax.osd.mil

Cellulitis

Acute, diffusebacterial infectionof dermis andsubcutaneoustissue

• Regional erythema

• May have fever andmalaise

Indurated patch that ispainful and warm totouch

• Localized red (rubor)

• Tender (dolor)

• Warm (calor)

• Marked nonpittingswelling (tumor)

• Assess regionallymphadenopathy

• Culture lesion

• CBC

• Mark borders ofinduration tofollow progression

Antibiot ic :

• Mild: Penicillin VK,or erythromycin (E-mycin)

• Severe: Ceftriaxone(Rocephin) IM

• Augmentin, if a bite

• F/U every 24hours untilresolved

• IF not resolved in7 days or severe,contact MO

Drug Reaction

Most commonadverse reaction todrugs is a skin rash

Generalized,confluent, pruriticmaculopapular rash

• Hx medication use

• Onset may bedelayed by 1 week;R/O anaphylaxis andbacterial pharyngitis

• Bright pink/redconfluentmaculopapularpatch(es)

• Complete HEENT,CV & respiratoryexams

• CBC if secondaryinfectionsuspected

• Rapid strep and/orthroat culture ifStreptococcussuspected

Antihistamine: Hydroxyzine (Atarax)or diphenhydramine(Benadryl)

• Discontinue drugcausing eruption

• CONTACT MO ifno improvement in24 hours

• Complete VAERSReport if vaccinereaction


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14–DERMATOLOGICAL

CHIEF COMPLAINT: ERYTHEMA (continued)

CONDITION &

DEFINITION

KEY FEATURES DIFFERENTIATING

SIGNS & SYMPTOMS

DIFFERENTIATING

OBJECTIVE FINDINGS

COMMON

DIAGNOSTIC TEST

TREATMENT FOLLOW-UP

Furuncle

Pus-filled masscaused bystaphylococcusaureus or MRSA

• Localized erythema

• Fever is rare

Papule or nodule, firmor fluctuant; painful andwarm to touch

• Localized red (rubor)

• Tender (dolor)

• Warm (calor)

• Papule or nodule(tumor)


• Culture lesion

• CBC.

• Patient contactsmay also becontaminated withMRSA

Antibiot ic: TMP/SMX(Septra DS) (coversboth staph. aureus andMRSA)

• Incise and drain iffluctuant lesion

• Large wound mayrequire Iodoform

packing – repackdaily or PRN

• F/U Every24 hoursuntilresolved

• If NOTresolved in7 days orsevere,

contact MO

Urticaria

‘Hives’ usually are aresult of an adversedrug or foodreaction; thoughthere are othercauses, they usually

are unknown.

Generalized, confluent,pruritic maculopapularrash

• Recent history ofingestion of drug orfood associated withgeneralized rash

• Ask about over-the-counter or herb use

• Aspirin (salicylate) ismost common cause

• General distribution ofwheals or hives inpatches

• Respiratory distress

Usually noneindicated

Antihistamine:

Hydroxyzine (Atarax) ordiphenhydramine(Benadryl)

• Avoid cause

• Respiratory distress

will need emergenttreatment (seeanaphylaxis)

F/U PRN.

Chronicconditionsrefer to MO


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15–DERMATOLOGICAL

CHIEF COMPLAINT: ERYTHEMA (continued)

CONDITION &

DEFINITION


SIGNS & SYMPTOMS

DIFFERENTIATING

OBJECTIVE FINDINGS

COMMON

DIAGNOSTIC TEST

TREATMENT FOLLOW-UP

Viral Exanthemas

Measles, mumps,and rubella arecontagious viraldiseases

• Generalized orregional erythemicmaculopapular rash

• May have fever,malaise, myalgia,headache andlymphadenopathy

Measles

• Coryza

• Cough

• Conjunctivitis

• Koplik’s Spots (white)on bucal mucosa

•

Rash spreads fromface to trunk andextremities

Mumps

• Parotid gland pain andswelling, 15% withmeningeal signs

• Maculopapular rashless common

Rubella

• Childhood disease

• Petechiae of softpalate

• Rosy red oval or roundmacules

• Rash spreads rapidlyfrom face to trunk andextremities; fades in24 to 48 hours

• Skin exam: asdescribed by history


• Complete HEENT, CVand respiratory exams

• CBC

• R/OMononucleosis

Antipyret ic: Acetaminophen

• Otherwise,symptomatic Tx

• Ensure MMRvaccination is up-to-date

If not improvedin 7 days,consult with MOPRN


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16–DERMATOLOGICAL

CHIEF COMPLAINT: GROWTHS

CONDITION &

DEFINITION


SIGNS & SYMPTOMS

DIFFERENTIATING

OBJECTIVE FINDINGS

COMMON

DIAGNOSTIC TEST

TREATMENT FOLLOW-UP

MolluscumContagiosum

• Contagious viraldisease

• In children it istransmitted fromfomites

• In adults it is

transmitted fromfomites, butprimarily sexuallyor intimate contact

Individual orgrouped papules

Usually an incidental andasymptomatic finding bythe patient

• Dome-shaped, pearlywhite to flesh coloredsmall lesions on trunk,extremities, or groin

• The lesions are firmand centrallyumbilicated

• Biopsy may beindicated if unable todifferentiate frombasal cell carcinoma(BCC)

• BCC usually havetelangiectasia andusually found on face

• Self limiting inmost cases

• Cryotherapy orcantharidinapplication maybe indicated

• Good hygiene

• Condom use if

genital

F/U PRN

Wart, common

Verruca vulgaris,verruca plantaris (soleof foot); caused by

direct contact; humanpapilloma virus

Individual papule

(also see genitalwarts)

• Smooth flesh coloredpapules that becomedome-shaped, gray-brown growths with

black dots• No skin lines through

lesion as corns do

“Cauliflower” flesh-colored papules thatbecome dome- shapedgrowths

Usually nothingindicated

• Self limiting inmost cases

• Cryotherapy orsalicylic acid

patch

• F/U PRN.

• Therapy mayrequirerepeated

applicationevery twoweeks


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17–DERMATOLOGICAL

CHIEF COMPLAINT: INFLAMMATORY

CONDITION &

DEFINITION


SIGNS & SYMPTOMS

DIFFERENTIATING

OBJECTIVE FINDINGS

COMMON

DIAGNOSTIC TEST

TREATMENT FOLLOW-UP

Acne Vulgar is

Inflammatorydisorder of thepilosebaceousglands.

Few or multiplepapules, pustules ornodules on face, chestor back

Closed comedonesand/or open comedones

Non-inflamedcomedones toinflammatory papules,pustules, nodules, andcysts on face, chestand/or back


Topical: Benzyl peroxidegel

• Apply after washingwith mild soap andwater twice per day

• F/U PRN

• Chronicconditionsrefer to MO

Insect Bite/Sting

(non-venomous)

Insect bites/stingsinoculate poisons,invade tissue, andtransmit disease.Here we discussirritative bites only.

Irritative bites: localizedinflamed papule

• Other varied reactionsmay be localized,

toxic systemic, orallergic systemic

• Consider relatedconditions like allergy,Lyme Disease, WestNile Virus, Malaria,etc.

• Irritative bites: localerythema, edema,

and pain• Complete thorough

skin exam and reviewof systems

Usually noneindicated unless

related conditionssuspected

• Symptomatic treatment

• Related conditions like

allergy, Lyme Disease,West Nile Virus,Malaria, etc will requirespecific treatments

• F/U PRN

• Chronic

conditionsrefer to MO

Miliaria

Sweat flow isobstructed (pricklyheat) by humidity(or extreme cold).

Regionalized papulesand pruritus

“Heat or prickly rash” Multiple discrete, small,red, inflamed papulesmostly on trunk and

back


Topical: Hydrocortisone1% lotion to affectedarea.

Cool environment

F/U PRN

PseudofolliculitisBarbae

Inflammatoryresponse to aningrown hair.

Papules on beard area Difficulty shaving; “razorbumps”

Beard area has multipleyellow or grayishinflamed pustulessurrounded by red basewith hair in middle oringrown


Topical: Benzyl peroxidegel

If associated with beard,massage beard areagently in a circular motionwith a warm, moist, soapysoft washcloth or facial

scrub pad; give a limited(days) “no shaving” chit.

F/U PRN


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18–DERMATOLOGICAL

CHIEF COMPLAINT: INFLAMMATORY (continued)



DIFFERENTIATINGOBJECTIVE FINDINGS

COMMONDIAGNOSTIC

TEST

TREATMENT FOLLOW-UP

Scabies

Mite infestationfrom close contactwith infectedindividual orlinen/clothing.

Papules and pruritus “Itch/scratch” that mayinterrupt sleep

Small, inflamed papulesof linear “burrows” mostcommon on groin,genitals, fingers/toeswebbing


Topical:

• Permethrins lotion orshampoo (Elimite/Nix)

• Also treat shipboard orhome contacts and washassociated clothing andlinen

F/U PRN

CHIEF COMPLAINT: SCALY





TREATMENT FOLLOW-UP

Candidiasis (oral)

‘Thrush’ is a fungalinfection of the oralepithelium caused

by antibiotics,steroids, or immuno-suppression (AIDS).

White intra-oral plaquethat is easily scrapedoff

• History of antibiotic ororal topical steroids(like asthmatreatment) or HIV

infection• Pasty ‘cottage

cheese’ taste

White curd-like patchesthat appear like ‘cottagecheese’

• Potassiumhydroxide (KOHpreparation)microscopic eval

• Investigate causeif unknown

Topical antifungal:

Clotrimazole troches

OR

Oral Antifungal:

Fluconazole

F/U if notimproved in 14days

Pityriasis Rosea

Self-limiting skindisorder of unknowncause (may be viral).

Delicate, salmon-colored round or ovalpatches of fine whiteflakes

• Onset with “heraldspatch” 2-10 mmpink/tan oval patchfrequentlymisdiagnosed asringworm.

• Pruritus

“Heralds patch” withsalmon-colored round tooval patches withdelicate flaking; overtrunk and occasionallyextremities; “Christmastree” rash pattern onback.


Reassurance – self-limiting, resolves in twoweeks to two months

F/U PRN

Psoriasis

Chronic, recurringskin disease of theepidermis; ofunknown cause(may be genetic).

Marked, silvery, flakingpatches or plaques

Gradual onsetexacerbated by stressand sunlight; nail pitting

Silvery pink scalypatches or plaques,classically on scalp,elbows and knees


• High-potency topicalsteroids have someeffect

• Refer to MO

Refer to MO


21/105

19–DERMATOLOGICAL

CHIEF COMPLAINT: SCALY (continued)


KEY FEATURES DIFFERENTIATINGSIGNS &

SYMPTOMS



TREATMENT FOLLOW-UP

SeborrheicDermatitis

Chronic “dandruff”condition affectingmostly hairyregions.

Regional greasyscaling patches orplaques

• Chronic

• Waxing andwaning Sx

Superficial, greasy, flakypatch on scalp, eyebrows,face, chest, and groin

• Usually none indicated

• May have fungalcomponent

Topical:

Selenium sulfide shampoo(Selsun Blue) every day for2 weeks

F/U PRN.

Consider low-potency topicalsteroid cream;hydrocortisone1% if unimproved

Fungal

Tinea Capiti s

Fungal infection ofscalp.

Scaly patch onscalp

• Alopecia

• Pruritis of scalp

Round scaly patches withalopecia

Potassium hydroxide(KOH) preparationmicroscopic evaluation

Oral antifungal:

Refer to MO

Refer to MO

Tinea Corporis

Fungal infection offace, trunk, orextremities.

Scaly patch onbody

• “Ringworm”

• Pruritis of affectedarea

Annular, erythematous, scalypatch with central clearing


Anti fungal:

Clotrimazole 1% cream

F/U PRN

Tinea Cruris

Fungal infection ofgroin.

Scaly patch on

groin

• “Jock itch”

• Pruritis of groin

Sharply demarcated patch or

plaque with elevated, scalyborder (occasionally vesicularborder)

Potassium hydroxide

(KOH) preparationmicroscopic evaluation

Anti fungal: Clotrimazole

1% creamLoose-fitting under-clothesmay help

• F/U PRN.

• Considerbacterialerythrasma ifnot improving

Tinea Pedis

Fungal infection offoot.

Scaly patch on feet • “Athletes foot”

• Pruritis of foot/feet

Diffuse, not well- demarcatedscaly patches on sole or toewebs


Anti fungal: Clotrimazole1% cream and/or tolnaftate1% powder, solution, cream

Keep area dry, wear cleanand dry socks

F/U PRN

Tinea Unguium

Fungal infection ofnail.

Scaly nails “Onychomycosis” Nail exam: subungual scalydebris with yellowish nail


Oral antifungal:

Refer to MO

Refer to MO

Tinea Versicolor

Fungal infection ofthe skin.

Scaly patch onbody

• Finehypopigmentedsmall patches,usually multipleon trunk

• Mild pruritis ofaffected area

White, tan or pink patcheswith fine flaking border


Woods’ Lamp

Topical:

Selenium sulfide shampoo(Selsun Blue) every day for2 weeks.

F/U PRN


22/105

20–DERMATOLOGICAL

CHIEF COMPLAINT: VESICULAR

CONDITION &

DEFINITION

KEY FEATURES DIFFERENTIATING SIGNS &

SYMPTOMS

DIFFERENTIATING

OBJECTIVE FINDINGS

COMMON

DIAGNOSTICTEST

TREATMENT FOLLOW-UP

Eczematous

Atopic Dermatit is

Recurrent eruptionsassociated withhistory of hay fever,asthma, dry skin oreczema.

• Papulovesicularpatch

• Pruritis isprominentsymptom

• Chronic history of same

• Scratching or oozing andcrusting may occur

Lichenified vesicularpatches with classicdistribution of flexuralarea of extremities


Topical:

Hydrocortisone 1%cream

Antihistamine:

Hydroxyzine (Atarax) ordiphenhydramine(Benadryl) for itch


Contact Dermatitis

Cutaneous reactionto irritant likechemical, product,metal, latex,clothing, soap,plant, etc.


• Severe pruritis.

Acute history of contact toexogenous plant, chemical ormetal; common offendingagents include poisonivy/oak/sumac

Wet, papulovesicularpatch with geometricoutline and sharpmargins


Oral Steroid:

Prednisone (tapereddose)

Antihistamine:

Hydroxyzine (Atarax) ordiphenhydramine(Benadryl) for itch


EczematousDermatitis orDyshidrosis

Recurrent eruptionsaffecting the handsand feet.


• Mild pruritis

Acute or chronic associatedwith excessive sweating,related to stress or irritation bynickel, chromate or cobalt

Papulovesicular patcheson hands or feet soles

(Some shoes havemetal that are causativeagent)


Topical:

Hydrocortisone 1%cream

F/U PRN; usuallychronic; maydevelopsecondarybacterial infection

Infectious

Herpes Simplex

VirusRecurrent,incurable,contagious viraldisease. (see oraland genital)

Localized, grouped,

uniform lesion

• Acute or chronic. Primary

infection; fever, malaise,headache, regionaladenopathy.

• Recurrent lesions withprodrome of fever or localwarmth, burning, usually justprior to eruption

• Grouped “grape-like”

cluster of uniformvesicles that quicklybecome papules thatrupture & weep

• May be found on anybody location

• Usually recurs in samelocation

Tzanck Smear or

HSV antibody titers

Antiviral :

• Acyclovir (Zovirax) forbest results, take withfirst onset of Sx

• Good hygiene

• Patient education ontransmission. Condomuse if genital

IF not resolved in

14 days, contactMO for advice

Disease AlertReport requiredIF primary genitalinfection


23/105

21–DERMATOLOGICAL

CHIEF COMPLAINT: VESICULAR (continued)


KEY FEATURES DIFFERENTIATING SIGNS& SYMPTOMS



TREATMENT FOLLOW-UP

Infectious (cont)

Herpes Zoster

“Shingles” is alatent cutaneousvaricella virusinfection involving asingle dermatome Itis not infectious,though it may

cause primaryvaricella if notimmune.

Localized,unilateral, linear,dermatomal lesion

Acute prodrome of knife-likepain, pruritis prior to eruption;lesion lasting weeks tomonths with predominantcomplaint of pain

Groups of vesicles on anerythematous basesituated unilaterally alonga dematomal (nerve)distribution


Antiviral:

Acyclovir (Zovirax)

Analgesic:

Acetaminophen ORibuprofen ORacetaminophen withcodeine (narcotic)

given short durationor as advised by MO

Lesion lasting weeksto months

Contact MO foradvice

Impetigo

Superficialcontagious skininfection caused by

Staphylococcusaureus, Group Abeta-hemolyticstreptococci orStreptoccusPyogenes

Localized crustedlesion

• Acute

• History of minor trauma toarea may be associatedwith disruption leading to

weeping lesion thatbecomes crusted

“Honey”-crusted lesionwith red base, usually onface, that may havemultiple new lesions

surrounding

Culture wound onthe advice of MO

Antibiot ic:

Dicloxacillin orcephalexin (Keflex)

Good hygiene

F/U if not improvedin 7 days

Smallpox

Highly contagious

and deadlyorthopox virus. Ithas beeneradicated throughaggressiveimmunizationprograms, thoughhas the potential foruse in bioterrorism.

Prodrome -regional

maculopapularrash

• Acute onset withoropharyngeal, facial, &

arm lesions spreading totrunk & legs

• Fever, headache,abdominal pain, vomiting,backache, & extrememalaise

After 1-2 days, cutaneouslesions become vesicular,

then pustular; unlikevaricella, all lesions are inthe same stage ofdevelopment on a givenbody part. After 8-9 daysall lesions becomecrusted.

Viral culture – notifylaboratory of

smallpox suspicion;highly contagious

Treatment isgenerally supportive,

with antibiotics forsecondary bacterialinfections. Antiviralshave never beenused clinically.

• CONTACT MOand Flight

Surgeon• Notify Command -

Disease AlertReport

• Be familiar withthe SVP.

http://www.smallpox.

army.mil/

http://www.smallpox/http://www.smallpox/


24/105

22–DERMATOLOGICAL

CHIEF COMPLAINT: VESICULAR (continued)

CONDITION &

DEFINITION

KEY FEATURESDIFFERENTIATING

SIGNS & SYMPTOMS

DIFFERENTIATING

OBJECTIVE FINDINGS

COMMONDIAGNOSTIC

TEST

TREATMENT FOLLOW-UP

Infectious (cont)

Varicella

“Chickenpox” is ahighly contagiousviral disease,spread byrespiratory dropletsor direct contact.

Generalized maculesthat quickly develop topapules, rupture &crust

• Acute prodrome ofchills, fever, malaise,headache, sore throat,anorexia, dry cough

• Lesions first develop ontrunk, then to head andextremities

• Classic “crops” oflesions with newpapules developsimultaneously withruptured crusted lesions

• Pruritis

“Crops” of vesiclesdescribed as “dewdropon a rose petal” invarying stages ofdevelopment frommacules to papules tovesicles to crusted

lesions; first on trunk,then head andextremities

CBC otherwiseusually nothingindicated

Symptomatictreatment; Self-limiting though acourse of acyclovirmy shortenduration

Antiviral :

Acyclovir (Zovirax)

Bed rest

CONTACT MOfor advice

• Infectious from48 hoursbefore rash towhen alllesions crustedover

• Disease AlertReport required

• Heals withoutscar


25/105

23–EENT

CHIEF COMPLAINT: RED EYE OR PAIN

CONDITION &

DEFINITION


SIGNS & SYMPTOMS

DIFFERENTIATING

OBJECTIVE FINDINGS

COMMON

DIAGNOSTICTEST

TREATMENT FOLLOW-UP

Blepharitis

Inflammation of theeyelid by eitherseborrhea orstaphylococcalcause.

• Erythema of theeyelid margin

• Itchy, watery,burning sensation

SeborrheicBlepharitis: Dry flakesand oily secretion onthe lid margins

StaphyloccocalBlepharitis: Ulcerations

at base of eyelashesand photophobia

• Complete eye exam

• Erythema of lid marginthat may be ulcerated ifstaphylococcal infection


• Clean eyelidmargin with babyshampoo (alsosee seborrheadermatitis)

• Forstaphylococcal:

Topicalophthalmic:Gentamycin ORerythromycinsolution/ointment

• No contact lensuse until resolved

F/U if not resolvedin 14 days

Chalazion

Non-infectious

meibomian glandocclusion causingswelling.

• Non-tendererythemicpapule of theeyelid

• Itchy, watery,burningsensation

Mild foreign bodysensation but usuallypainless


• Swelling behind the lid

margin


• Warm compressto promotedrainage 5-10minutes tid



F/U if not resolvedin 14 days

Chemical Bu rn toeye

Self explanatory.

• Erythema of theaffected part ofthe eye


Determine causativeagent


• Generalized erythema ofaffected area

• Assess for cornealabrasion with fluoresceinstain–epithelial defectshows brilliant green withfluorescent staining

• Usually noneindicated

• Fluoresceinstaining todetermineulceration orabrasion

• Immediateirrigation withcopious normalsaline for at least

10 minutes. Holdeyelid open.

• If alkali burn,irrigate for at least40 minutes andduring transport ifpossible

MEDEVAC

CONTACT MO orDuty FlightSurgeon

Emergencytransport toemergencydepartment orophthalmologistmust be considered


26/105

24–EENT

CHIEF COMPLAINT: RED EYE OR PAIN (continued)

CONDITION &

DEFINITION


SIGNS & SYMPTOMS

DIFFERENTIATING

OBJECTIVE FINDINGS

COMMON

DIAGNOSTIC TEST

TREATMENT FOLLOW-UP

Conjunctivitis, Al lergic

Inflammation of theconjunctiva.

• Erythema ofthe eyelid

• Bilateral Itchy,watery,burningsensation

• History of allergies,Rhinorrhea, itchy,watery eyes

• Seasonalenvironmentalconditions present


• Different Palpebralconjunctiva withcobblestone-likeswelling


Topical ophthalmic:

liquid tears

Oral Antihistamine:

Diphenhydramine(Benadryl), loratadine(Claritin), orFexofenadine(Allegra)

• Treat underlyingallergic symptoms


F/U if notresolved in 14days

Conjunctivitis,Infectious

Contagious viral or

bacterial infection ofthe conjunctiva.

“Pink eye” refers tobacterial infection.

• Erythema ofthe eyelid

• Itchy, watery,

burningsensation

• Bacterial - may havehistory of inoculationor family memberwith “pink eye,”purulent dischargewith morningcrusting of lidmargin

• Viral – may haveassociated viralsymptoms withwatery discharge


• Injected conjunctivaand margin edema

• Bacterial – crusteddischarge may or maynot be present

• Viral - may havepreauricularadenopathy


Topical ophthalmic:

• Bacterial infection- Gentamicin OR

erythromycinsolution/ointment

• Viral infection –liquid tears

• Good hygiene



Corneal Abrasion

Breakdown in theepithelial barrier dueto an abrasive injuryor contact lenses.Most common eyeinjury.

Foreign body

sensation, tearing

• History of trauma or

contact lens irritation

• Severe pain andphotophobia


• Consider tetracaine0.5% ophthalmicsolution to helpexamine eye

• Epithelial defect showsbrilliant green withfluorescein staining

Fluorescein staining

to confirm abrasion

Irrigation with normal

saline for at least 10minutes

Topical ophthalmic:

Gentamicin ORerythromycinsolution/ointment


• Usually

resolves in 24hours

• If not resolvedin 24 hoursconsult MO


27/105

25–EENT


CONDITION &

DEFINITION


SIGNS & SYMPTOMS

DIFFERENTIATING

OBJECTIVE FINDINGS

COMMON

DIAGNOSTIC TEST

TREATMENT FOLLOW-UP

Foreign Body oneye

Self explanatory

Foreign bodysensation, tearing

• History of trauma

• Mild to severe pain

• Photophobia

• Foreign bodysensation

• Tearing


• Consider tetracaine0.5% ophthalmicsolution to helpexamine eye

• Foreign body may beimbedded andsometimes difficult to

find & may or may notcause abrasion

• Epithelial defect showsbrilliant green withfluorescein staining

Fluorescein stainingto determineabrasion

• Attempt tovisualize foreignbody and carefullyremove usingcotton-tip moistwith normal saline

• Irrigation withnormal saline for

at least 10minutes

• Topicalophthalmic: Entamicin ORerythromycinsolution/ointment


• IF/U if notresolved in24 hours

• Reinforce eyeprotectionuse

Glaucoma

Closed-angleglaucoma is an acutedecreased outflow ofaqueous humorthrough pupil due toan anatomicallynarrow anteriorchamber increasing

intraocular pressure.(open-angle is a slowprogressive disease)

• Injectedconjunctivaand ocularpain

• May haveeyelid edema

• Acute blurredvision

• Frontal headache

• Lacrimation

• “Halos” aroundlights

• Possible nausea &vomiting


• Increased intraocularpressure (IOP) to 50-65mmHg. IOP in uveitis isgenerally 35-45 mmHg

• Tonometry

• If no tonometry,red, painful eyewith visualhalos is‘warning’ sign

Emergency treatmentis required as theoptic nerve maybecome compressedby high intraocularpressure


CONTACT MOor Duty FlightSurgeon

MEDEVAC


28/105

26–EENT


CONDITION &

DEFINITION


SIGNS & SYMPTOMS

DIFFERENTIATING

OBJECTIVE FINDINGS

COMMON

DIAGNOSTICTEST

TREATMENT FOLLOW-UP

Hordeolum

Infection orinflammation ofeyelid hair follicleinternal or external(aka sty)

• Tendererythemicpapule oneyelid margin


Sudden onset oflocalized tenderness oneyelid margin


• Erythemic papule oneyelid margin

• Bacterial infection usuallyhas discharge in area


• Warm compressto promotedrainage 5-10minutes tid

• No contact lensuse

• Bacterial infection:

gentamicin orerythromycinsolution/ointment



Hyphema

Blood in the anteriorchamber

May or may nothave erythema ofthe eyelid

• History of trauma orspontaneouspresentation

• Dull ache &

decreased vision


• Blood in anteriorchamber, decreasedvisual acuity, intraocular

pressure may rise

Tonometry Think: concern forincreased intraocularpressure

Bed rest for 3-5 days



Pinguecula

Benign ‘yellowish’colored lesion onbulbar conjunctivacaused by irritation

• Perceived asunsightly

• Asymptomatic

Eye irritation and patientconcern


• Triangular, fleshy papuleover sclera/bulbarconjunctiva


Reassurance


• F/U PRN

• Consult withMO if in doubt

Pterygium

Benign ‘yellowish’colored lesionencroaching ontothe cornea causedby irritation

• Perceived asunsightly

• Asymptomatic

Eye irritation, visualchanges, & patientconcern


• Triangular, fleshy growthof bulbar conjunctiva ontothe cornea; nasal side


Reassurance


• F/U PRN

• Consult withMO if indoubt. Referto optometristif change inacuity.


29/105

27–EENT






TREATMENT FOLLOW-UP

Retinal Detachment

Self-explanatory. Thecause can be traumaor retinal tearcommon in highlymyopic [good near-sight (minus lens)]individuals

Decrease or lossof vision

• History of visualflashes of lights orsparks

• May be described asa “curtain falling” orcloudy or smoky infront of their eye


• Detached retinaappears gray withwhite folds duringophthalmoscope exam

• Ophthalmoscope

• Tonometry

• Patch as directed

• Emergencytreatment isrequired



MEDEVAC

SubconjunctivalHemorrhage

Blood under theconjunctiva

May or may nothave erythema ofthe eyelid

• Asymptomatic.

• History of venouspressure fromstraining


• Blood under theconjunctiva may spillover into the lower lidmargin

Tonometry • No treatment isnecessary short oftreatment toassociated minortrauma if any.

• Treat underlyingillness if present



Uveitis

Acute inflammation ofthe uveal tract (iris,ciliary body andchoroids), increasingintraocular pressure

Injectedconjunctiva &ocular pain

• Acute blurred vision,deep ache & photo-phobia

• May have history oftrauma or inflam-matory condition


• Dilated pupil, injectedflare along limbusborder

• Increased intraocularpressure to 35-45mmHg

• Tonometry

• If no tonometry, red,painful eye withphotophobia is‘warning’ sign.

Emergency treatmentis required as theoptic nerve maybecome compressedby high intraocularpressure


CONTACT MOor FlightSurgeon

MEDEVAC


30/105

28–EENT

CHIEF COMPLAINT: EARACHE

CONDITION &

DEFINITION


SIGNS & SYMPTOMS

DIFFERENTIATING

OBJECTIVE FINDINGS

COMMON

DIAGNOSTIC TEST

TREATMENT FOLLOW-UP

Barotrauma

Ear pain or damagecaused by rapid changein pressure

Ear pain • History of trauma orrapid pressurechange

• Acute hearing loss

• Conductive hearing loss

• R/O TM perforation

• Weber or RinneTest

• Whisper test or Audiogram

• Self-limiting

• Decongestantor Valsalvamaneuver maybe helpful


Cerumen Impaction

Cerumen is a natural

lubricant for the earcanal; accumulation ofcerumen can causeobstruction, thus hearingloss, tinnitus, andinfection.

• Ear pain and/orhearing loss

•

May beasymptomatic

• Bilateral or unilateralitchy sensation in earcanal

• Chronic Q-tip use inear canal causescerumen productionleading to impaction

TM not visible withirritated appearingexternal canal

Usually none indicated Emulsifying Agent :

Debrox• Ear irrigation

with warmsterile water

F/U if notimproved in 7day

Eustachian TubeDysfunction

ET equalized pressure inthe middle ear. Viralsymptoms and allergiesmay block tube withswelling.

Ear pain and/orhearing loss

Popping sensation inear

Normal TM Tympanometry.(normal peak thoughmay be diminished)

Decongestant:

Pseudoephedrine


Mastoiditis

Infective process of themastoid air cells

Ear pain • History of recurrent orinadequate treat-mentof otitis media

• Feverish feeling

• Fever, bulging purulent& erythemic TM

• Postauricular edemaand tenderness

CBC & mastoidradiographs

Antibiot ics:

Ceftriaxone IV(Rocephen)

(consult with MOprior toadministering drug)

Emergencytreatment isrequired


MEDEVAC


31/105

29–EENT

CHIEF COMPLAINT: EARACHE (continued)

CONDITION &

DEFINITION


SIGNS & SYMPTOMS

DIFFERENTIATING

OBJECTIVE FINDINGS

COMMON

DIAGNOSTIC TEST

TREATMENT FOLLOW-UP

Otitis Externa

Infection of theexternal auditory canal

Ear pain • May have history ofswimming

• Itchy sensation inear canal

• May have otorrhea

• Tenderness with pinna‘tug’

• Edema and erythema ofexternal canal

• Normal TM

Usually none indicated Topical:

Corticosporin

F/U if notimproved in 7days;

R/OPseudamonas infectionwithpersistentsymptoms

Otitis Media

Infection of the middleear

Ear pain • History of viralsymptoms orEustachian tubedysfunction

• May have nasaldischarge, otorrhea,fever or dizziness

TM inflamed, non-mobile,bulging with decreasedlight reflex

Tympanometry Antibiot ics: Amoxicillin(Amoxil), orerythromycin(Emycin)


Perforation ofTympanic Membrane

Self-explanatory

Ear pain andhearing loss

• History of trauma,

barotrauma, orinsertion of objectinto ear canal

• Bleeding from canal,hearing loss, tinnitus

TM perforated. Blood maybe present in canal

• Tympanometry

• Audiogram beforeand after treatment

• No specific

treatment• Keep ear dry

with ear plugsin shower

• No swimming


Serous Otitis Media

Effusion of serousfluid in middle ear

Ear Pain • History of viral orallergy symptoms orEustachian tubedysfunction

• Popping sensationin ears

TM is relatively normal withfluid line or fluid bubblevisible

Tympanometry Decongestant:

Pseudoephedrine


TemporomandibularJoint (TMJ)Syndrome

Pain in the TMJ thatmay be referred to theear; commonly causedby grinding of teeth

Ear or TMJ pain • Popping sensationin TMJ or ears

• Headache

• Normal ear exam

• May have tendernessand crepitus of TMJwith range of motiontest or mastication

Usually none indicated • Stressreduction maybe helpful

• Referral todental clinic

F/U PR


32/105

30–EENT

CHIEF COMPLAINT: STUFFY NOSE




COMMON DIAGNOSTICTEST

TREATMENT FOLLOW-UP

All ergic Rhini tis

Allergic response toairborne allergensaffecting the noseand eyes

• Nasalcongestion

• Seasonalallergiescommon in thespring whereperennialallergies maylast all year

• Watery, itchy eyesand nose, sneezing,clear nasal discharge

• Postnasal drip maycause cough

• Pale, boggyturbinates, conjunctivainjection

• May have dark circlesunder eyes


• CBC (eosinophilia)

• CT of sinus if Sxpersist

Antihistamine:

loratadine(Claritin), orfexofenadine(Allegra)

F/U PRN

Common Cold

Viral upperrespiratory infectionoccurring anytimeduring the year.(influenza is usuallyin winter months)

Nasal congestion. • General malaise andlow-grade fever

• Rhinorrhea, sorethroat, and cough

• Influenza has highfever with more acute& severe Sx

• Possible fever

• Nasal turbinate edemaand erythema withclear/white discharge

• Injected conjunctivaand throat

• Clear lungs

Usually none indicated Self limiting. Analgesic:

Acetaminophen oribuprofen

Decongestant:

Pseudoephedrineor combined withantihistamine

F/U if notimproved in7 days

Epistaxis

(Nosebleed):

• Anterior:Kiesselbach’splexus

• Posterior:posterior half ofroof of nasal

cavity• May be

idiopathic,traumatic ormedical cause

Stuffy nose • Bloody nose

• May have history ofaspirin or NSAID useor trauma

Bleeding from thenostril(s) and/or clot

Usually none indicated

• CBC

• CT of sinus if Sxpersist

Anter iorepistaxis:

Pinch nostrils forseveral minutes.Vasoconstrictorlike Afrin mayhelp.

Posteriorepistaxis: Pack

nostril withVaseline-coatedgauze

Refer foremergencyinterventionifunsuccessfulimmediatetreatment


33/105

31–EENT

CHIEF COMPLAINT: STUFFY NOSE (continued)




COMMONDIAGNOSTIC

TEST

TREATMENT FOLLOW-UP

Sinusitis

Inflammation orinfection of mucousmembranes ofparanasal sinus

Nasal congestion • Sinus pressure,facial pain orheadache

• May have yellow -green nasaldischarge, maxillarytoothache, fever ormalaise

• Turbinates areerythemic and swollen

• Face pain worse whenbending over (tilt test),sinus tenderness withpercussion

• May be unable to

transilluminate sinuses


• CT of sinus ifSx persist

• Reserveantibiotics forpatients that fail a7 day course ofdecongestantsand analgesics

• Antibiot ic: Amoxicillin-

clavulanate(Augmentin) orSeptra DS

F/U if notimproved in 7days orincreased feveror headache


34/105

32–EENT

CHIEF COMPLAINT: SORE MOUTH/THROAT

CONDITION &

DEFINITION

KEY

FEATURES

DIFFERENTIATING

SIGNS & SYMPTOMS

DIFFERENTIATING

OBJECTIVE FINDINGS

COMMON

DIAGNOSTICTEST

TREATMENT FOLLOW-UP

Aphthous Ulcer

Mouth ulceration onbuccal mucosa referredto as “canker sore.”Cause is idiopathicthough may be related tostress or other moreserious condition ifrecurrent.

Mouth sore Painful ulcers White circular lesionssurrounded by anerythematous margin


• OTC benzocainepreparations like

Anbesol andOragel

• Reassurance

• F/U PRN

• Refer to MO ifrecurrent

Epiglottitis

Inflammation andinfection of the epiglottis.More common inchildren.

Sore throat Fever, dysphagia,drooling, muffled voice,and may hold tripodposition (head forwardand tongue out)

• Inspiratory strider,cervical adenopathy

• Throat most likelyappears normal

• Do NOT use tongueblade to visualizethroat

• Blood culture

• Chest radiograph

• Throat cultureconducted ONLYin emergencyroom withtracheostomy kitavailable

Antibiot ics:

Ceftriaxone IV(Rocephen)

(consult with MOprior toadministering drug)

Emergencytreatment isrequired


MEDEVAC

Herpes Simplex Virus

Incurable, contagious,recurrent viral disease.HSV1 generallyassociated with oralsymptoms and HSV2genital symptoms thoughmay be mixed and notdistinguishable clinically.Referred to as “feverblister.” Recurrence maybe associated with sun-light, illness, or emotionalstress.

Mouth sore • May have prodromeof localized pain,warmth, burningusually just prior toirruption

• Occasional tenderadenopathy

• Headache, myalgia,or fever

• Primary infection maybe worst of Sx

• Primary infection:grouped “grape-likecluster of uniformvesicles onerythematous base;

lesions erode andcrust, last 2 to 6weeks

• Recurrent Infection:same as abovethough domeshaped lesionsrupture and crustlasting about 8 days

Tzanck Smear orHSV antibody titers

Antiviral:

Acyclovir (Zovirax)For best results,take with first onsetof Sx

• Patienteducation ontransmission

• Condom use ifgenital

• IF not resolvedin 14 dayscontact MO foradvice

• Disease AlertReport requiredIF primarygenital infectiononly


35/105


36/105


37/105


38/105

36–CARDIOVASCULAR

CHIEF COMPLAINT: CHEST PAIN (continued)

CONDITION &

DEFINITION


SIGNS & SYMPTOMS

DIFFERENTIATING

OBJECTIVEFINDINGS

COMMON

DIAGNOSTIC TEST

TREATMENT FOLLOW-UP

Cardiac (continued)

Pericarditis

Inflammation of thepericardium(fibroserous sacsurrounding theheart)

Acute onset ofchest pain

O – acute

P – relieved by leaningforward and sitting up

Q – dull, tight, pressing

R – substernal ache,radiating to back orshoulders

S – severe to vague

T – may have recent viralsyndrome

Shortness of breath,nausea, diaphoresis, &weakness may beassociated

• Appears anxious,diaphoretic, pallor,dyspnea

• Assess vitals,febrile, “friction rub”heart sound,

adventitious lungsounds

• ECG may haveST-segment“concave”elevation in mostleads creating a“smile face”

• CBC and Chestradiograph

Analgesics:

• Aspirin oribuprofen

• Oxygen PRN

• Comfortable rest.

• Emergencytreatment may benecessary

CONTACT MOor Duty FlightSurgeon.

• ConsiderMEDEVACas MI cannot

be ruled out

Non-Cardiac

Anxiety

Excessive worry,fear, nervousness,and hypervigilance.May be associatedwith adjustmentdisorder orgeneralized.

Chest pain may beassociated withstress or panicattack

Physical complaintsprompt patient to seekmedical attention; worry,insomnia, muscle tension,headache, fatigue, GIupset.

• Appears anxious,diaphoretic, pallor,dyspnea

• Mental healthinterview

• Assess vitals andR/O cardiac

involvement

• ECG is normal

• Objective AnxietyQuestionnaire.(Beck’s)

Acute Tx:

Antianxiety:hydroxyzine (Atarax)OR diazepam(Valium)

Chronic Tx:

Refer to MO

CONTACT MOor Duty FlightSurgeon IFdoubt

Costochondritis

“Tietze’s disease”is an inflammationof the rib cartilage/ligament/muscles.

Chest pain isexacerbated bycough or deepbreathing

History of physicalexertion or trauma tochest or ribs

Direct palpable chestwall tenderness ofcostochondralligament/muscle

ECG is normal Analgesics: Acetaminophen oribuprofen

Reassurance



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37–CARDIOVASCULAR

CHIEF COMPLAINT: CHEST PAIN (continued)





TREATMENT FOLLOW-UP

Non-Cardiac (continued)GastroesophagealReflux Disease

Irritation caused byreflux of gastricsecretions into theespophagus (i.e.GERD). Excessiveuse of tobacco,alcohol, &

caffeinated productscan be contributingfactors

Chest pain andnausea may beassociated withmeal, exercise, orpatient restingsupine

• Epigastric “heartburn”

• Regurgitation causingbitter taste

• Symptoms relieved bysitting up or antacids

• May have naggingcough

• May have normalexam findings

• Assess for epigastrictenderness

• ECG is normal

• Antigen/antibodyfor H. pylori

Acute Tx:

H2 Inhibitor:Ranitidine (Zantac)

For chronic Tx orH. pylori refer toMO

CONTACT MO orDuty FlightSurgeon IF doubt

Pleuritis

Viral infectioncausinginflammation of thepleurae sacsurrounding the

lungs

Chest pain • Marked sharpstabbing pain withrespiration

• May have recent viralsyndrome

• Febrile

• Friction fremitus withrespiratory sounds

• ECG is normal

• Chestradiographs

Analgesics:

Aspirin or ibuprofen

• F/U if notimproved in 7days

• Consult withMO PRN


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CHIEF COMPLAINT: SYNCOPE





TREATMENT FOLLOW-UP

Arrhythmia

Rhythm is just that;regular, coordinatedelectrical impulses.

Arrhythmia is loss ofheart rhythm, eithera regular or irregularabnormality.

Transient, suddenloss of conscious-ness that resolvesspontaneously

• May have history ofarrhythmia andfainting

• Palpitations andlightheadednessmay precedesyncope

• Age usually greaterthen 50

• Appears anxious,diaphoretic, pallor,dyspnea or normal

• Complete physicalexamination

• Orthostatic bloodpressure

• ECG is indicatedbut may benormal at time ofexam

• Refer to MO

• Evaluateurgency of case

CONTACT MO orDuty FlightSurgeon IF doubtor abnormal ECG

OrthostaticHypotension

Benign failure ofnormalcompensation forblood pressure dropreducing blood flowto brain due to

dehydration

Vasovagal syncope has similar endresult with differentmechanism of action

Transient, suddenloss of conscious-ness that resolvesspontaneously

• Brought on bydehydrationsecondary tovomiting, diarrhea,bleeding, diureticmedication,emotional stress,warm environment

• Palpitations andlightheadednessmay precedesyncope

• Appears anxious,diaphoretic, pallor,dyspnea or normal

• Complete physicalexamination

• Orthostatic bloodpressure

• ECG is indicatedbut may benormal at time ofexam

• Electrolyte

imbalance cancause ECGchanges

IV – NS or oral fluidreplenishment

CONTACT MO orDuty FlightSurgeon IF doubtor abnormal ECG


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39–CARDIOVASCULAR

CHIEF COMPLAINT: SYNCOPE (continued)





TREATMENT FOLLOW-UP

Seizure

Paroxysmal hyperexcitation of theneurons in the brain;epilepsy is chronicrecurrent seizures

Compromisedmotor activity

• Partial Seizure – noloss ofconsciousness,though simple musclecontractions,paresthesias, loss ofbowel & bladder

• Petit Mal Seizure –sudden stopping of

motor function withblank stare

• Grand Mal Seizure –loss ofconsciousness, tonic-clonic musclecontractions, loss ofbowel & bladder;postictal period

Between seizuresphysical exam is normalthough may havebruising or trauma totongue just after

• CBC

• Chemical Panel

• Urinalysis

• Drug & alcoholscreening

• CT scan or MRI

• During seizure,maintain airwayand preventinjury

• Refer to MO

Seizure > 10minutes needsemergencyintervention!

Consult with MO orFlight Surgeon


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40–CARDIOVASCULAR

CHIEF COMPLAINT: VASCULAR SYMPTOMS





TREATMENT FOLLOW-UP

Deep VeinThrombosis

Blood clot(s) in thecalf or femoral veinsresulting ininflammation

(e.g., DVT)

Leg pain Limb pain and swelling Calf tendernessswelling with increaseddiameter (notedifference betweenunaffected calf)

Positive Homan’ssign

• Support hose

• Refer to MO

• Evaluateurgency of case


Raynaud’s Disease

Vasospasm of thevessels of the digitsin response to coldor stress

Hand pain • Fingertips turnmottled white andred then cyanotic

• Tobacco useexacerbates Sx

• Normal examinationbetween attacks

• Cold challenge testwill reproduce Sx

Cold challenge test Caution patientabout coldexposure and tostop tobacco use

Refer to MO

Varicose Veins

Superficial veinswith incompetentvalves cause dilationof veins

Burning sensationand unsightlydiscoloration at site

Patient concern mostlyabout appearancethough extensive

varicosities haveconstant dull ache

Dilated, tortuous veinsof the medial anteriorankle, calf or thigh

Usually nothingindicated

Avoid prolongedstanding, and usesupport hose PRN

Refer to MO PRN


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41–RESPIRATORY

CHIEF COMPLAINT: COUGH

CONDITION &

DEFINITION


SIGNS & SYMPTOMS

DIFFERENTIATING

OBJECTIVE FINDINGS

COMMON

DIAGNOSTIC TEST

TREATMENT FOLLOW-UP

Acu te

Bronchitis,Mycoplasma

Inflammatorycondition of thetracheobronchialtree caused by

mycoplasmpneumoniae (non-bacterial)

Non-productive,recurrent, barkingcough early, thenbecomesproductive

• Severe cough withpurulent sputumlate

• Sx persist for > 2weeks

• Fever, fatigue, and

possiblehemoptysis

• Low-grade fever

• Lung sounds: coarserhonchi and possiblyrales

Chest radiograph Cough suppressionwith expectorant:

Robitussin DM

Antibiot ic:

Erythomycin (E-Mycin)or Bactrim DS

Bed rest


Bronchitis, Viral

Inflammatorycondition of thetracheobronchialtree caused by virus

Non-productive,recurrent, barkingcough

• Scant white to clearsputum

• May or may nothave fever

• Sx usually 7-10

days• Common in

smokers

Lung sounds: coarserhonchi and possiblyrales

Chest radiograph Cough suppressionwith expectorant:

Robitussin DM


Influenza

“Flu” is a viralinfection that affectsthe nasopharynx,conjunctiva, and

respiratory tract,usually in wintermonths.

(common coldoccurs anytimeduring the year)

Non-productiveacute cough,usually worse atnight

Abrupt onset ofnonproductive coughwith high fever,malaise, headache,Rhinorrhea, sore throat,

& conjunctivitis

(Common cold has low-grade fever with lesssevere Sx and may notbe seasonal)

• High fever

• Nasal turbinateedema & erythemawith clear/whitedischarge

• Injected conjunctiveand throat. Clearlungs.

Chest radiograph Analgesic:

Acetaminophen oribuprophen

Cough suppressionwith expectorant:

Robitussin DM

• Self limiting

• Annual influenzavaccine



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42–RESPIRATORY

CHIEF COMPLAINT: COUGH (cont inued)





TREATMENT FOLLOW-UP

Acu te (cont inued)

Pneumonia,Bacterial

“Communityacquired”(outsidehospital/nursinghome) bacterialinfection of thelung

Streptococcuspneumoniae

• Productive,severe coughwith copiouspurulent sputum

• Usually worse atnight

• High fever

• Dark, thick, rustysputum

• Tachypnea, shakingchills, tachycardia,malaise, confusion

• Appears ill

• Febrile >100F/37.8C

• Pulse > 100

• Lung sounds: ralesand whispered

pectoriloquy

• Assessbronchophony &egophony

• Chest radiographwith lobarconsolidation

• Pulse Ox

• CBC

Note: Repeat chest x-ray in 4-6 weeks

Antibiot ic:

Ceftriaxone (Rocephin)Plus azithromycin(Zithromax)

Analgesic:

Acetaminophen or

ibuprofenCough suppressionwith expectorant:

Robitussin DM or withcodeine

• Consider oxygenand IV – NS

• Bed rest


Pneumonia,Mycoplasma

Atypicalpneumonia,“walkingpneumonia” is aninfection of thelung morecommon in the

summer monthsand in youngadults.

Mycoplasmapneumoniae

Non-productive, drycough

• Mild symptoms,sore throat, low-grade fever, sorethroat & malaise

• Headache usuallyalways present

• May appear ill

• Erythematous throat,fluid-line or bubblesbehind TM

• Lung sound: pleuralfriction rub

• Chest radiographwith bilateralpleural effusion

• Pulse Ox

• Consider RapidStrep & MonoSpot if sore throatsevere

Antibiot ic:

Azithromycin(Zithromax) orerythromycin (E-Mycin)

Analgesic:

Acetaminophen oribuprofen

Cough suppression

with expectorant:Robitussin DM or withcodeine

Bed rest



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43–RESPIRATORY


CONDITION &

DEFINITION


SIGNS & SYMPTOMS

DIFFERENTIATING

OBJECTIVE FINDINGS

COMMON

DIAGNOSTIC TEST

TREATMENT FOLLOW-UP

Acu te (cont inued)

Pneumonia, Viral

Viral infection ofthe lungs withrecent history ofcommon cold orinfluenza

Productive, mildcough

• Severe cough withwhite to clearsputum

• Fever & fatigue

• Recent history ofupper respiratory

viral illness

• Fever

• Tachycardia

• Usually has cervicaladenopathy

• Lung sounds: rales or

pleural friction rub

• Chest radiographwith peribronchialthickening andbilateral sparsinfiltrate

• Pulse Ox

Analgesic:

Acetaminophen oribuprophen

Coughsuppression withexpectorant:

Robitussin DM.

Bed rest


Chronic

ChronicObstructivePulmonaryDisease

Permanent dilationand destruction ofthe alveolar ductsand bronchicaused by chroniclung irritation seenin ages > 40(occupational,cigarette smoking,or alpha1-

antirypsindeficiency)

Chronic coughingwith scant sputum

• Weight loss &dyspnea

• History of recurrent

bronchial infections

• Respiratory effort anduse of accessorymuscles, barrelchest, pursed lipbreathing

• Clubbing of fingers

• Change in weight

• Pulse Ox

• Peek flow beforeand after treatment

Bronchodilator:

Nebulized albuterol

Oxygen NC

CONTACT MOor Duty FlightSurgeon ifdoubt


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44–RESPIRATORY






TREATMENT FOLLOW-UP

Chronic (continued)

GastroesophagealReflux Disease(GERD)

Irritation caused byreflux of gastricsecretions into theesophagus

Chronic, mildnagging cough andnausea

• Epigastric‘heartburn’

• Regurgitationcausing bitter taste

• Symptoms relievedby sitting up or

antacids• May have chest pain

• May have normalexam findings

• Assess forepigastrictenderness

• Complete HEENT,

CV, Respiratory, &GI Exam

• Antigen/antibodyfor H. pylori

• ECG is normal

Acute Tx:

H2 Inhibitor:Ranitidine (Zantac)

• For chronic Tx or H.pylori refer to MO


Tuberculosis “TB” is primarily alung infectioncaused by inhalationof tubercle bacillifrom close contact

with actively infectedperson

Chronic cough • Productive yellow/green sputum thatprogresses

• Prominent featuresare chronic “notfeeling well” with

drenching nightsweats

• Hemoptysis is lateSx

• History of closecontact with infectedperson

Lung sounds: rales inupper lobes withwhispered pectoriloquy

• PPD (PPDconverter doesnot necessarilymean activedisease (may bepast exposure),

though all withactive disease arepositive)

• CBC

• Sputum culturewith acid-fastsmear x 3 (culturetakes 3-6 wks)

• Chest radiograph:multi-noduleinfiltrate in apicallobe and hilaradenopathy

• Multi drug therapyis required

• Direct observationtherapyrecommended

• Consult with MO.



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45–RESPIRATORY

CHIEF COMPLAINT: DIFFICULT BREATHING

CONDITION &

DEFINITION


SIGNS & SYMPTOMS

DIFFERENTIATING

OBJECTIVE FINDINGS

COMMON

DIAGNOSTIC TEST

TREATMENT FOLLOW-UP

Anaphylax is

Immune hyper-sensitivity reactionto an antigen(insect, food,medication)

IgE mediated

Acute laboredtachypnea, cough,and wheeze

• History of exposure

• May have Urticariaand angioedema ofthe face withcyanosis

• Obvious distressrequiring immediatecare

• ABCs fi rs t

• Lung sounds:rhonchi and wheeze

• Vitals: hypotension

•

Complete HEENT,CV, respiratory, skinexam

• Pulse Ox

• Peak Flow beforeand after Tx

Bronchodilator:

Epinephrine 1:10000.3 to 0.5 mg IM and

Nebulized albuterol;

oxygen, IV – NS

Antihistamine: Diphenhydramine(Benadryl)

Oral steroid: Prednisone may beindicated to preventrecurrence


• IF reaction tovaccine,completeVAERS Report

Asthma

Disorder of thetracheobronchialtree with reversibleairway obstruction(bronchospasmwith inflammatoryprocess)

Acute laboredtachypnea, cough,and wheeze

• History of asthma

• Prolongedexpiratory wheeze

brought on byexposure trigger

• May have cyanosis

• Obvious distressrequiring immediatecare

•

ABCs fi rs t • Lung sounds:

expiratory wheeze

• Pulse Ox

• Peak Flow beforeand after Tx

Bronchodilator:

Epinephrine 1:10000.3 to 0.5 mg IM and

Nebulized albuterol;oxygen, IV – NS

Oral steroid: Prednisone may beindicated to preventrecurrence


Pneumothorax,Spontaneous

Sudden collapseof lung mostcommon in young,tall, thin men(primary) orpersons whosmoke(secondary)

• Acute laboredtachypnea,

cough, andwheeze

• Sx may besubtle

• History of smoking,vigorous exercises

• Sharp chestdiscomfort that isworse withbreathing

• Asymmetrical chestmovements and

decreased lungsounds

• Just listening to thelungs makes the Dx

• Pulse Ox

• Chest radiograph

• Oxygen

• Emergency

treatment isrequired

CONTACT MO orDuty Flight

SurgeonMEDEVAC


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CHIEF COMPLAINT: ABDOMINAL PAIN


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47–GASTROINTESTINAL





TREATMENT FOLLOW-UP

Appendici tis Acute inflammationof the vermiformappendix

Nausea, vomiting,constipation & fever•

Early, colicky toconstant pain inepigastrium orperiumbilical; RLQlater

• Vomiting after pain& pain worse withmovement

•

RLQ involuntaryguarding

• RLQ reboundtenderness; painmay be referred(Rovsing’s sign)

• Pain withpsoas/obturatormaneuver (Psoas –Obturator sign)

•

CBC• UA

•

Prompt referralto ER or directhospitaladmission

• Emergencytreatment isrequired


MEDEVAC

Cholecystitis

Acute inflammationof the gallbladder

Nausea, vomiting,loose stool, andfever

• Colicky to constantpain at RUQ toinferior angle ofright scapula

• Brought on by fattyfoods. Morecommon infemales

• May have dark

urine, light stool,and/or jaundice

RUQ tender with deeppalpation duringinspiration (Murphy’sSign)

• CBC

• UA

• LFT

• Gallbladderultrasound

Prompt referral toER or directhospital admission


MEDEVAC

Constipation(symptom)

Difficulty passingstool or diminishedfrequency ofdefecation. May besymptom of otherconditions

Nausea • Diffuse cramps

• Difficulty expellingfeces; less frequentdefecation thennormal for patient

• Abdomen bloatedand tender

• Hyperactive bowlsounds

• Labs directedtowards cause

• MO mayrecommendrectal exam foroccult blooddetection

Stool so ftener: Docusate sodium(Colase)

• Increase waterintake

• Increase dietary

fiber AFTERrelief of Sx

• F/U if notimproved in 24hours

• Consult withMO PRN


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CHIEF COMPLAINT: ABDOMINAL PAIN (cont inued)





TREATMENT FOLLOW-UP

Diarrhea (symptom)

Acute diarrhea isabnormal andincreasedfrequency andliquid stoolconsistency.

May be symptom of

other conditions.Symptoms lasting> 2 weeks =chronic diarrhea.

Nausea, vomiting,fever

• Diffuse cramps

• Abnormal andincreasedfrequency andliquid stoolconsistency

• Diffuse, abdominaltender

• May have poor skinturgor indicatingdehydration

• CBC

• UA

• Stool culture andova/parasite maybe indicated

• MO mayrecommend rectalexam for occult

blood detection

Antidiarrheal :

Loperamide(Immodium)

Antibiot ics may beindicated

• Increase waterintake; considerIV normal saline if

dehydrated

• NO solids x 24hours thenBRATS diet x 24hours

• Consider cause

F/U if notimproved in 72hours or chronicsymptoms,CONTACT MOand or DutyFlight Surgeon.

Diverticulitis

Inflamed diverticula(outpouchings ofthe mucosathrough themuscular wall ofthe intestine)

Nausea, vomiting,fever, anorexia, andconstipation ordiarrhea

Intermittent chronicpain, usually LLQ

LLQ tenderness,tympanic sound onpercussion

• CBC

• UA• MO may

recommend rectalexam for occultblood detection

Bowel spasm relief: Dicyclomine (Bentyl)

Antibiot ic : Metronidazole(Flagyl) PLUSciprofloxacin (Cipro)


Food Poisoning

Bacterial causefrom contaminatedfood

• Nausea

• Vomiting

• Fever• Diarrhea

• Onset of nausea,vomiting & diarrheawithin 12–24 hours

of eating

• Diffuse cramps

• Diffuse abdominaltender

•

May have poor skinturgor indicatingdehydration

• CBC

• Stool culture may

be indicated• MO may

recommend rectalexam for occultblood detection

Antibiot ic : Ciprofloxacin (Cipro)

•

Increase waterintake; considerIV normal saline ifdehydrated

• NO solids x 24hours thenBRATS diet x 24hours

F/U if notimproved in 24hours



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TREATMENT FOLLOW-UP

Gastroenteritis, Acu te

Viral cause ofvomiting anddia

List of Differentials

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Transcript of List of Differentials