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 beneficial, and the patient should be advised to wash with an antiseborrheic cleanser, such as Fostex.

    Urticaria (Hives)

    This is an acute or chronic allergic inflammatory skin reaction. It is normally the result of ingesting certain foods or drugs (commonly shellfish, eggs, milk, and penicillin).

    Symptoms-Raised wheals may occur over any or all of the body and itch intolerably. The patient may run a mild fever and experience general malaise. Swelling may cause laryngeal obstruction.

    Treatment-Antihistamines are indicated for itching. Urticaria is usually self-limiting, but may last for years. Caution the patient to avoid reexposure to sensitizing foods or drugs. Epinephrine 1:1000 may be administered for laryngeal obstruction.

    Calluses and Corns

    These are callous skin lesions that normally occur on the feet or toes. Faulty fitting shoes are the common cause.

    Symptoms-There is usually tenderness or sensitivity to pressure. These lesions may be differentiated from plantar warts by their glassy cores.

    Treatment-Soak the affected area in warm water and carefully pare the callus. Correct any orthopedic abnormalities, and make sure the patient's shoes fit correctly.

    Herpes Simplex (HSV) Type 1 and 2

    Herpes simplex is a double stranded DNA virus that is responsible for a primary and recurrent infection in humans. Primary infection is acquired in childhood from close contact with infected adults or other children, or in adults from contact through intercourse or kissing an infected individual. The virus is always present in an active blister or ulcer and is also shed in some cases from individuals without a clinical lesion.

    Symptoms-The virus is divided into two types. Type 1 is usually associated with a childhood infection and occurs on the lips as a cold sore or fever blister. Type 2 is associated with an adult infection and is usually of the genital type. This classification is not restrictive as either of the viruses can cause an infection on any area of the skin or mucous membranes. The infections are also divided into a primary or initial infection and a recurrent infection. The primary infection of type 1 and type 2 HSV tends to be severe with multiple grouped vesicles on an erythematous base, regional lymphadenopathy, fever, and malaise. The time from exposure to development of symptoms is 3 to 10 days. The duration of the primary infection is from 2 to 6 weeks. Following the primary infection the virus enters a dormant stage, residing in the dorsal root ganglia of the sensory nerve that supplied innervation to the blister site. The virus can remain dormant for many years with the type 1 HSV, but tends to reoccur 3 to 4 times per year with the type 2 HSV. Recurrent lesions may appear without cause or follow trauma, stress, menses, sunburn, or intercourse. The recurrent infection is usually much less severe, manifested by pain locally and some regional adenopathy. The lesions appear in the same location with each recurrent eruption. These lesions resolve spontaneously in 5 to 7 days.

    Treatment-At the present time there is no cure for HSV infection. In most cases, relief of pain with analgesics or topical anesthetics is adequate, especially for recurrent lesions. Primary infections can be treated with acyclovir. There are topical and oral preparations available. Recurrent infections if very frequent and severe may be candidates for oral acyclovir prophylaxis.

    NOTE:Do not touch the lesion or any vesicular or ulcerated lesion without exam gloves. HSV can easily be transmitted to your hands, causing a herpetic Whitlow lesion.

    Herpes Zoster

    Shingles is an acute viral infection of the central nervous sytem. characterized by vesicular eruptions and neuralgic-type pain in areas supplied with peripheral sensory nerves. This infection is caused by the same virus that causes chickenpox (varicella) and is most commonly encountered in persons over the age of 50.

    Symptoms-Chills, fever, malaise, and gastrointestinal disorders may precede distinctive features of the disease. On about the fourth or fifth day, crops of vesicles appear on an erythematous base in the area of the involved nerve. Pain may be present at this time; however, the skin in the involved area is extremely sensitive.

    Treatment-No specific remedy exists. The disease normally clears with no permanent damage except for scarring or postherpetic neuralgia. A corticosteroid, such as prednisone, may help to shorten the duration and relieve some of the symptoms. Soothing lotions and powders are often effective, and aspirin or other analgesics may be administered for pain. NOTE: Before giving a corticosteroid, rule out herpes simplex.

    Verrucae

    Warts are very common, contagious, benign epithelial tumors that may persist as single lesions or develop satellites. Occasionally the warts may disappear spontaneously.

    Treatment-The warts themselves may be easily removed; however, the virus often remains, producing recurrent warts at the same or different sites. Therefore, it is often advisable to leave single warts alone. Trichloroacetic acid should be applied to warts every 3 to 4 days, followed by phenol neutralized with alcohol or nitric acid when the wart whitens. If the warts are in warm, moist anogenital areas, podophyllum resin in tincture of benzoin is often effective. Plantar warts, found on the soles of the feet, are warts that have been flattened by pressure and are usually very painful. These are the most difficult warts to remove. Peel away the keratotic tissue and apply a concentrated phenol solution. Follow this with an application of nitric acid, and cover it with a salicylic acid plaster and adhesive bandage. Repeat this treat ment every 5 days; it normally takes from three to seven treatments for complete resolution. Patients may be referred to a dermatologist for other wart removal techniques, such as freezing and electrosurgical or surgical excision.

    Impetigo

    This is a superficial staph or strep skin infection.

    Symptoms-Normally lesions consist of small pustules, but they may be larger with rupturing and crusting. The lesions may remain localized but are often autoinoculated over large areas. It is most commonly found in children. Impetigo may appear on apparently healthy skin, but sometimes complicates other skin infections.

    Treatment-Topical antibiotics will normally result in prompt resolution. Gentle but thorough washing to remove any crust and debris should precede the application of ointment. If left untreated, impetigo may result in cellulitis or furunculosis. These complications should be treated with systemic antibiotics.

    Furuncles and Carbuncles

    A furuncle (boil) is an acute tender inflammation around perifollicular areas that is caused by staphylococci. Carbuncles are goups of furuncles adjacent to one another.

    Symptoms-A furuncle has a single core of necrotic tissue. The core exudes a purulent fluid and is most commonly found on the neck, axillae, and buttocks. These lesions are extremely painful. A carbuncle has two or more cores with multiple drainage sites and deep suppuration. There may be extensive sloughing of the tissues with large scar formation. A fever may be present and the patient is often prostrated. Carbuncles occur more frequently in men.

    Treatment-A single furuncle should be treated with moist heat to facilitate pointing. Once it has pointed, incise and attempt to remove the central core. Implant an iodoform pack to promote drainage and to prevent premature healing. Systemic antibiotics are indicated. Large furuncles and carbuncles require special care in debridement to avoid spreading the infection. Refer severe cases to a dermatologist.

    Cellulitis

    This is a spreading inflammation of the tissues, which usually affects the skin and subcutaneous tissues. Streptococcus and staphylococcus are the causative agents.

    Symptoms-These include fever, chills, malaise, headache, acute pain upon palpation, and swollen, red, and warm areas. Regional lymphangitis or lymphadenitis is common. Severe cases will often result in septicemia or bacteremia.

    Treatment-Place the affected part at rest and elevate. Bed rest is indicated if the condition is severe. Apply moist heat and administer erythromycin or lincomycin systemically. Continue the treatment until the symptoms have ceased for 5 days.

    Folliculitis

    This condition is the result of a staphylococcal infection of hair follicles. Sycosis barbae is a chronic and recalcitrant type better known as barber's itch. It appears in the bearded area and is aggravated by shaving.

    Symptoms-Burning and itching are common, and manipulation of hair causes pain.

    Treatment-Apply hot packs to the affected area. Apply topical antibiotics, and give systemic antibiotics if the areas around the eyes, nose, or mouth are involved (dangerous triangle).

    Tinea Capitis

    Ringworm of the scalp is a highly contagious fungal infection usually affecting school children.

    Symptoms-It is characterized by small gray lesions in which the hair is broken off, scant, or without luster. It may involve all or a part of the scalp.

    Treatment-Griseofulvin is definitive and 0.5 g should be administered twice daily with meals for 4 to 8 weeks or a single dose of 2 to 6 g repeated every 3 to 4 weeks.

    Tinea Corporis

    Ringworm of the body is an infection that usually involves the trunk and upper extremities and is uncommon in temperate climates.

    Symptoms-The lesions have raised borders spread peripherally and clear centrally. The various forms of this infection are pityriasis rosea, seborrheic dermatitis, and psoriasis. Tinea versicolor involves the upper trunk.

    Treatment-It is the same as for tinea capitis.

    Tinea Cruris

    Jock itch is a fungous infection occurring in the area of the upper inner thighs. Growth of the organisms is favored by obesity and tight clothing and is often recurrent.

    Symptoms-They include severe itching with active erythematous macules with sharp margins and cleared centers.

    Treatment-Aluminum acetate, corticosteroid lotion, or short-term oral corticosteroids may prove effective. Griseofulvin may be indicated in chronic cases. Advise the patient to rinse all soap away and dry thoroughly when bathing.

    Tinea Pedis

    Athlete's foot is a very common fungal infection of the feet.

    Symptoms-Normally the third and fourth interdigital spaces are first affected with subsequent spreading to the plantar surfaces of the arch. The lesions appear as macerated areas with scaling borders. When the toenails are involved, they become thickened and distorted. Tinea pedis may be mistaken for maceration due to excessive sweating.

    Treatment-Keep the feet clean and dry, change socks frequently, and apply an antifungal powder, ointment, or lotion.

    Tinea Versicolor

    This is a mild superficial fungal infection of the skin that occurs normally in the trunk area. Affected areas are resistant to tanning, and the fungus is more likely to occur in individuals who wear heavy clothing and tend to perspire freely. It occurs most frequently in tropical climates.

    Symptoms-There may be mild itching. The lesions appear velvety and are chamois-colored macules that are easily scraped off with the fingernail. The trunk, upper arms, neck, and face are often affected.

    Treatment-Good skin hygiene is essential. Salicylic acid soap may be the most effective treatment. It recurs frequently.

    Scabies

    This condition is a parasitic skin infection characterized by superficial burrows, intense pruritus, and secondary inflammation. The female itch mite burrows into the epidermis and lays her eggs. The larva hatch, surface, mate, and repeat the cycle. Good hygiene helps prevent this infection. It is readily transmittable.

    Symptoms-There is severe itching, especially at night. The male genitals, interdigital spaces of the hand, flexor surfaces on the wrist, areola of the breast in women, along the belt line of the abdomen, and the area of the lower buttocks are prone to inflammatory lesions. The face is rarely involved in adults. The burrows may be identified as fine, dark, wavy lines just beneath the skin. It may be hard to detect the burrows due to secondary lesions. A needle may be used to remove the parasite from its burrow to facilitate diagnosis.

    Treatment-General measures consist of vigorous cleansing of papules and vesicles during prolonged hot baths. Apply an emulsion or lotion containing benzocaine and benzyl benzoate from the area of the neck down. Reapply in 3 days to destroy the larvae.

    Pediculosis Capitis

    This is an infestation of the scalp, eyebrows, eyelashes, or beard by head lice. It is transmitted by personal contact with such items as combs and hats. Nits attach to the hair, resulting in severe itching.

    Pediculosis Corporis

    This condition is an infestation of the skin by body lice. The louse inhabits the seams of clothing and feeds on the skin, which results in severe itching and produces small red lesions occurring from the bites. The most common sites of lesions are the buttocks, shoulders, and abdomen. The body louse is an important vector in transmitting typhus, trench fever, and relapsing fever.

    Pediculosis Pubis

    This condition is characterized by infestation of the anogenital regions with crab lice. This infestation is the result of direct contact with the lice through sexual activity, toilet seats, clothing, or bedding. The louse is comparatively large but not easily seen, and itching is almost always present. The patient may note the presence of small specks on the sheets upon arising.

    Treatment-The treatment for all pediculosis infestations consists of applying ointments containing benzoate and benzocaine and maintaining proper hygiene habits. Use caution when treating around the eyes. Two applications of medication are usually sufficient. Check contacts. Use calamine lotion to control itching, and launder all bedding and clothing.

Abnormal levels of consciousness may be associated with decreased or increased neurological activity, such as stupor, coma, delirium, or violent behavior. There may be partial to complete mental clouding or loss of consciousness. Frequent causes are cerebrovascular accident (CVA), drugs, poisons, and fever.

The two major categories of loss of consciousness are stupor and coma. Stupor ranges from partial to almost complete loss of consciousness. Coma is complete unconsciousness from which the patient cannot be roused.

In any case of consciousness disorder, it is important to obtain a complete history from those who know the patient or who may have witnessed the incident causing it. Perform a thorough physical examination, including checking the pupils for size and reaction to light. The key points to look for when a neurological disorder is suspected are abnormal vital signs, signs of injury, or alcohol or drug intoxication. Also look for discolorations of the skin in the area behind the ears that may indicate a skull fracture.

Treatment-The immediate objective of treatment is to maintain life until a specific diagnosis is made. Avoid sedatives and stimulants, and keep semiconscious patients NPO. Catheterize unconsicious patients and test the urine for sugar, acetone, and albumin. Treat symptomatically.

Syncope is a temporary loss of consciousness as in fainting. Vertigo is an illusionary sensation of motion.

Symptoms-The patient is usually in an upright position when an attack occurs. He or she may experience motor weakness, epigastric distress, perspiration, restlessness, yawning and sighing, bradycardia, and a fall in blood pressure.

Treatment-Place the patient in the shock position, and administer spirits of ammonia.

Headaches are so common that most everyone has some experience with them at one time or another. They may be caused by tension, tumors, trauma, or any number of other causes. The following are the more common types of headaches.

• Tension-These headaches are caused by spasm or contraction of diseased muscles or adjacent structures, or they may be associated with fatigue or emotional stress. The muscles attached to the occiput are the most frequently involved. This is the most common type of headache.

  Symptoms-The common complaints are a feeling of pressure or tightness or a bandlike constriction and pain.

  Treatment-General measures consist of analgesics, rest, relaxation, massage, and heat applied to the involved musculature.

• Migraine-This type of headache is characterized by a paroxysmal attack often preceded by psychologic or visual disturbance that is followed by drowsiness. Women are affected more often than men. Migraine headaches are believed to be the result of vascular changes.

  Symptoms-There is usually a throbbing sensation or pain resulting from vasoconstriction followed by dilation. The patient often experiences nausea and vomiting. Often there is a family history of migraines, and the frequency of attacks may vary from daily to once every few years. The pain is usually unilateral and may last for 2 or 3 days.

  Treatment-Cafergot is the most widely used drug in the treatment of migraines. It should be administered at the first sign of headache (provided a history of migraine is obtained or you have actually diagnosed it). Place the patient on bed rest for a few hours in a darkened room and withhold any food or drink. At times the pain is so severe that narcotics may be necessary for pain; Demerol is the drug of choice. Codeine is contraindicated.

• Cluster-There is usually no clear history of headaches in the patient's family. Middle-aged males are most often affected, and the headaches may be precipitated by the use of vasodilators, alcohol, or histamine.

  Symptoms-The onset is sudden and is characterized by severe unilateral pain that may disappear after 1 or 2 hours as rapidly as it came. Nocturnal attacks are common, and the patient may have associated symptoms such as redness and lacrimation of the eyes, rhinorrhea, and nasal congestion.

  Treatments-The pain of this headache is so severe that the patient should be kept on bed rest until the pain ceases. Administer Sansert (methysergide maleate) to help prevent cluster headaches from becoming vascular headaches. Cluster headaches are so severe and of such short duration that adequate therapy is difficult; however, administering antihistamines may be effective.

• Hypertensive-Normally these headaches are the result of chronic hypertension. They are characterized by a persistent bilateral throbbing pain. The best treatment is to control the patient's hypertension. The patient may be helped by analgesics, understanding, and reassurance.

This is a convulsive disorder that is characterized by abrupt transient symptoms of a motor, sensory, psychic, or autonomic nature. Attacks are usually accompanied by altered levels of consciousness, and there is usually a history of epilepsy in the patient's family. The onset of epilepsy is usually before the age of 30. There are several types of epileptic seizure classifications. The three major classifications are generalized, partial, and unclassifiable epilepsies. The generalized epilepsies are the most commonly encountered and include the petit mal and grand mal types.

• Grand Mal Seizures-These are divided into the following two groups.
  • Jacksonian Seizure-This type of seizure is characterized by an aura, often referred to as a warning, but which in reality is a part of the seizure. The patient will experience convulsions without lapsing into unconsciousness. The seizure may start in the toes or thumbs or in the face (the eyes and head may turn to one side), and the seizure may then spread to other areas.
  • Typical Grand Mal Seizure-This type of seizure may have the initial aura as described above. The patient may fall down and cry out, lose bladder and bowel control, and froth at the mouth. There is convulsive movement of the body, dyspnea, and cyanosis. Corneal reflexes are usually absent and Babinski's reflex is positive. Often the patient bites the tongue and, if not completely unconscious, will be confused and disoriented. The seizure usually lasts 2 to 5 minutes. A period of deep sleep is common after the seizure, and the patient will complain of muscle soreness and stiffness upon awakening.

    Treatment-Immediate treatment is aimed at preventing the patient from injuring himself or herself. A tongue depressor or other type of padded gag should be placed between the patient's teeth to prevent biting the tongue; however, this may not be possible if the jaws are clenched. Don't force it. Never try to restrain a patient during convulsions; however, do not leave the patient alone. Loosen the clothing around the neck, and turn the head to the side to prevent aspiration of saliva and mucus. After the attack, administer anticonvulsants, such as barbiturates or Dilantin®. The objective of drug therapy is complete supression of symptoms. Refer the patient for evaluation.

• Petit Mal Seizure-This type of seizure is characterized by myoclonic jerks (shocklike contractions of all or a part of a muscle or group of muscles), akinetic seizures (abnormal absence of muscular movement or loss of muscle tone), and sudden clouding of consciousness for a few seconds. Also, the patient will normally not fall down. The classical symptoms of a sudden vacant expression, cessation of motor activity, and loss of muscle tone are almost always present. This condition is very common in children but almost never occurs after the age of 20. Activity will resume abruptly. The patient may experience as many as 100 attacks per day.

  Treatment-Administer phenobarbital or other anticonvulsants. Refer the patient for evaluation.

Strokes are caused by destruction of brain matter by intracerebral hemorrhage, thrombosis, embolism, or vacular insufficiency.

Symptoms-They include headache, nausea, vomiting, convulsions, and coma. Consciousness may not always be altered. The patient may experience speech disturbances, confusion, loss of memory, reduction of sensation, and paralysis of extremities or of a complete side of the body. The onset may be sudden and violent, with the patient falling into an immediate coma and exhibiting stertorous breathing. Death from serious strokes may result in a few minutes to a few days.

Treatment-Administer IV fluids, and place the patient on immediate and strict bed rest. Evacuate the patient for hospitalization immediately.

This is characterized by sudden bleeding into the subarachnoid space that may be the result of trauma or a ruptured aneurysm.

Symptoms-Before the aneurysm ruptures, it may apply pressure to nerves that will manifest as headaches, ocular palsies, diplopia, squint and facial pain, and a diminished visual field. After rupture, severe headache, nausea, vomiting, stiffness of the neck, positive Kernig's sign, and bilateral Babinski's reflex are usually present. The consciousness of the patient may or may not be affected, and the blood pressure is often elevated.

Treatment-Keep the patient at rest and maintain a fluid balance, avoid opiates and anticoagulants, and evacuate the patient immediately.

Head Injuries

Head injury is the most common of the traumatic conditions of the CNS. These may be open or closed, and in each case of head injury, a neurological evaluation should be performed.

• Concussion-This is the most common form of head injury and may be diagnosed by an altered state of consciousness; abnormal vital signs; bleeding from the ears and nose; convulsions; and altered pupillary reactions. The patient normally recovers with no permanent damage; however, recurrent concussion may cause permanent damage.

  Extradural hematoma is hemorrhage into the extradural spaces. This condition is a rare occurrence. The patient will suffer a loss of consciousness at the time of the injury and eventual coma with several hours of lucidity in between. While lucid, the patient will exhibit signs of increased intracranial pressure, such as headache, irritability and mental confusion, variations in level of consciousness, and hemiplegia (paralysis on one side of the body). The condition will deteriorate and death will result if the problem if not corrected.

  Subdural hematoma is caused by the rupture of a cerebral vein. There will normally be a loss of consciousness at the time of the injury followed by an asymptomatic period that may last for several days or weeks. Later the patient may have symptoms of increased intracranial pressure as described above. About one half of all persons with subdural hematoma will experience facial muscle weakness.

  Treatment-Ensure that the patient has a patent airway. If oxygen is to be administered, a nasal catheter is the preferred method of administration. Manipulation such as suturing or setting fractures should be held to a minimum, if possible, until the patient's condition is stable. If the patient demonstrates extreme restlessness that may further complicate his or her condition, sedate quickly; otherwise avoid sedation. DO NOT attempt to stem bleeding or the escape of fluids from the ears or nose. Tell the patient to try to avoid sneezing, coughing, or blowing the nose. Evacuate the patient immeditely.

Herniated Disk

In most cases, herniation or rupture of an intervertebral disk is the result of trauma. It may occur with sudden straining of the back in an odd position or while lifting in the trunk flex position. Herniation may occur immediately or may take years to occur. Most herniation occurs in the lumbosacral area but may also occur in the cervical or thoracic regions.

Symptoms-Over 90 percent of all herniated disks occur at the fourth or fifth lumbar interspace. There is pain upon palpation, and the patient will have a limited range of motion. The posture of the spine will be abnormal due to the loss of curvature of the spine. The patient may exhibit mild weakness of the foot or extensor areas of the great toe. There may be impaired sensations of pain or touch, and coughing or sneezing may cause radiation of the pain to the calf.

Treatment-Place the patient on bed rest with a backboard and administer analgesics for pain. If possible, apply traction and prevent the patient from using any severe physical effort. Applications of heat to the area of tenderness is beneficial. Definitive treatment of herniated disks will normally require surgery. Therefore, evacuate the patient as soon as possible.

Psychiatric disorders are more commonly encountered now than at any time in the past. This is due in part to improved diagnostic techniques, changing technology, and many other factors.

Psychiatric disorders run the gamut from anxiety reactions to schizophrenia. The independent duty hospital corpsman is not properly trained to treat acute psychiatric disorders. He should, however, be familiar with the signs and symptoms of psychiatric disorders and be able to manage those individuals who may be a threat to themselves or to other personnel.

Classification of Psychiatric Disorders

The major classifications of psychiatric disorders are neuroses, psychoses, and personality disorders.

• Neuroses-Emotional maladjustments that may impair thinking and judgment, but cause minimal loss of contact with reality. Neuroses often manifest themselves in the form of anxiety reactions, phobias, and obsessive depressive states. (Suicide is a definite possibility in depressive states.) The management of individuals with neuroses includes removing them from stressful environments, listening, and the presentation of alternatives versus being given advice.
• Psychoses-Mental disorders in which mental functioning is so impaired that it interferes with the capacity of the individuals to meet the ordinary demands of life. These disorders manifest themselves in the form of schizophrenia, psychotic depression, and paranoid reactions. Tranquilizers and antipsychotic medications may be necessary to protect the patient if immediate evacuation is not possible.
• Personality Disorders-Characterized by relatively fixed and inflexible lifelong reactions to stress. Common personality disorders include hysterias and antisocial, paranoid, obsessive compulsive, passive aggressive, and inadequate personalities. The processing of personality disorders is administrative in nature and medical department responsibilities in managing them may be limited to confirmation and counseling.

The following are some of the more commonly encountered disorders of the endocrine system.

Diabetes Mellitus

This is a hereditary disease characterized by an inadequate secretion and production of insulin by the pancreatic beta cells. It may also be caused by destruction of the pancreas from disease or tumors.

Symptoms-In children and young adults, diabetes is normally characterized by a sudden onset of symptoms. The onset is more insidious in older patients. The classic symptoms of polyuria, polydipsia (excessive thirst), hunger, weight loss, itching, blurred vision, and fatigue will normally be the first signs of diabetes. There are many complications that arise from this disease. In many instances, diabetes may not be detected until the rise of these complications that include ketosis, acidosis, and coma (often the result of inadequate insulin, although coma may also be induced by hypoglycemia); vascular complications (i.e., slow healing injuries, ulcers, and decreased blood supply to feet); diabetic neuropathy (e.g., tingling, paresthesias, decreased or absent sweating); and skin infections.

Treatment-The treatment for diabetes is centered around restoring the patient's metabolism and maintaining the general health and nutritional state. The diabetic diet is a normal diet with the exception that caloric and carbohydrate intake is restricted. Oral hypoglycemia agents are well tolerated as a rule. A physician will prescribe insulin therapy for patients whose hypoglycemia cannot be controlled by alternate methods. When diabetes is suspected, refer the patient for definitive diagnosis.

Diabetes Insipidis

This is a chronic disorder of the pituitary gland or hypothalmus that is the result of a deficiency of vasopressin (also called the antidiuretic hormone or ADH). Inadequate ADH secretion reduces water resorption and is more frequently found in males. Trauma or tumors may also cause this condition.

Symptoms-The onset is normally slow with increasing polydipsia and polyuria. If preceded by trauma, infectious disease, or emotional shock, the onset may be abrupt. The patient will exhibit thirst, drinking up to 40 liters per day. The patient experiences rapid dehydration when fluid intake is altered. Rapid weight loss will follow the rapid dehydration.

Treatment-In almost all cases, vasopressin tannate in oil given IM (never IV) normally controls the symptoms. Diuretics, such as hydrochlorothiazide, will normally reduce urinary output.

Hyperthyroidism

This disease is characterized by excessive secretion of the thyroid hormones, increased metabolic rate, and exophthalmos (protrusion of the eyeball).

Symptoms-These include weakness, nervousness, sensitivity to heat, restlessness, weight loss, increased appetite, eyelid sag, headaches, nausea, abdominal pain, diarrhea, and an enlarged thyroid. Normally there is a history of hyperthyroidism in the family.

Treatment-Refer the patient for definitive evaluation.

Hypothyroidism

Myxedema is a condition in which decreased thyroid secretions produce characteristic reactions. This condition may be the result of radioiodine therapy, surgical excision, or atrophy of the pituitary gland.

Symptoms-There is a gradual personality change with the patient becoming more and more apathetic. Characteristic myxedematous features such as an enlarged tongue; slow deep-toned speech; dry, thickened, edematous skin; and puffiness of the eyelids, hands, and face are common. Alopecia (loss of hair) of the scalp and eyebrows is common. The patient will complain of drowsiness, increased sensitivity to cold, and constipation, and the deep tendon reflexes will be delayed.

Treatment-Refer the patient for definitive evaluation and treatment.

Addison's Disease

This disease is an insufficiency of the adrenocortical hormones. It is an insidious, progressive disease that is charcterized by increasing weakness, fatigability, increased pigmentation of the skin and mucous membranes, weight loss, hypotension, dehydration, anorexia, nausea, vomiting, and occasional hypoglycemia. The cause of this condition is normally due to adrenocortical atrophy of unknown etiology. Other causes include inflammatory necrosis, neoplasms, and granuloma.

Treatment-Refer the patient for definitive evaluation.

As the roles and numbers of women entering the naval service have increased, so has the role of the independent duty hospital corpsman expanded. With the assignment of women to duty aboard ships, the responsibilities for taking care of the health care needs of the ship's personnel have expanded to include those of the Navy's women.

Most of the conditions and complaints that bring women to seek medical attention will be no different than those of their male counterparts. However, there are some conditions that are obviously limited to females. To effectively treat these conditions, you must become familiarized with the female anatomy and physiology, techniques of physical examination, and diagnosing and treating the more commonly encountered female specific conditions.

With the exception of the female genitals and the breasts, the techniques for physical examination, as discussed earlier in this chapter, will apply to both males and females. The Navy policy as set forth in the Manual of the Medical Department (MANMED) establishes the requirement that in other than emergency situations or when totally impractical, no member of the Medical Department will examine or treat a member of the opposite sex without the presence of a witness. That witness, whenever possible, must be a member of the same sex as the patient.

1. Menstrual History

   Just as there are certain aspects of the physical examination of women that differ from the physical examination of men, there are also different types of information to be extracted during the medical history. The single most important part of the history to be taken when a woman presents with a gynecologic condition is the menstrual history. It should be remembered that many women are currently taking oral contraceptive pills that may modify the menstrual cycle. No history of the menstrual cycle is complete without making a note of the form of contraception employed. The following points are important data concerning the menses.

   • Age of Onset-An unusually late or early menarche (beginning of menstrual function) may be indicative of various endocrinopathies.
   • Interval-Although the typical menstrual interval is 28 days, there are many variations even in otherwise normal women. The normal range is 21 to 35 days and any departure from normal must be viewed as potentially produced by various pathologic conditions.
   • Duration-As stated above, any change from the normal must be viewed as possibly the result of a pathologic condition. The quantity of the flow frequently parallels the duration; a prolonged flow will generally be excesive. The normal duration of the flow is from 2 to 7 days.
   • Quantity-A marked reduction in the flow may indicate certain endocrinopathies, while a marked excess may indicate a dysfunctional disorder or other problems.
   • Character of Menstrual Flow-Normal appearance of menstrual blood is dark venous and unclotted. Bright red, clotted blood is the type of flow seen in excessive menstruation.
   • Menstrual Pain-Painful menstruation (dysmenorrhea) is one of the most frequently encountered of all gynecologic complaints. The character of the pain or cramps, onset, and duration should be determined. Most menstrual pain will begin the day of onset of menses. Any increase of severity of pain or the appearance of pain in a previously asymptomatic woman requires further investigation.
   • Intermenstrual Bleeding-Intermenstrual bleeding is a serious symptom. Even light bleeding frequently can indicate organic causes, such as polyps, erosion of the cervix, and occasionally cervical malignancy.
   • First Day of the Last Menstrual Period (LMP)-Many women are unsure of the exact date their LMP began; however, it is important to establish it. Dates are necessary to determine whether the cycle is irregular as well as to establish the time of conception.
   • Other Specific Areas to Record-List histories of vaginal discharge (leukorrhea) and such characteristics as the duration, odor, consistency, and color. When recording the obstetric history, include past and present urinary symptoms and any nausea or vomiting. It is important to list the patient's sexual history when STD is suspected or when there are complaints of painful coitus or postcoital bleeding.
2. Physical Examination of the Female Genitalia

   Before starting an examination of the female genitalia, obtain a history of any urinary tract infection symptoms, such as pain, frequency, and urgency. If the patient has symptoms, you can then determine the appropriate method of specimen collection. The next step is to ask the patient to void. After voiding (or collecting a specimen), place her in the dorsal lithotomy position (lying on the back with thighs flexed and abducted). Place a pillow under her head and put the feet in stirrups. The buttocks should extend slightly over the edge of the table.

   The examination of the genitals will be divided into three distinct parts.

   • External Genitalia-Inspect the mons pubis, labia, perineum, thighs, and lower abdominal regions. These are illustrated in figures 2-1 and 2-2. Using a gloved hand, separate the labia majora and inspect the labia minora, the clitoris, urethral orifice, and the introitus. Make a note of any swellings, ulcerations, inflammations, and nodules. Note any sign of discharge and any sores or lesions. Insert your index finger into the vagina, and milk the urethra gently from the inside to the outside. If there is any discharge, culture it on room temperature, Thayer-Martin media. If the labia are swollen, or if the patient has a history of past infections of the Bartholin's gland duct, insert your finger into the vagina at the posterior aspect of the introitus and your thumb on the outside posterior aspect of the labia majora. Palpate for swelling or tenderness, and check for signs of discharge around the duct openings. Repeat the procedure for the opposite side. Note any bulgings of the anterior vaginal wall.
   • Internal Genitalia-Use a vaginal speculum that has been warmed to body temperature. Use a medium-sized Graves for women without a hymen and medium-sized Pederson for women with an intact hymen. Instruct the patient to bear down. Place your gloved index and middle fingers at or just inside the introitus as shown in figure 2-3 (I), and exert downward pressure on the perineum. With your other hand, gently insert the speculum at a 450 downward angle (fig. 2-3 (II)). When inserting the speculum, make sure that the blades are closed and held at an oblique angle. Remove your fingers from the introitus, and rotate the blades of the speculum horizontally while maintaining downward pressure with the speculum. When the blades are fully inserted, open the blades and rotate the speculum until the cervix comes into view. Lock the blades into the open position using the thumbscrew (fig. 2-3 (III)). Inspect the cervix, making note of the color, position, bleeding, discharge, ulcerations, and masses. After obtaining the necessary cervical specimens, withdraw the speculum while slowly rotating it to observe the vaginal mucosa. Release the thumbscrew, but keep the speculum blades in the open position with hand pressure. During withdrawal of the speculum, note the color of the vaginal mucosa and any signs of masses, ulcerations, inflammations, and discharges. Allow the blades to close only when the speculum is free of the introitus.
   • Bimanual Examination-Insert your welllubricated gloved index and middle fingers into the vagina, exerting pressure posteriorly. Note any areas of tenderness or swelling in the vaginal walls. Identify the cervix and note its position, consistency, mobility, and indications of cervical tenderness on motion. Palpate the fornix as illustrated in figure 2-4 (I). Using your other hand (referred to as the abdominal hand), palpate downward midway between the umbilicus and the symphysis pubis toward your pelvic hand. Identify the uterus between your hands, noting any masses or tenderness, the size, shape, consistency, and mobility (fig. 2-4 (II)). Place your pelvic hand in the right lateral fornix and your abdominal hand in the right lower abdominal quadrant. Exert downward pressure with your abdominal hand and palpate the ovary. Note the size, shape, consistency, and presence of any masses or tenderness. Repeat the procedures for the left side.

     Withdraw your fingers from the vagina. Relubricate, if necessary, and then slowly introduce your middle finger into the patient's rectum and your index finger into her vagina (fig. 2-4 (III)). The anal sphincter may be relaxed by asking the patient to bear down while you are introducing your fingers. Repeat the steps of the bimanual examination. Pay special attention to the region that lies behind the cervix and the posterior uterine surface itself, as these areas may only be accessible to the rectal finger. Take note of any masses or areas of tenderness. Look for signs of rashes, excoriation, and external hemorrhoids.

3. Commonly Encountered Female Conditions

   Vaginitis

   This is an inflammation of the vaginal mucosa caused by fungal, bacterial, or mechanical factors. The zone of inflammation may extend from the vagina to the cervix and the vulvar region. It may be caused by inflammations of Bartholin's or Skene's gland ducts. The three most commonly encountered forms of vaginitis are Trichomonas, Monilia, and bacterial.

   • Trichomonas Vaginitis-The etiologic agent in this form of vaginitis is Trichomonas vaginalis.

     Symptoms-The most prominent symptom will be leukorrhea. With this type of vaginitis, the discharge may be thick or thin and profuse, may have a fetid odor, and will range in color from white to greenish-yellow. The discharge is often pooled in the vaginal fornix and is quite often bubbly in appearance. Visualization of the vaginal mucosa will disclose a red, inflamed mucosa and a cervix with small red, granular, strawberry looking spots. The patient will normally reveal a history of vulvar (external genitalia) irritation, vaginismus (painful spasms of the vagina), dyspareunia (painful coitus), and itching. Motile Trichomonas vaginalis organisms may be noted in a fresh wet preparation made by diluting the secretions with normal saline and examining the preparation under a microscope.

     Treatment-Flagyl (metronidazole) is administered in 250-mg doses 3 times a day for 1 week. However, this drug is contraindicated in pregnancy and should, therefore, not be administered until pregnancy has been ruled out. A vinegar douche (2 tablespoons of vinegar to 1 quart of warm water) administered once or twice a week may prove beneficial.

   • Monilia Vaginitis-This inflammation is the result of an overgrowth of the Candida albicans yeast. History may show a recent period of antibiotic therapy. Yeast infections are more common in warm, moist climates. Patients with persistent or recurrent monilial infections should be investigated for possible diabetes.

     Symptoms-The discharge is most often thick, curdlike, white in color, and may have a musty order. This discharge is not usually as profuse as the discharge of Trichomonas. Visual examination may reveal a red, inflamed vaginal mucosa, with white or grayish patches of discharge. When these patches are scraped off, there is frequently a small amount of bleeding. Vulvar irritation, itching, vaginismus, and dyspareunia are common. Preparation of a wet smear with 15 percent potassium hydroxide added will help to visualize the Candida hyphae and spores.

     Treatment-MONISTAT 7 vaginal cream (miconazole nitrate 2 percent) administered once daily over a 2-week period is the treatment of choice. Hydrocortisone 1 percent cream applied locally to the vulva 3 times a day will help to relieve local irritation and itching. Mycostatin vaginal tablets taken once daily at bedtime for 15 days may also be used.

   • Bacterial Vaginitis-The etiologic agent may range from Haemophilus vaginitis to Neisseria gonorrhea and a wide range of other bacteria.

     Symptoms-The discharge in this form of vaginitis may range from scanty to profuse, may have a foul or musty odor, may be viscid to watery in consistency, and the color may range from greenish-yellow, brown, pink, gray, or milky white. The vaginal mucosa may be red and swollen, but this is not always true. Vulvitis, urethritis, and ulceration of the cervix are commonly accompanying symptoms. Infections of the Bartholin's and Skene's glands are common, especially in gonorrheal infections. A purulent discharge is often seen exuding from the cervical os, and pain and swelling of the cervix itself is often noted. The only definitive method of determining the specific etiologic agent is through a culture.

     Treatment-General measures consist of perineal and vulvar hygiene to control pruritus and local itching. Specific measures include vaginal application of sulfa creams once daily for 2 weeks. Ampicillin taken orally may also be beneficial.

     When the causative agent is unknown, a broad-spectrum drug such as Betadine® vaginal gel may prove effective in treating any of the more commonly encountered types of vaginitis. A culture for Neisseria gonorrhea should always be considered in sexually-active women.

   Vulvitis

   This is an inflammation of the vulvar region. The causes include mechanical and chemical irritation; hygiene neglect; urinary, fecal, or vaginal contamination; allergic reactions to detergents or drugs; parasitic infestations (pediculosis pubis); herpes simplex; psoriasis; condylomata acuminata; and folliculitis.

   Symptoms-They include burning, severe pain, pruritus, redness, swelling, ulceration, pustular formation, edema, and vesicular itching. Areas of irritation may extend to the perineal region and the inner areas of the thighs.

   Treatment-When a specific infection exists, treat the cause. Symptomatic relief may be obtained by the use of cool compresses of Burow's solution or tepid sitz baths. The area should be kept as clean and dry as possible, and the use of soaps and other harsh cleansing agents should be avoided, as they tend to dry the tissues and increase irritation. If an allergic reaction is the suspected cause, oral antihistamines may prove beneficial. Hydrocortisone 1 percent cream is often helpful. Chronic or intractable cases should be referred to a medical treatment facility as soon as possible.

   Cysts and Abscesses of Bartholin's Gland

   Infections, most commonly gonorrhea, may involve Bartholin's duct and gland, causing obstruction that prevents the drainage of secretions. This, in turn, leads to pain and swelling on either side of the introitus. A localized fluctuant swelling in the interior portion of the labia minora indicates an occlusion of the duct opening. Pain without undue swelling indicates an occlusion of the duct opening and an active infection of the gland itself. The patient's vital signs may be elevated. An abscess presents as a tense, hot, and tender local swelling. There may be pus or exudate in the region of the duct opening. Cysts are manifestations of chronic involvement and are normally not tender.

   Treatment-If there is no abscess formation apparent, treat the patient with broad spectrum antibiotics. Warm saline soaks will help to localize the infection. If an abscess is present, refer the patient to a medical facility.

   Salpingitis

   Salpingitis, or pelvic inflammatory disease (PID), is an inflammation of the uterine tubes. It may be acute or chronic as well as unilateral or bilateral. It is almost always bacterial in origin and is commonly, though not always, caused by gonococci.

   Symptoms-The patient will frequently reveal a history of vaginal coitus. There may be a greenish-yellow discharge present. The patient normally experiences severe nonradiating lower abdominal cramps in acute cases. Chills, moderate fevers, and a history of menstrual irregularity are common complaints. When a patient presents with an acute abdominal condition, it is essential to diagnose it correctly. Pain accompanied by uterine bleeding and signs of shock would be suspect of ectopic pregnancy. Examination of the internal genitalia may reveal pus exuding from the cervical os or urethra, and the tender adnexal (pelvic) masses may be palpable.

   Treatment-Whenever an acute abdominal condition is evident, transfer the patient for definitive treatment as soon as possible. Start the patient on 4.8 to 12 million units of aqueous penicillin G IM in divided doses. If the patient is allergic to penicillin, she is given Vibramycin (doxycycline) 200 mg to start, followed by 100 mg twice a day for 7 to 10 days. Analgesics may be administered to relieve pain.

   Premenstrual Tension Syndrome

   This syndrome is characterized by nervousness, depression, irritability, emotional instability, headaches, and mastalgia (painful breasts). The cause of this syndrome is unknown, but may be due to fluid retention with edema of the nerve tissues.

   Treatment-Generally, with the exception of a sympathetic ear and reassurance, no treatment is required. Mild analgesics may be prescribed to relieve headaches and mastalgia. In severe cases, limiting salt and using intermittent diuretics during the last 7 to 10 days of the menstrual cycle may be of value. The course of this syndrome is progressive and self-limiting, and it will usually clear up within the first few hours of onset of the menstrual cycle.

   Dysmenorrhea

   Dysmenorrhea is classified as either primary or secondary. Secondary dysmenorrhea is an acquired type and occurs most frequently as the result of an organic cause, such as salpingitis, uterine tumors, and endometriosis. Normally secondary dysmenorrhea occurs in the third and fourth decades of life. Thus, hospital corpsmen onboard ships will not normally be required to treat this type of disorder. The more frequently encountered primary dysmenorrhea is painful menses for which no organic cause can be found. Excessive release of prostaglandins from the endometrium may be one cause. Cervical obstruction and vasoconstriction are other possible causes.

   Symptoms-Pain may develop approximately I to 2 days before the onset of menses. The pain may be dull or sharp and cramping and may be referred to the legs and suprapubic regions. Associated symptoms include mastalgia, nausea, vomiting, depression, and abdominal distention.

   Treatment-This condition is also self-limiting and is best treated symptomatically. Treatment is dependent upon the severity and extent of the symptoms. Many women have pain, but few will be incapacitated by it. The basic keynotes of patient care, understanding, sympathy, and reassurance are essential in relieving some of the patient's anxieties. Advise the patient to engage in a program of physical exercise; however, fatigue should be avoided, as it tends to decrease the patient's tolerance of pain. Mild analgesics and antispasmodics may be administered, and for severe and incapacitating pain, light duty and bed rest for I or 2 days may be indicated. Refer the patient to a medical treatment facility for evaluation if the dysmenorrhea is interfering with the performance of duties.

   Amenorrhea

   Menstrual cycles that are absent or more than 6 months apart are considered to be amenorrhea. The causes of amenorrhea include ovarian or uterine tumors, obstruction, endocrine function abnormalities, and pregnancy, which is discussed elsewhere in this chapter. Refer nonpregnant patients with primary amenorrhea for evaluation.

   In addition to amenorrhea, any other type of abnormal uterine bleeding patterns should be referred as soon as possible for definitive diagnosis and treatment.

   Pregnancy

   A woman will usually suspect that she is pregnant before coming to sick call for confirmation. The physical changes that occur in pregnancy are variable and may not hold true in all cases, so make sure that a false diagnosis is not made. The patient will normally reveal a history of recent coitus with subsequently missed periods. The classic symptom of morning sickness is common. Pelvic examination may reveal a soft, enlarged uterus (detectable at or about the sixth week) and a purplish hue to the cervix and the surrounding vaginal mucosa. There may be frequency of urination and some amount of breast enlargement and tenderness. Laboratory diagnosis is accomplished by means of several tests that are available through the Federal Stock Catalog and are complete with instructions. In the event of a pregnancy aboard ship, consult NAVMEDCOM and NAVMILPERSCOM instructions for disposition. Refer the patient for an obstetric workup.

   Emergency Conditions in Pregnancy

   • Ectopic Pregnancy-This condition results when a fertilized ovum is implanted and develops outside of the uterine cavity. Ectopic gestation occurs in approximately 1 out of every 200 pregnancies. Most of the time the implantation occurs in the fallopian tube.

     Symptoms-The patient will reveal a history of amenorrhea or irregular menses, followed by a sudden onset of bleeding. There may or may not have been a previously diagnosed pregnancy. She may complain of severe abdominal cramping pain in the lower quadrant. The pain is nonradiating, and a soft, tender pelvic mass may be palpable. The decidual tissues may pass and the patient may show signs of shock.

     Treatment-Transfer the patient to a medical facility as soon as possible. Surgical treatment is required.

   • Spontaneous Abortion-This is termination of gestation before the 24th week of pregnancy. Most spontaneous abortions are the result of ovular or sperm defects. It may be the result of anatomic malformation of the fetus or diet deficiencies.

     Symptoms-The patient will reveal a history of amenorrhea or irregular menses. A previous diagnosis of pregnancy may or may not have been established. The usual signs and symptoms of pregnancy are often lacking. An abortion is classified as follows:

     • Threatened-This is any time vaginal bleeding or cramping occurs after conception.
     • Imminent-Bleeding is heavier and cervical effacement of dilation is present, and it may be accompanied by cramping pain.
     • Inevitable-The membranes are ruptured and portions of tissue may be visible at the cervical os.
     • Incomplete-Some tissue has been passed, and the remainder of the conceptus remains in the uterus.
     • Complete-There is total passage of all parts of the conceptus, the uterus has returned to normal size, and the cervix has closed.
     • Missed-The viability of the pregnancy has been terminated for at least 1 month, but the conceptus has been retained.

     Treatment-Place the patient on complete bed rest until the transfer is completed. If bleeding is severe, replace fluids and treat for shock. Analgesics may be administered to relieve pain. Administer antibiotics if signs of infection are present. Transfer the patient to a medical facility as soon as possible.

   Sexual Assault/Rape

   Sexual offenses, including rape, may be associated with serious injury, pregnancy, and sexually transmitted diseases and are criminal offenses. The medical management of sexual offenses must be a joint medicolegal function. The Medical Department representative (MDR) should ensure that the victim's commanding officer is notified. It is the responsibility of the command to contact NIS and the responsibility of the Medical Departnent to provide medical management. BUMEDINST 6320.57 series, Family Advocacy Program, provides guidelines on managing sexual offenses. The victim of a sexual assault should be referred immediately to the nearest NRMC or other fixed medical treatment facility when circumstances permit. When the circumstances of the command do not permit such (e.g., when at sea), the MDR must treat any resultant injuries and safeguard and obtain evidence, as directed by NIS and instructed in the NIS Sexual Assault Investigative Kit. Reassurance and calm, efficient, sympathetic handling of the victim is essential. In all cases, refer the victim to a medical treatment facility as soon as possible for further treatment.

   Common Breast Conditions

   Usually afflictions of the breasts that will be brought to your attention may be referred to a physician for routine evaluation and treatment. The most commonly encountered breast conditions are contusions. These are best treated by using a breast binder for immobilization and support. Hot or cold compresses may help to alleviate the severity of pain. Breast infections and abscesses are rare in nonlactating women, but they do occur. Treat these conditions with antimicrobials. Refer patients with breast abscesses, drainage, lesions, lumps, or persistent pain and related symptoms for definitive treatment.

   Although discussed earlier in this chapter, it would be appropriate to again stress that the cultivation of a professional, mature, sincere, and compassionate attitude by the hospital corpsman is essential. Medical ethics is stressed at all times and is indeed mandatory when treating patients, regardless of the sex.

Ensuring that the entire crew is in good dental health before deployment will prevent most dental-related problems. Predeployment examinations are therefore very important.

In the absence of a dental officer aboard ship, you, the MDR, must perform basic emergency dental first aid to alleviate pain, arrest hemorrhage, and prevent further or complicating injury to dental structures that are associated with the most common oral conditions and injuries.

Only attempt to administer emergency basic dental care. You should refer all routine cases to a dental treatment facility, and refer all cases treated by nondental personnel for follow-up at the earliest opportunity.

1. Dental Fundamentals

   Some knowledge of dental terminology is important to interpret emergency treatment plans prepared by dentists and to prepare consultation sheets for referral to a dental treatment facility. Make sure you use standard dental abbreviations when recording entries in a patient's dental record. These abbreviations are in MANMED, chapter 6, article 115.

   Terminology

   The following terms are defined as used in this section.

   Abscess-a localized collection of pus in a cavity formed by distintegrating tissues in or about the tooth

   Alveolar Bone-a thin layer of bone making up the bony processes of the maxilla and mandible, and surrounding and containing the teeth. It is pierced by many small openings through which blood vessels, lymphatics, and nerve fibers pass.

   Apical Foramen-an aperature at or near the apex of the root of a tooth, through which blood vessels and nerves supplying the pulp pass

   Buccal-pertaining to or directed toward the cheek

   Buccal Vestibule-the area between the cheeks and the teeth and gingivae

   Cementum-the bonelike connective tissue covering the root of a tooth and assisting in tooth support

   Cervix-the neck of the tooth

   Crown-the portion of a tooth covered by enamel

   Dentin-the chief hard tissue of the tooth; it surrounds the tooth pulp and is covered by enamel on the crown and by cementum on the root

   Enamel-the white, compact, and very hard substance that covers and protects the dentin of the crown of a tooth

   Eugenol-a colorless or pale yellow, oily liquid, obtained from oil of clove and other natural sources; used as a topical analgesic and antiseptic; and used in combination with zinc oxide as a sedative dressing in a tooth

   Gingivae-the gums: the mucous membrane, with the supporting fibrous tissue, which overlies the alveolar bone and encircles the necks of the teeth

   Gingival Sulcus-a furrow surrounding a tooth, bounded internally by the tooth surface and externally by the epithelium lining the free gingivae

   Interdental Papilla-the triangular pad of gingival tissue filling the space between the proximal surfaces of two adjacent teeth

   Mesial-nearer the center line of the dental arch

   Mecrotizing Ulcerative Gingivitis-trench mouth; an acute or chronic gingival infection characterized by redness and swelling, by necrosis extending from their interdental papillae along the gingival margins, and by pain, hemorrhage, and a necrotic odor

   Occlusal-a term applied to the chewing surface of premolars and molars

   Pericoronitis-inflammation of the gingiva surrounding the crown of a partially erupted or unerupted molar

   Periodental Ligament-a modified periosteum consisting of collagenous connective tissue fibers that connect the tooth to the alveolar bone

   Periodontotis-an inflammatory reaction of the periodontium, usually resulting from the extension of gingival inflammation into the periodontium

   Periodontium-the tissue that surrounds and supports the teeth

   Scaling-the removal of calculus from the exposed tooth surfaces

   Varnish-a solution of rosin, of resin, or of several resins in a suitable solvent or solvents, applied to protect the pulp

2. Dental Anatomy

   When you refer a patient to a dentist, it will help if you can describe the specific location of the problem. To do that you must use the proper terms to describe the location, identification, and surfaces of the teeth. Since this does not occur frequently, we will not take space here to cover it. This information is available in detail in DentalAssistant, Basic, NAVEDTRA 10677.

3. Dental Histology

   Dental anatomy deals with the external form and appearance of the teeth. Dental histology studies the tissues and internal structure of the teeth, along with the tissues that surround and support them. A knowledge of dental histology will be helpful when you provide emergency dental treatment.

   Tissues of the Teeth

   Structurally, the teeth are composed of four different tissues: enamel, dentin, cementum, and pulp. They are shown in figure 2-5 and are discussed below.

   • Enamel is the calcified substance that covers the entire crown of the tooth. It is thickest at the cusps, thinning to a knife edge at the cervical line. It is formed only once and cannot regenerate or repair itself. Thus, when enamel is destroyed by decay, operative dentistry is required to reconstruct the tooth. Enamel has no nerve fibers and cannot register sensations.
   • Dentin is the light yellow substance that makes up the bulk of the tooth. It is softer than enamel but harder than bone and is located inside the crown under the enamel. The point at which the dentin and the enamel meet is called the dentinoenamel junction. Dentin is also found inside the root of the tooth under the cementum. The inner surfaces of the dentin forms a hard-walled cavity that contains and protects the pulp.

     Unlike enamel, dentin continues to form throughout the life of the tooth. When the dental pulp is mildly stimulated as a result of caries, cavity preparation, abrasion, attrition, or erosion, a protective layer of secondary dentin is formed on the pulp wall.

     Even though dentin is not sensitive to stimuli, sensation may result when mechanical, thermal, or chemical stimuli are applied to it. The sensation comes not from the dentin itself but from cells that extend into it. These cells are actually part of the pulp, not the dentin, and they are sensitive to stimuli.

   • Cementum is a bonelike substance, although it is not as hard as bone. It forms a protective layer over the root portion of the dentin. The cementum joins the enamel at the cervix of the tooth.

     The main function of cementum is to anchor the tooth to the socket by attaching to the principle fibers of the periodontal ligament. Cementum is formed continuously throughout the life of the tooth. Thus, it compensates for the loss of tooth substance due to wear by attaching new fibers of the periodontal ligament to the root.

   • Pulp is soft tissue that fills the pulp cavity. This tissue contains numerous blood vessels and nerves that enter the tooth through the apical foramen. It is enclosed within the hard, unyielding dentin walls of the pulp cavity. The cavity has two parts: the pulp chamber and the root, or pulp canal. The chamber is located inside the crown. The canal is located inside the root.

     An important function of the pulp is to form dentin. It provides the cells from which dentin is formed and supplies the dentin with blood.

     Pulp responds to external stimuli, providing sensation to the tooth. It responds to irritation either by forming secondary dentin or by becoming inflamed. Since the walls of the pulp chamber and root canal permit no expansion of the pulp tissue, any inflammatory swelling of the tissue will compress the blood vessels against the walls. This results in a condition known as hyperemic pulp, which can lead to necrosis of the pulp tissue.

   Tissues of the Periodontium

   The tissues that surround and support the teeth are the cementum, the alveolar process, the periodontal ligament, and the gingivae. Collectively, these tissues are known as the periodontium. Throughout the following dis cussion, refer to figure 2-5.

   • The alveolar process is the portion of the maxillae and mandible that forms and supports the sockets (alveoli) of the teeth.

     The alveolar process can be divided into two parts: the alveolar bone proper and the supporting alveolar bone. The alveolar bone proper is a thin layer of bone that lines the tooth socket and attaches the principal fibers of the periodontal ligament. The supporting alveolar bone is the portion of the alveolar process that surrounds the alveolar bone proper and gives support to the tooth socket.

   • The periodontal ligament consists of hundreds of tissue fibers that, except at the apical foramen, completely surround the tooth root. The ligament acts as a shock absorber, reducing the impact of the teeth as they occlude.
   • The gingivae are the soft tissues that cover the alveolar process and surround the necks of the teeth. They consist of an outer layer of epithelium and an inner layer of connective tissue.

     Healthy gingivae are pink, firm, and resilient. They have a stippled appearance. Stippling refers to the "orange peel" texture of the healthy tissue. Inflammation causes a loss of stippling. When inflamed, the gingivae may become sore and swollen, and they may bleed.

4. Oral Examination

   Before performing an oral examination, review the patient's medical and dental history. Note any history of allergies, heart disease, and hepatitis. Note the medications the patient is currently taking. Review and update the patient's NAVMED 6600/3, as needed.

   When you examine the oral cavity, use a thorough and systematic approach. Some knowledge of the normal dental anatomy is essential to recognize oral diseases. The starting point of the examination is determined by the individual performing it. However, the examination should include the entire orofacial region. The following approach is merely a suggested guideline. First, examine the patient's tongue and the floor of the mouth. Check for signs of ulceration, swelling, deviations in normal anatomy and appearance, and lack of papillae on the tongue. To properly visualize these areas, grasp the tongue with a 2 x 2 or 4 x 4 gauze pad, and move the tongue from side to side.

   Next examine the buccal mucosa and vestibule areas for signs of ulceration, swelling, or sinus tracts. Examine the hard and soft palates, gingivae, and alveolar mucosa. Record any deviations from normal. Palpate the patient's submental, submaxillary, and tonsillar lymph nodes, and record any palpable nodes and whether they are tender, fixed, or mobile.

   Using a mirror and an explorer, examine the teeth for caries, chips or fractures, faulty restorations, and other anomalies. Use the mirror and a periodontal probe to check the periodontium for depth of the periodontal sulcus around the teeth. A depth in excess of 3 mm is indicative of periodontal disease, especially if bleeding accompanies gentle probing.

   You must now evaluate the chief complaint that brought the patient to seek treatment. If the complaint is a fractured restoration, the exposed dentin may be sensitive to thermal changes, or the sharp edges may irritate the tongue. If the problem is a painful carious lesion, determine the status of the pulp. This is done by percussion in which a painful response may indicate periapical pathology. Sensitivity to heat or cold may indicate pulpal changes, which may be the result of caries, trauma, a new restoration, or a fractured tooth. If pain persists after the stimulus is removed, the pulpal tissue is probably seriously damaged and undergoing degenerative changes.

   If the chief complaint is a periodontal problem, evaluate the color, contour, and uniformity of the gingivae. Hemorrhage upon probing indicates periodontal disease. The pain may be related to a pus-filled, fluctuant periodontal abscess. The teeth may be mobile as a result of advanced bone loss or trauma from a recently placed high restoration.

5. Local Anesthesia

   Most emergency dental procedures may be performed without the use of anesthetics. Incising and draining a well-localized soft tissue abscess with a single stab incision, opening the pulp chamber of a painful nonvital tooth, or placing a temporary filling in a carious tooth can usually be performed without a local anesthetic. Often it is disadvantageous to use an anesthetic. For example, if an anesthetic is used when excavating and filling a large carious lesion, you must wait for the anesthesia to wear off before determining whether or not the restoration has eliminated the pain. Placing a temporary sedative filling will usually bring relief without using anesthesia.

   Placing a dressing on an exposed vital pulp may require an anesthetic. However, in this case profound anesthesia may not make this procedure pain free. Extensive manipulation of painful tissues, such as irrigation and debridement of an acute pericoronitis, will be more tolerable when you administer an anesthetic. You, the independent duty hospital corpsman, and the patient must decide whether to use an anesthetic.

   Pain is perceived differently by patients. One patient may perceive pain as minimal, while another will describe it as excruciating. Fear and anxiety increases the patient's perception of pain. It is up to you to reassure the patient to help alleviate this problem.

   The problems involved in anesthetizing the mandibular arch are different from those involved in anesthetizing the maxillary arch. In the maxillary arch, most teeth can be effectively anesthetized by injecting 2 ml of anesthetic solution in the loose tissue just above the tooth. It is important to penetrate the loose oral mucosa above the lighter pink attached gingiva that is immediately adjacent to the teeth. The attached gingiva and the similarly attached tissues of the palate are denser, more difficult, and more painful to penetrate. The needle should not penetrate the mucosa more than 5 to 6 mm to approximate the apex of the root of the tooth. Make sure the needle point does not contact the bone.

   Local anesthesia of the maxilla will diffuse readily through the periosteum and bone to the nerves supplying the teeth, but the greater density of the cortical bone in the mandible makes diffusion more difficult. Some lower front teeth may be anesthetized by an infiltration injection, but the lower posterior teeth will generally require nerve block anesthesia. Techniques for the administration of nerve block anesthesia are described in the Cooke- Waite Manual of Local Anesthesia.

   Before administering an intraoral injection, wipe the injection site free of saliva and debris. Swab the area with a Betadine sponge. Whenever possible, avoid multiple injections in the oral cavity. By carefully analyzing the location of the teeth you want to anesthetize, you will normally be able to block the area with a single injection.

   Place the patient in a recumbent or supine position for the injection. Reassure the patient about the procedure to help calm him or her and to avoid syncope. Never leave a patient alone following an injection. Do not inject into an area of swelling and inflammation. When swelling or other indication of soft tissue inflammation exists, the nerve may be blocked central to the area of inflammation.

   The most commonly used anesthetic for dental injections is lidocaine (HCL) or Xylocaine in a 2 percent aqueous solution. Xylocaine with 1:100,000 epinephrine may be used to prolong the anesthetic effect. Use a 23- to 27-gauge 1-inch needle for all infiltration injections; however, a 23- to 25-gauge 1 5/8-inch needle may be required for some regional blocks.

   Xylocaine is a relatively nontoxic preparation. The maximum safe dose for an adult is 300 mg. Toxic reactions may be the result of either exceeding the maximum safe dose or injecting the anesthetic intravenously faster than the body can detoxify it. Always remember to aspirate before injecting the anesthetic. A toxic reaction to Xylocaine may have a brief excitatory stage followed by depression or may simply be evidenced by respiratory and cardiac depression. Cerebral anoxia may precipitate convulsions. Most toxic reactions are mild and transitory. Place the patient in a supine position, and ensure that there is a clear airway and adequate oxygen. Support the respiratory and cardiac functions until the body can detoxify the drug, thus ending the reaction. Unless an extreme overdose has been administered, the reaction will be brief and transitory and require no medications. Other possible reactions to look for when administering intraoral injections are hematomas, blanching of the skin, temporary paralysis of facial muscles, and sometimes loss of eye control and temporary blindness. These reactions will usually disappear as the drug is detoxified by the body.

6. Oral Diseases and Injuries

   As is true of all diseases and injuries, the symptoms discussed here refer to what the patient describes and the signs pertain to what you observe.

   Dental Caries

   This is the most widespread chronic disease of mankind. The most common cause of dental caries is bacterial plaque. The plaque on a tooth gives bacteria a place to breed. These bacteria release acids and other toxins that attack tooth enamel. This produces carious lesions (cavities).

   Dental caries destroys tooth tissues. Caries begins in the enamel. Usually, it first appears as a chalky white spot on the enamel. It may stop there, but if it does not, it goes through the enamel and into the dentin. As the caries goes farther into the dentin, the tooth pulp may be affected. Figure 2-6 shows how caries progresses into the tooth. If the pulp cannot resist the irritation caused by the caries, it will die.

   Symptoms-The patient may complain that the affected tooth is sensitive to heat and cold (usually cold), to sweets, or to pressure from food particles impacted in the cavity.

   Sometimes a patient will point to a healthy tooth and complain that it aches. There may be trouble in such a tooth, but it is always advisable to examine the other teeth on the same side (both upper and lower arches) for a cavity. This may be referred pain; that is, a patient feels pain in a healthy tooth while the true cause of the pain is located elsewhere.

   Signs-Examine the patient for caries by using a mouth mirror, an explorer, a cotton forceps, and a spoon excavator. Locate the affected tooth by asking the patient to point to it. You may observe some of the following signs.

   • Chalky white spot on tooth surface
   • Surface roughness when explorer point passes lightly over tooth
   • Dark, stained cavity
   • Cavity filled with spongy mass of decaying dentin

   Find out the depth of the caries. To do this, you may have to remove loose debris from the cavity. Use the spoon excavator and very gently lift out the debris as illustrated in figure 2-7. NOTE: Never try to scrape or dig the debris from the interior of the tooth.

   Stop the examination if there is bleeding in the pulp area, if the pulp is exposed, or if the patient's pain is greatly increased.

   If there is no pulpal bleeding or exposure or increased pain, continue removing the debris. When all of it is removed, lightly dry the interior of the tooth with a cotton pellet as shown in figure 2-8. Do not use air or extreme pressure in drying the tooth.

   Treatment-The following is a treatment plan for a tooth with no pulpal opening. For a tooth with a pulpal opening, see the treatment plan for acute pulpitis.

   If you have not done so before, remove all debris from the cavity with an excavator, and flush the cavity with warm water. Isolate the tooth with cotton rolls to free the cavity of saliva. If the tooth is in the mandibular arch, cotton roll holders will be helpful in isolating it. You can easily isolate a tooth in the maxillary arch by placing cotton rolls between the arch and the cheek or lip, depending upon the location of the cavity. Carefully dry the interior of the cavity with clean cotton pellets. Mix a zinc oxide-eugenol (ZOE) temporary filling, following the instructions on the kit. Use a Woodson No. 2 or 3 plastic instrument to place the filling in the cavity as illustrated in figure 2-9. Do not pack the cavity. Do not exert pressure on the filling; however, be sure the cavity is sealed off from the saliva. Smooth the filling with a cotton pellet dipped in water, so the filling does not keep the patient from closing the teeth together. Tell the patient not to chew solids for 2 hours, then to chew on the opposite side of the mouth until seen by a dentist. Stress the temporary nature of the treatment.

   Acute Pulpitis

   Acute pulpitis is a severe inflammation of the tooth pulp. Usually, it is the result of dental caries. It is the most frequent cause of severe dental pain. The pain is caused by the pressure of fluids building up inside the pulp chamber or the root canal(s).

   Symptoms-The patient may present with a continuous, piercing, and pulsating pain in the affected area; an increase of pain upon lying down; an increase or decrease of pain when the tooth is exposed to heat or cold; or an increase of pain when pressure is applied to the tooth.

   Signs-You may see a large cavity with or without a pulpal opening, with blood or pus oozing from an opening, or with swollen gingival tissue near the affected tooth. A painful reaction may occur when pressure is applied to the tooth by pressing the exterior of the tooth lightly with a finger or an instrument.

   Treatment-Gently remove loose debris from the cavity with a spoon excavator, being careful not to touch the pulpal opening. Dry the cavity very gently with a cotton pellet. Remove enough cotton fibers from a cotton pellet to make a smaller pellet. Slightly moisten the smaller pellet with a small amount of eugenol, and then blot the pellet on a gauze pad. NOTE: Excess eugenol can harm the tooth pulp. Place the pellet moistened with eugenol in the cavity, and cover the pellet with a dry cotton pellet.

   Tell the patient that the treatment is temporary and may have to be repeated during the night. Give analgesics for pain, and refer the patient to a dentist as soon as possible.

   Periapical Abscess

   A periapical absscess usually results from an infection of the tooth pulp. Therefore, the abscess often develops as a result of unchecked pulpitis. Infection of the tooth pulp causes fluids to build up within the walls of the pulp chamber and root canal(s). A periapical abscess is formed when these fluids escape from the interior of the tooth through the apex of a root canal. The escaping fluids create a fistula in the soft tissue. When the fluids reach a soft tissue drainage site, they form a large swelling called a parulis, or gumboil, as shown in figures 2-10 and 2-11.

   Symptoms-The patient may complain of a constant, throbbing pain in the affected area and an increase of pain when chewing or lying down. The complaint may also include a bad taste, a tooth that feels longer than the others, or a gumboil.

   Signs-You may cause severe pain when applying finger pressure to the affected tooth or when you tap the tooth lightly with the end of an instrument. You may see swelling or a gumboil on the soft tissues and facial swelling near the affected area. You may also discover the tooth is loose, and the patient may have an elevated temperature.

   Treatment-Drain the abscess to relieve the pressure, which will cause the pain to disappear. If a carious lesion is present in the affected tooth, use an excavator and gently remove the debris from the lesion. If this exposes the tooth pulp, drainage will result, and the pain will disappear. NOTE: Do not dig or gouge through the caries to reach the pulp.

   If drainage does not result when debris is removed, have the patient rinse with warm saline for 10 minutes every 2 hours. This may result in forming a gumboil for drainage to pass through. The method is also reliable if a gumboil is present when the patient reports for treatment. NOTE: Never apply heat to the face because it may cause drainage through the face rather than the abscess.

   As a last resort, if drainage does not result from the two methods already mentioned, apply ice packs to the affected area. They can be safely applied to the external surfaces of the face and will reduce the patient's discomfort until proper treatment can be given.

   Marginal Gingivitis

   Gingivitis is an inflammation of the gingival tissue as illustrated in figure 2-12. In marginal gingivitis, the inflammation is relatively mild and is sometimes localized, existing around one, two, or several teeth. The most frequent cause of marginal gingivitis is poor oral hygiene.

   Symptoms-The patient most likely will present with sore, swollen, bleeding gums.

   Signs-You may notice a painful reaction or gingival bleeding when you apply finger pressure to the affected area. You may also see a red, swollen gingivae with a loss of stippling; cuts or abrasions on the gingivae; and heavy plaque and calculous deposits in the affected area.

   Treatment-Give the patient plaque control instruction as explained in NAVEDTRA 10677, and refer to a dental treatment facility for scaling and polishing.

   Necrotizing Ulcerative Gingivitis (NUG)

   This is a severe inflammation of the gingival tissue. See figure 2-13. Sometimes NUG is called by the more common name-trench mouth. It may result from untreated marginal gingivitis. Other factors that contribute to NUG include poor oral hygiene and dietary habits, excessive smoking or alcohol consumption, and poor physical condition of the patient. NUG is not contagious.

   Symptoms-The symptoms are the same as those of marginal gingivitis. In addition, the patient may complain of a bad taste and pain when eating or brushing.

   Signs-The signs are similar to those for marginal gingivitis, but they will probably be more severe. For example, there may be more bleeding, and the patient may feel more pain when finger pressure is applied to the affected area. Also, calculous and plaque deposits may be greater. The following are signs associated with NUG that are not normally present with marginal gingivitis.

   The most characteristic sign of NUG is ulceration and cratering of the interdental papillae. Frequently, so much of a papilla is lost that the triangular area between the crowns of the teeth presents a "punched out" appearance. In addition, you may detect the following.

   • Gray-white membrane covering the gingivae
   • Foul odor from the oral cavity
   • Pus oozing from the gingivae
   • Areas of gingival recession
   • Elevated temperature

   Treatment-Treat NUG in the same way as marginal gingivitis, but referral to a dental treatment facility is more important than in marginal gingivitis.

   Periodontitis

   This is an inflammatory condition that involves the gingivae, the crest of the aleolar bone, and the periodontal membrane above the alveolar crest as shown in figure 2-14. It usually develops as a result of untreated marginal gingivitis. The disease is marked by a gradual recession of the periodontal tissues. Tooth mobility may also occur. Periodontitis may affect the entire dentition or only localized areas.

   Symptoms-The patient may complain of any of the following.

   • Deep, gnawing pain in the affected area
   • Itchiness of the gums
   • Sensitivity to heat and cold
   • Bad taste
   • Bleeding gums
   • Food sticking between the teeth
   • Toothache (in the absence of caries)
   • Increased spacing between anterior teeth
   • Loose or elongated teeth
   • Uneven bite

   Signs-Examination will reveal any or all of the following.

   • Heavy plaque and calculous deposits
   • Gingival inflammation, bleeding, or bluish-red discoloration
   • Local or general gingival recession
   • Ulcerated or destroyed interdental papillae
   • Tooth mobility

   Treatment-The emergency treatment for periodontitis is the same as for marginal gingivitis and NUG.

   Periodontal Abscess

   A periodontal abscess is caused by an infection in the periodontal tissues. This infection is usually the result of long-continued irritation by food debris; deep deposits of calculus; or a foreign object such as a toothbrush bristle or a popcorn husk being tightly packed into the interproximal spaces or between the tooth and the soft tissues.

   Symptoms and Signs-The symptoms and signs for periodontal abscesses are similar to those for periapical abscesses.

   Treatment-Gently probe the affected area with a scaler or a periodontal probe to establish drainage. Probe the space between the tooth surface and the soft tissue.

   If probing fails to start drainage, apply warm saline soaks to the affected area. NOTE: Never apply soaks to the face because they may cause drainage through the face rather than the abscess.

   Pericoronitis

   This is an inflammation of the gingiva around a partially erupted tooth. When a tooth begins to erupt, breaking through the gingival tissue, a small flap of tissue may remain over the tooth surface. Debris can accumulate beneath the tissue flap, and if the patient is unable to keep the area properly cleansed, inflammation can result. It can also result from constant contact between the tissue flap and a tooth in the opposing arch.

   Pericoronitis most often affects mandibular third molars, although any erupting tooth may be involved. The condition often occurs in the 18- to 25-year age group. Because many Navy personnel are in this age group, pericoronitis is one of the most frequent periodontal emergencies encountered.

   Symptoms-A patient's symptoms may include the following.

   • Pain when chewing
   • Bad taste
   • Difficulty in opening the mouth
   • Swelling in the neck or in the area of the affected tooth
   • Sore neck or throat
   • Elevated temperature

   Signs-Your examination may reveal the following.

   • Partially erupted tooth
   • Red, inflamed tissue around a partially erupted tooth
   • Pus oozing from under an overlying tissue flap
   • Painful reaction when finger pressure is applied to affected tissue
   • Swelling in the cheek near the affected area
   • Enlarged lymph nodes under the mandible or on the side of the neck
   • Elevated temperature

   Treatment-Irrigate the undersurface of the tissue flap and the surrounding area with warm saline. Use a 5-ml Luer-Lok syringe with a blunted 18-gauge needle. Figure 2-15 shows how to blunt the needle, and figure 2-16 shows the proper irrigating technique.

   Wrap a spoon excavator with a portion of a cotton pellet. Place a small amount of glycerite of iodine on the pellet, and wipe the pellet gently under the flap. See figure 2-17. Instruct the patient to rinse with warm saline every 2 hours.

   Stomatitis and Recurrent Labial Herpes

   Stomatitis is an inflammation of the oral mucosa. Two types of stomatitis commonly encountered are herpetic gingivostomatitis and aphthous stomatitis. Both conditions are marked by the formation of small blisters and ulcers on the oral mucosa as illustrated in figures 2-18 and 2-19.

   Recurrent labial herpes is an infection that produces a fever blister or cold sore. Such a lesion is usually found on the lip as shown in figure 2-20.

   NOTE: Some oral lesions are caused by an infectious disease; therefore, wear rubber gloves when examining the patient.

   Symptoms-The patient may complain of a painful swelling; a fever blister, cold sore, or canker sore; a great amount of pain when eating or drinking; and a fever, a headache, or a rundown feeling (herpetic gingivostomatitis).

   Signs-Your examination may show red, swollen areas with blisters or small craters formed in the centers, or these lesions covered with grayish-white or yellowish membrane.

   Treatment-Since these conditions will normally disappear spontaneously within 7 to 10 days, measures to eliminate the patient's discomfort are all that is necessary. Have the patient rinse with a warm solution of sodium bicarbonate several times daily. Treat stubborn recurrent cases by encouraging the patient to hold 1 teaspoon of tetracycline oral suspension in the mouth for 2 minutes 4 times daily for 5 days.

   Symptomatic relief may be obtained from anesthetic troches, ointments, or solutions such as an anesthetic mouth rinse. Also, tell the patient not to smoke; eat hot, spicy, or acidic foods; or drink alcoholic beverages.

   Postoperative Hemorrhage

   This condition may occur any time from a few hours to several days after the tooth extraction. The bleeding from the extraction site may be light or heavy. Treat all abnormal postextraction bleeding as serious.

   Symptoms-The patient may say that bleeding started or failed to stop after an extraction and that he or she is swallowing or spitting out large amounts of blood and feels weak from blood loss. A patient may also complain of a large amount of blood on bed clothing after sleeping; however, a small amount of blood in the saliva is normal after extraction.

   Signs-These include blood oozing or flowing from a recent extraction site after normal clotting should have occurred and a large amount of blood or large blood clots in the patient's mouth or on the clothing.

   Treatment-Initial attempts at controlling the hemorrhage should be directed at removing any clot in the mouth extraneous to the alveolus. Place a tightly folded 4 x 4 gauze pad or tea bag over the wound site, and have the patient bite firmly for 15 to 20 minutes. Keep the mouth as dry as possible, and encourage the patient to breathe through the mouth because this will help to keep it dry.

   If the above efforts do not control the hemorrhage, and if the bleeding appears to be coming directly from the alveolus, dry the alveolus, pack it with Surgicel or Gelfoam, and place a gauze pad as a pressure dressing over the wound site. Have the patient bite down for 15 to 20 minutes. Refer the patient to a dental treatment facility if the hemorrhage continues. Occasionally postextraction hemorrhage occurs 3 to 5 days following the extraction. In general, follow the same treatment procedures for hemorrhage within the first 24 hours.

   Alveolar Osteitis

   This condition, also known as dry socket, results when a normal clot fails to form in the socket of a recently extracted tooth. Since this condition is usually very painful, always consider it a serious emergency.

   Symptoms-A patient presenting with a dry socket will usually have a history of extraction within 5 days; a complaint of excruciating, constant pain; and the loss of a blood clot or the failure of a clot to form.

   Signs-Upon examination, you will probably note the absence of a blood clot in the socket of a recently extracted tooth; however, the socket may contain food debris. Alveolar bone may be visible in the socket, and you may smell foul breath. The patient's temperature is probably elevated.

   Treatment-Gently rinse the socket with warm saline. Moisten a small strip of surgical gauze with eugenol, and press the gauze between two dry gauze pads to remove excess moisture. Place a strip of surgical gauze loosely in the socket. Do not exert pressure on the socket when placing the strip. Have the patient return daily. Clean the socket and change the dressing until the condition is corrected.

   Fractured Teeth

   Pain in fractured teeth usually results from the irritation of the pulp tissue. The primary goal is to lessen the pain and, if possible, prevent further injury while awaiting treatment by a dentist.

   There are four different types of tooth fractures.

   • Type I-This is a slight chip fracture of the tooth enamel as illustrated in figure 2-21. The pulp is not exposed. The tooth may be sensitive to heat or cold.

     Treatment-Smooth sharp edges of the chipped area with sandpaper strips to eliminate irritation of the tongue and lips. Apply small amounts of cavity varnish over the chipped area. Tell the patient not to take extremely hot or cold foods and liquids, since this may damage the tooth pulp and be very painful.

   • Type II-This is a fracture with slight exposure of the pulp (fig. 2-21). It is a more serious fracture than type I. The patient experiences severe pain from thermal changes in the affected tooth.

     Treatment-Select a plastic crown form, and trim it with scissors to adapt it to the fractured crown. Place two or three small holes in the incisal edge of the crown form with a sharp, clean needle or pin. Fill the crown form with a thin mix of calcium hydroxide or ZOE. Gently place the crown form over the fractured crown. Remove excess moisture from the crown form with gauze and cotton pellets. Tell the patient to eat a diet consisting of soft foods and to avoid extremely hot or cold foods and liquids and sticky foods.

   • Type III-This is a large fracture with much pulp exposure, such as when the entire crown of the tooth is broken off (fig. 2-21). The pain is severe and mastication of food is almost impossible.

     Treatment-Place a crown over the affected tooth as explained in the treatment of type II fractures. It may be impossible to place a crown form over the fractured tooth because the pressure of the crown aginst the pulp tissue may cause pain. If this happens, place a splint rather than a crown form on the tooth.

     Make the splint by preparing a large mixture of ZOE, and add cotton fibers from a cotton pellet for strength. Place the splint so that it covers the affected tooth and the teeth immediately adjacent to it. See figure 2-22. Place the mixture well up on the lingual and facial aspects of the gingival tissue. Gently compress the splint between your finger and thumb to lock it into the interproximal spaces. Trim the splint from the incisal edges of the teeth so the patient's occlusion is normal.

     Advise the patient to let the splint harden for several hours before attempting to eat (see food restrictions under type II). Refer the patient to a dentist as soon as possible.

   • Type IV-This is a fracture of the root, which may be further complicated by a fracture of the crown (fig. 2-21). The pain is severe, mastication is almost impossible, and there may be a great deal of tooth mobility. Radiographic diagnosis is often the only sure way to determine a type IV fracture. However, any mobile tooth with a very recent history of trauma should be treated as a type IV fracture.

     Treatment-Place a splint in the same way as for a type III fracture.

   Traumatically Extracted Teeth

   Occasionally, a patient may report with a tooth that has been knocked out of socket. When this happens, immediately place the tooth in sterile saline, and send it along with the patient to a dentist. If a dentist is not available, attempt to replace the tooth in the socket and stabilize it. If there is no root or alveolar fracture, anterior teeth often slip back into the socket very easily.

A working knowledge of the dental records and forms used in the Navy is essential for you to correctly use and understand their purpose.

Military Health (Dental) Treatment Record

A Military Health (Dental) Treatment Record Jacket (NAVMED 6150/10-19, fig. 2-23) shall be prepared upon initial entry of a member into the naval service, and shall also be prepared when either the existing jacket has been damaged or, because of deterioration, is approaching the point of illegibility. A felt tip pen is used to record all identifying data, except the information recorded on the inside of the front leaf. The information on the inside of the front leaf shall be recorded in pencil to permit changes and updating.

The outside front of the treatment jacket will have the patient's name and SSN (Social Security number). The second to the last digit of the SSN is preprintedon the treatment record jacket. The color of the treatment record jacket corresponds to the preprinted digit as follows:

Preprinted Digit	Jacket Color
0	Orange
1	Light Green
2	Yellow
3	Grey
4	Tan
5	Light Blue
6	White
7	Brown
8	Pink
9	Red

The patient's dental classificiation will be designated in the top right corner on the jacket's back leaf. To facilitate recognition of the four ental classifications of patients, a standard color code, utilizing a strip of appropriately colored cellophane tape shall be placed on the record so that it will be readily visible when filed.

White tape indicates a Dental Class 1- Patients who do not require dental treatment.

Green tape indicates a Dental Class 2- Patients who have dental conditions that are unlikely to result in a dental emergency within 12 months.

Yellow tape indicates a Dental Class 3- Patients who have oral and/or dental conditions that are likely to result in a dental emergency within 12 months.

Red tape indicates a Dental Class 4- Patients whose oral classification is unknown because the patient has not received a dental examination in the past 12 months or the patient's dental record is not held by the responsible medical department activity.

The military health (dental) treatment record shall be verified annually by Medical Department personnel maintaining the record. In addition, verification shall be accomplished upon reporting and upon detachment from a duty station, and at the time of physical examination. A signed, dated entry to the effect that the verification has been accomplished shall be recorded on the current SF 603 and the appropriate year block on the treatment record jacket front leaf shall be blocked out.

Military Health (Dental) Treatment Record Contents

Each member's military health (dental) treatment record shall consist of NAVMED 6150/10-19, Treatment Record Jacket, containing the health care treatment forms prescribed below. The forms shall be arranged in top to bottom sequence with the most recent placed on top of each previous form.

Right Side:

1. Record Identifier for Personnel Reliability Program, NAVPERS 5510/1, when appropriate
2. Health Record-Dental Continuation, SF 603A (If applicable)
3. Health Record-Dental, SF 603
4. Consultation Sheet, SF 513 (when related to dental treatment)
5. Narrative Summary, SF 502; Doctor's Progress Notes, SF 509; and Tissue Examination, SF 515
6. Request for Administration of Anesthesia and for Performance of Operations and other Procedures, SF 522; and Anesthesia, SF 517
7. Navy Periodontal Screen Exam

Left Side:

1. Unmounted radiographs in envelopes
2. Sequential bitewing radiograph mounts
3. Panographic and/or full mouth radiographs
4. Dental Health Questionnaire, NAVMED 6600/3
5. Privacy Act Statement, DD Form 2005
6. Record of Disclosure-Privacy Act of 1974, OPNAV 5211/9

The Health Record-Dental (SF 603) is an aid to diagnosis, treatment, planning practice management. It is a means of identification and a record of the initial examination showing missing teeth, existing restorations, diseases, and other abnormalities. It is also a record of diseases and abnormalities occurring after the initial examination; a chronological record of dental care; and a basis for dental statistical information.

The Dental Health Questionnaire (NAVMED 6600/3, fig. 2-24) is a self-explanatory form. The first part is used to record the patient's chief complaint. The second part is the Check and Sign section and is normally completed by the patient. It is a simplified statement of the patient's medical history. All positive responses require explanation, especially the items for "any allergies or sensitivities," "ill effects from injections of Novocaine or Xylocaine," and "heart disease/ rheumatic fever/murmur. " You must make sure the responses are marked in red in prominent letters across the top of SF 603. Also, on the NAVMED 6150/10-19 record jacket immediately below the name, indicate in the alert box whether the member has sensitivities or allergies by entering an "X" in the appropriate box or boxes. The third portion of NAVMED 6600/3 is used to record dental radiographs. The fourth portion is the Routing/Treatment Plan and is used to consult with other medical and dental personnel in the facility and to plan a course of examination leading to a diagnosis. The Patient Identification section must be completely filled out and updated as necessary.

References:

1. Bates, B.: A Guide to Physical Examination, ed 3, Lippincott
2. Krupp, M. A., and Chatton, M. J.: Current Medical Diagnosis and Treatment, Lange Medical Publications
3. Berkow, R.: The Merck Manual, Merck Sharp and Dohme Research Laboratories
4. NAVEDTRA 10677, Dental Assistant, Basic
5. BUMEDINST 6150.34, Health Care Treatment Records