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8/9/2019 List of Differentials
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U N
I T E D
S T A T
ES C O A S T G
U A R D
H E A L T H
S E R V I CE S
T E C H
N I C
I A N
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TABLE OF CONTENTS
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1– CONDITIONS
DERM EENT CV RESP GI GU GYN MUS/SKEL NEURO MH
Erythema Red EyeCardiac Chest
Pain Acu te Cough Abdomi nal Pain STD Menses Neck Pain
Alt ered MentalStatus
MoodDisorders
• Anthrax(cutaneous)
• Cellulitis
• DrugReaction
• Furuncle
• Urticaria
• Viral
Exanthemas(measles,mumps,rubella)
• Blepharitis
• Chalazion
• Chemical Burn
• Conjunctivitis,allergic/infectious
• Corneal Abrasion
• Foreign Body
•
Glaucoma• Hordeolum
• Hyphema
• Pinguecula
• Pterygium
• Retinaldetachment
• SubconjunctivalHemorrhage
•
Uveitis
• Acute CoronarySyndrome
• Angina Pectoris
• Pericarditis
• Bronchitis,Mycoplasm
• Bronchitis– Viral
• Influenza
• Pneumonia,Bacterial
• Pneumonia,
Mycoplasma• Pneumonia,
Viral
• Appendicitis
• Cholecystitis
• Constipation
• Diarrhea
• Diverticulitis
• Food Poisoning
• Gastroenteritis,
Acute• GERD
• Hepatitis
• Hernia, Abdominal
• Irritable BowlSyndrome
• Pancreatitis, Acute
• PUD
• Chancroid
• Chlamydia
• Condyloma Acuminata
• Gonorrhea
• HIV
• HSV II
•
Lymphogran-ulomaVenereum
• Pediculosis
• Syphilis
• Trichomoni-asis
• Cervical Disk(HNP)
• MuscleStrain,Cervical
• Alcohol Abuse
• CVA
• Seizure
Growths Earache Non-Cardiac
Pain ChronicCough
Female Specific Abdomi nal Pain
MaleComplaint
Shoulder Pain Headache,Emergent
• MolluscumContagiosum
• Wart,Common
• Barotrauma
• CerumenImpaction
• Eustachian TubeDysfunction
• Mastoiditis
• Otitis Externa
• Otitis Media
• Perforation ofTympanicMembrane
• Serous OtitisMedia
• Temporomandibular Joint (TMJ)Syndrome
• Anxiety
• Costochondritis
• GERD
• Pleuritis
• COPD
• GERD
• Tuberculosis
• EctopicPregnancy
• Endometriosis
• Ovarian Cyst
• Epididymitis
• Hydrocele, Acute
• InguinalHernia
• Prostatitis,
Acute• Testicular
Torsion
• UTI
• Varicocele
• DysfunctionalUterineBleeding
• Dysmenorrhea,Primary
END
• BicipitalRupture,Proximal
• BicipitalTendonitis
• Bursitis,Subacromial
• ImpingementSyndrome
• Rotator CuffTear
• Hemorrhage,Subarachnoid
• HypertensionEmergency
• Meningitis
• AdjustmentDisorder
• Anxiety
• Depression
• SuicidalIdeation
END
Continued on Next Page
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2– CONDITIONS
DERM EENT CV RESP GI GU MUS/SKEL NEURO
Inflammatory Stuffy Nose SyncopeDifficult
BreathingRectal
Pain/BleedingFemale Complaint Elbow Pain
Headache,
Non-emergent
• Acne Vulgaris
• Insect Bite/Sting(non-venomous)
• Miliaria
• PseudofolliculitisBarbae
• Scabies
• Allergic Rhinitis
• Common Cold
• Epistaxis
• Sinusitis
• Arrhythmia
• OrthostaticHypotension
• Seizure
• Bacterial Vaginosis
• Bartholin’s Cyst
• Candidiasis,Volvovaginal
• UTI
• Bursitis, Olecranon
• Epicondylitis
• Cluster
• Sinusitis
• Tension
• Vascular
Scaly
Sore
Mouth/Throat Vascular Hematuria Wrist pain Vertigo
• Carpal TunnelSyndrome
• Ganglion Cyst
• Scaphoid Fracture
Finger pain
• Candidiasis(oral)
• Pityriasis Rosea
• Psoriasis
• SeborrheicDermatitis
• Tinea Capitis
• Tinea Corporis
• Tinea Cruris
• Tinea Pedis
• Tinea Unguium
• Tinea Versicolor
• Aphthous Ulcer
• Epiglottitis
• Herpes SimplexVirus
• Laryngitis
• Mononucleosis
• Peritonsillarabscess
• Pharyngitis,Bacterial
• Pharyngitis,Viral
• Salivary Stone
END
• Deep VeinThrombosis
• Raynaud’sDisease
• VaricoseVeins
END
• Anaphylaxis
• Asthma
• Pneumothorax,Spontaneous
END
• Colorectal Cancer
• Hemorrhoid
• Pilonidal Cyst
• Ulcerative Colitis
END
• Glomerulonephritis
• Pyelonephritis, Acute
• Renal Calculi
END
• Paronychia
• Labyrinthitis
• Meniere’s Disease
• Motion Sickness
• Vertigo, BenignPositional
Continued on Next Page
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3– CONDITIONS
DERM MUS/SKEL NEURO
Vesicular Lower Back Pain Facial Neuropathy
•
Mechanical, Muscular Strain• Neurological, Herniated Disk
• Prostatitis
• Pyelonephritis
• Renal Calculi
Knee Pain
• Bursitis, Patellar
• Collateral Ligament Tear
•
Cruciate Ligament Tear• Meniscal Tear
• Patellofemoral Syndrome
• Popliteal Cyst
Ank le Pain
• Achilles Tendon Rupture
• Ankle Sprain
Foot Pain
• Fifth Metatarsal Fracture
• Heel Spur
• Plantar Fasciitis
Toe Pain
• Ingrown Toenail
Leg Pain
•
Atopic Dermatitis• Contact Dermatitis
• Eczematous Dermatitis/Dyshidrosis
• Herpes Simplex Virus
• Herpes Zoster
• Impetigo
• Smallpox
• Varicella (Chickenpox)
END
• Shin Splints
END
•
Bell’s Palsy• Cerebrovascular accident
(CVA)
• Trigeminal Neuralgia
END
END
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4 – GUIDE TO SCOPE OF PRACTICE FOR HS TECHNICIANS
GUIDE TO SCOPE OF PRACTICE FOR HS TECHNICIANS
A Health Services Technician (HS) provides supportive services to medical officers and basic primary health care in
their absence. Each HS who provides medical treatment to patients at a Coast Guard clinic shall have an assignedDesignated Supervising Medical Officer (DSMO) from that facility. One of the primary goals of the HS is to eventuallywork independently after completion of the Independent Duty Health Services Technician School.
An Independent Duty Health Services Technician (IDHS) works outside of a clinical setting, and is supervised by aDesignated Medical Officer Advisor (DMOA). The IDHS practices independently, though acts as the ‘eyes, ears andhands’ in consultation with the DMOA or Duty Flight Surgeon when a situation is beyond the scope of technician healthcare.
This job aid captures all of the medical conditions that the HS3 (A for apprentice), HS2 (J for journeyman), and IDHS(M for master) should be familiar with. This job aid is divided into nine categories by body system plus a tenth formental health conditions. The categories are further broken down into patient chief complaints or presenting situation.The chief complaints have a list of conditions with corresponding potential differential diagnosis. Though the condition’spathogenesis is not discussed here, each condition is presented with:
•
A definition• Key features
• Differentiating signs and symptoms
• Differentiating objective findings
• Common diagnostic test considerations
• Proposed treatment
• Recommended follow-up
As you use the following guide to determine if a condition is within your scope of practice, remember that the “A” is for Apprentice and indicates that the HS, in achieving their rank, has included that condition in their scope of practice.
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5 – GUIDE TO SCOPE OF PRACTICE FOR HS TECHNICIANS
DERMATOLOGICAL
CHIEFCOMPLAINT
CONDITION HS3 Post‘A’ School
HS2 IDHS ‘C’School
Anthrax (cutaneous) A J M
Cellulitis A J M
Drug Reaction A J M
Furuncle A J M
Urticaria A J M
Erythema
Viral Exanthemas(measles, mumps,rubella)
A M
MolluscumContagiosum
A MGrowths
Wart (common) A J M
Acne Vulgaris A
J M
Insect bite/sting(nonvenomous)
A M
Miliaria A M
Pseudofolliculitis,Barbae
A M
Inflammatory
Scabies A M
Candidiasis(oral) A M
Pityriasis Rosea A M Psoriasis A M
Seborrheic Dermatitis A M
Tinea Capitis A M
Tinea Corporis A J M
Tinea Cruris A J M
Tinea Pedis A J M
Tinea Unguium A M
Scaly
Tinea Versicolor A J M
DERMATOLOGICAL, Continued
CHIEFCOMPLAINT
CONDITION HS3 Post‘A’ School
HS2 IDHS ‘C’School
Atopic Dermatitis A J M
Contact Dermatitis A J M
Eczema (dyshidrosis) A J M
Herpes Simplex Virus A M
Herpes Zoster A J M
Impetigo A M
Smallpox A J M
Vesicular
Varicella (chickenpox) A J M
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6 – GUIDE TO SCOPE OF PRACTICE FOR HS TECHNICIANS
EYES, EARS, NOSE, AND THROAT
CHIEFCOMPLAINT
CONDITION HS3 Post‘A’ School
HS2 IDHS ‘C’School
Blepharitis A J M
Chalazion A M
Chemical Burn A M
Conjunctivitis, Allergic A J M
Conjunctivitis, Infectious A J M
Corneal Abrasion A J M
Foreign Body A M
Glaucoma A M
Hordeolum A J M
Hyphema A J M
Pinguecula A M
Pterygium A M
Retinal Detachment A M
SubconjunctivalHemorrhage
A J M
Red Eye
Uveitis A M
Barotrauma A M
Cerumen Impaction A J M
Eustachian Tube
Dysfunction
A J M
Mastoiditis A M
Otitis Externa A J M
Otitis Media A J M
Perforation A J M
Earache
Serous Otitis Media A J M
EYES, EARS, NOSE, AND THROAT, Conti nued
CHIEFCOMPLAINT
CONDITION HS3 Post‘A’ School
HS2 IDHS ‘C’School
Earache,continued
Temporomandibular JointSyndrome
A M
Allergic Rhinitis A J M
Common Cold A J M
Epistaxis A J M
Stuffy Nose
Sinusitis A J M
Aphthous Ulcer A J M
Epiglottitis A M
Herpes Simplex Virus A M
Laryngitis A M
Mononucleosis A M
Peritonsillar Abscess A M
Pharyngitis, Bacterial A J M
Pharyngitis, Viral A J M
Sore Throat
Salivary Stone A M
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7 – GUIDE TO SCOPE OF PRACTICE FOR HS TECHNICIANS
CARDIOVASCULAR
CHIEFCOMPLAINT
CONDITION HS3 Post‘A’ School
HS2 IDHS ‘C’School
Acute CoronarySyndrome (ACS)
A J M
Angina Pectoris A J M
Cardiac ChestPain
Pericarditis A M
Anxiety (see Mental
Health–Feeling Downor Worried)
A M
Costochondritis A J M
GastroesophagealReflux Disease(GERD– seeRespiratory–ChronicCough)
A J M
Non-CardiacChest Pain
Pleuritis A
J M
Arrhythmia A M
OrthostaticHypotension
A M Syncope
Seizure (seeNeurological –AlteredMental Status)
A M
Deep Vein Thrombosis A M
Raynaud’s Disease A M Vascular
Varicose Veins A M
RESPIRATORY
CHIEFCOMPLAINT
CONDITION HS3 Post‘A’ School
HS2 IDHS ‘C’School
Bronchitis,Mycoplasma
A M
Bronchitis, Viral A J M
Influenza A J M
Pneumonia, Bacterial A J M
Pneumonia,Mycoplasma
A J M
Acute Cough
Pneumonia, Viral A J M
Chronic ObstructivePulmonary Disease
A M
GastroesophagealReflux Disease
A J M ChronicCough
Tuberculosis A J M
Anaphylaxis A J M
Asthma A J M DifficultBreathing
Pneumothorax,Spontaneous
A M
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8 – GUIDE TO SCOPE OF PRACTICE FOR HS TECHNICIANS
GASTROINTESTINAL
CHIEF
COMPLAINT
CONDITION HS3 Post
‘A’ School
HS2 IDHS ‘C’
School
Appendicitis A J M
Cholecystitis A M
Constipation(symptom)
A J M
Diarrhea (symptom) A J M
Diverticulitis A M
Food Poisoning A J M
Gastroenteritis, Acute(viral)
A J M
GastroesophagealReflux Disease
A J M
Hepatitis A M
Hernia, Abdominal A M
Irritable BowelSyndrome
A M
Pancreatitis, Acute A M
Abdominal pain
Peptic Ulcer Disease A M
Ectopic Pregnancy A M
Endometriosis A M Abdominal Pain – Female
Ovarian Cyst A M
Colorectal Cancer A M
Hemorrhoid A M
Pilonidal Cyst(abscess)
A M
RectalPain/Bleeding
Ulcerative Colitis A M
GENITOURINARY
CHIEF
COMPLAINT
CONDITION HS3 Post
‘A’ School
HS2 IDHS
‘C’School
Bacterial Vaginosis A M
Bartholin’s Cyst A M
Candidiasis, Vulvovaginal A J M FemaleComplaint
Urinary Tract Infection A J M
Epididymitis A J M
Hydrocele, Acute A M
Inguinal Hernia A J M
Prostatitis, Acute A J M
Testicular Torsion A J M
Urinary Tract Infection(UTI)
A J M
MaleComplaint
Varicocele A M
Glomerulonephritis A M
Pyelonephritis A J M Hematuria
Renal Calculi A J M
Chancroid A J M
Chlamydia A J M
Condyloma Acuminata A M
Gonorrhea A J M
Herpes Simplex Virus A J M
Human ImmunodeficiencyVirus (HIV)
A J M
LymphogranulomaVenereum
A M
Pediculosis A M
Syphilis A J M
SexuallyTransmittedDisease
Trichomoniasis A M
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9 – GUIDE TO SCOPE OF PRACTICE FOR HS TECHNICIANS
GYNECOLOGICAL
CHIEF
COMPLAINT
CONDITION HS3 Post
‘A’ School
HS2 IDHS ‘C’
School
Dysfunctional UterineBleeding
A M Menses
Dysmenorrhea A J M
MUSCULOSKELETAL
CHIEF
COMPLAINT
CONDITION HS3 Post
‘A’ School
HS2 IDHS ‘C’
School
Cervical Muscle Strain A J M
Neck painHerniated Cervical Disk(HNP)
A M
Bicipital TendonRupture, Proximal
A M
Bicipital Tendonitis A J M
Impingement Syndrome A M
Rotator Cuff Tear A M
Shoulder pain
Subacromial Bursitis A J M
Bursitis, Olecranon A J M
Elbow painEpicondylitis A J M
Carpal TunnelSyndrome
A J M
Ganglion Cyst A M Wrist pain
Scaphoid Wrist Fracture A J M
Finger pain Paronychia A M
Continued next page
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10 – GUIDE TO SCOPE OF PRACTICE FOR HS TECHNICIANS
MUSCULOSKELETAL, Continued
CHIEF
COMPLAINT
CONDITION HS3 Post
‘A’ School
HS2 IDHS ‘C’
School
Mechanical MuscularStrain
A J M
Neurological, HerniatedDisk
A J M
Prostatitis (see GU– male) A M
Pyelonephritis (see GU–hematuria)
A J M
Lower BackPain
Renal Calculi (see GU–hematuria)
A J M
Bursitis, Patellar A A M
Collateral Ligament Tear A M
Cruciate Ligament Tear A M
Meniscal Tear A M
Patellofemoral Syndrome A M
Knee Pain
Popliteal Cyst A M
Achilles Tendon Rupture A M Ankle Pain
Ankle Sprain A J M
Fifth Metatarsal Fracture A J M
Heel Spur A M Foot Pain
Plantar Fasciitis A M
Toe Pain Ingrown nail A M
Leg Pain Shin splints A J M
NEUROLOGICAL
CHIEF
COMPLAINT
CONDITION HS3 Post
‘A’ School
HS2 IDHS ‘C’
School
Alcohol Abuse A J M
Cerebrovascular Accident (CVA)
A M Altered MentalStatus
Seizure A J M
Hemorrhage,Subarachnoid
A M
HypertensionEmergency
A M EmergentHeadache
Meningitis A J M
Cluster Headache A M
Sinusitis A J M
Tension Headache A J M
Non-Emergent
Headache
Vascular Headache A M
Labyrinthitis A M
Meniere’s Disease A M
Motion Sickness A M Vertigo
Vertigo, BenignPositional
A M
Bell’s Palsy A M
Cerebrovascular Accident
A M FacialNeuropathy
Trigeminal neuralgia A M
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12 – GUIDE TO SCOPE OF PRACTICE FOR HS TECHNICIANS
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13–DERMATOLOGICAL
CHIEF COMPLAINT: ERYTHEMA
CONDITION &DEFINITION
KEY FEATURES DIFFERENTIATINGSIGNS & SYMPTOMS
DIFFERENTIATINGOBJECTIVEFINDINGS
COMMONDIAGNOSTIC TEST
TREATMENT FOLLOW-UP
Anthrax(cutaneous)
Caused by Bacillusanthracis and istransmitted tohumans by infectedanimals; has alsobeen used forhostile purposes as
a bio- logicalwarfare agent.
• Begins as alocalized, painless,pruritic, red papule1-6 days afterexposure
• May have fever,malaise, myalgia,headache, nausea,vomiting
• Progressiveenlargement withmarked erythema,edema, vesicles,central ulceration,and black pustules
• Exposure Hximportant
• Same as s/s
• Assess localizedlymphadenopathy
• Culture lesion
• Chest radiographand specific testsas indicated
Antibiot ic :
Ciprofloxacin 500 mgpo bid for 60 days
• CONTACT MOand FlightSurgeon
• Notify Command -Disease AlertReport
• Be familiar withthe AVIP
www.anthrax.osd.mil
Cellulitis
Acute, diffusebacterial infectionof dermis andsubcutaneoustissue
• Regional erythema
• May have fever andmalaise
Indurated patch that ispainful and warm totouch
• Localized red (rubor)
• Tender (dolor)
• Warm (calor)
• Marked nonpittingswelling (tumor)
• Assess regionallymphadenopathy
• Culture lesion
• CBC
• Mark borders ofinduration tofollow progression
Antibiot ic :
• Mild: Penicillin VK,or erythromycin (E-mycin)
• Severe: Ceftriaxone(Rocephin) IM
• Augmentin, if a bite
• F/U every 24hours untilresolved
• IF not resolved in7 days or severe,contact MO
Drug Reaction
Most commonadverse reaction todrugs is a skin rash
Generalized,confluent, pruriticmaculopapular rash
• Hx medication use
• Onset may bedelayed by 1 week;R/O anaphylaxis andbacterial pharyngitis
• Bright pink/redconfluentmaculopapularpatch(es)
• Complete HEENT,CV & respiratoryexams
• CBC if secondaryinfectionsuspected
• Rapid strep and/orthroat culture ifStreptococcussuspected
Antihistamine: Hydroxyzine (Atarax)or diphenhydramine(Benadryl)
• Discontinue drugcausing eruption
• CONTACT MO ifno improvement in24 hours
• Complete VAERSReport if vaccinereaction
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14–DERMATOLOGICAL
CHIEF COMPLAINT: ERYTHEMA (continued)
CONDITION &
DEFINITION
KEY FEATURES DIFFERENTIATING
SIGNS & SYMPTOMS
DIFFERENTIATING
OBJECTIVE FINDINGS
COMMON
DIAGNOSTIC TEST
TREATMENT FOLLOW-UP
Furuncle
Pus-filled masscaused bystaphylococcusaureus or MRSA
• Localized erythema
• Fever is rare
Papule or nodule, firmor fluctuant; painful andwarm to touch
• Localized red (rubor)
• Tender (dolor)
• Warm (calor)
• Papule or nodule(tumor)
• Assess regionallymphadenopathy
• Culture lesion
• CBC.
• Patient contactsmay also becontaminated withMRSA
Antibiot ic: TMP/SMX(Septra DS) (coversboth staph. aureus andMRSA)
• Incise and drain iffluctuant lesion
• Large wound mayrequire Iodoform
packing – repackdaily or PRN
• F/U Every24 hoursuntilresolved
• If NOTresolved in7 days orsevere,
contact MO
Urticaria
‘Hives’ usually are aresult of an adversedrug or foodreaction; thoughthere are othercauses, they usually
are unknown.
Generalized, confluent,pruritic maculopapularrash
• Recent history ofingestion of drug orfood associated withgeneralized rash
• Ask about over-the-counter or herb use
• Aspirin (salicylate) ismost common cause
• General distribution ofwheals or hives inpatches
• Respiratory distress
Usually noneindicated
Antihistamine:
Hydroxyzine (Atarax) ordiphenhydramine(Benadryl)
• Avoid cause
• Respiratory distress
will need emergenttreatment (seeanaphylaxis)
F/U PRN.
Chronicconditionsrefer to MO
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15–DERMATOLOGICAL
CHIEF COMPLAINT: ERYTHEMA (continued)
CONDITION &
DEFINITION
KEY FEATURES DIFFERENTIATING
SIGNS & SYMPTOMS
DIFFERENTIATING
OBJECTIVE FINDINGS
COMMON
DIAGNOSTIC TEST
TREATMENT FOLLOW-UP
Viral Exanthemas
Measles, mumps,and rubella arecontagious viraldiseases
• Generalized orregional erythemicmaculopapular rash
• May have fever,malaise, myalgia,headache andlymphadenopathy
Measles
• Coryza
• Cough
• Conjunctivitis
• Koplik’s Spots (white)on bucal mucosa
•
Rash spreads fromface to trunk andextremities
Mumps
• Parotid gland pain andswelling, 15% withmeningeal signs
• Maculopapular rashless common
Rubella
• Childhood disease
• Petechiae of softpalate
• Rosy red oval or roundmacules
• Rash spreads rapidlyfrom face to trunk andextremities; fades in24 to 48 hours
• Skin exam: asdescribed by history
• Assess regionallymphadenopathy
• Complete HEENT, CVand respiratory exams
• CBC
• R/OMononucleosis
Antipyret ic: Acetaminophen
• Otherwise,symptomatic Tx
• Ensure MMRvaccination is up-to-date
If not improvedin 7 days,consult with MOPRN
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16–DERMATOLOGICAL
CHIEF COMPLAINT: GROWTHS
CONDITION &
DEFINITION
KEY FEATURES DIFFERENTIATING
SIGNS & SYMPTOMS
DIFFERENTIATING
OBJECTIVE FINDINGS
COMMON
DIAGNOSTIC TEST
TREATMENT FOLLOW-UP
MolluscumContagiosum
• Contagious viraldisease
• In children it istransmitted fromfomites
• In adults it is
transmitted fromfomites, butprimarily sexuallyor intimate contact
Individual orgrouped papules
Usually an incidental andasymptomatic finding bythe patient
• Dome-shaped, pearlywhite to flesh coloredsmall lesions on trunk,extremities, or groin
• The lesions are firmand centrallyumbilicated
• Biopsy may beindicated if unable todifferentiate frombasal cell carcinoma(BCC)
• BCC usually havetelangiectasia andusually found on face
• Self limiting inmost cases
• Cryotherapy orcantharidinapplication maybe indicated
• Good hygiene
• Condom use if
genital
F/U PRN
Wart, common
Verruca vulgaris,verruca plantaris (soleof foot); caused by
direct contact; humanpapilloma virus
Individual papule
(also see genitalwarts)
• Smooth flesh coloredpapules that becomedome-shaped, gray-brown growths with
black dots• No skin lines through
lesion as corns do
“Cauliflower” flesh-colored papules thatbecome dome- shapedgrowths
Usually nothingindicated
• Self limiting inmost cases
• Cryotherapy orsalicylic acid
patch
• F/U PRN.
• Therapy mayrequirerepeated
applicationevery twoweeks
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17–DERMATOLOGICAL
CHIEF COMPLAINT: INFLAMMATORY
CONDITION &
DEFINITION
KEY FEATURES DIFFERENTIATING
SIGNS & SYMPTOMS
DIFFERENTIATING
OBJECTIVE FINDINGS
COMMON
DIAGNOSTIC TEST
TREATMENT FOLLOW-UP
Acne Vulgar is
Inflammatorydisorder of thepilosebaceousglands.
Few or multiplepapules, pustules ornodules on face, chestor back
Closed comedonesand/or open comedones
Non-inflamedcomedones toinflammatory papules,pustules, nodules, andcysts on face, chestand/or back
Usually noneindicated
Topical: Benzyl peroxidegel
• Apply after washingwith mild soap andwater twice per day
• F/U PRN
• Chronicconditionsrefer to MO
Insect Bite/Sting
(non-venomous)
Insect bites/stingsinoculate poisons,invade tissue, andtransmit disease.Here we discussirritative bites only.
Irritative bites: localizedinflamed papule
• Other varied reactionsmay be localized,
toxic systemic, orallergic systemic
• Consider relatedconditions like allergy,Lyme Disease, WestNile Virus, Malaria,etc.
• Irritative bites: localerythema, edema,
and pain• Complete thorough
skin exam and reviewof systems
Usually noneindicated unless
related conditionssuspected
• Symptomatic treatment
• Related conditions like
allergy, Lyme Disease,West Nile Virus,Malaria, etc will requirespecific treatments
• F/U PRN
• Chronic
conditionsrefer to MO
Miliaria
Sweat flow isobstructed (pricklyheat) by humidity(or extreme cold).
Regionalized papulesand pruritus
“Heat or prickly rash” Multiple discrete, small,red, inflamed papulesmostly on trunk and
back
Usually noneindicated
Topical: Hydrocortisone1% lotion to affectedarea.
Cool environment
F/U PRN
PseudofolliculitisBarbae
Inflammatoryresponse to aningrown hair.
Papules on beard area Difficulty shaving; “razorbumps”
Beard area has multipleyellow or grayishinflamed pustulessurrounded by red basewith hair in middle oringrown
Usually noneindicated
Topical: Benzyl peroxidegel
If associated with beard,massage beard areagently in a circular motionwith a warm, moist, soapysoft washcloth or facial
scrub pad; give a limited(days) “no shaving” chit.
F/U PRN
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18–DERMATOLOGICAL
CHIEF COMPLAINT: INFLAMMATORY (continued)
CONDITION &DEFINITION
KEY FEATURES DIFFERENTIATINGSIGNS & SYMPTOMS
DIFFERENTIATINGOBJECTIVE FINDINGS
COMMONDIAGNOSTIC
TEST
TREATMENT FOLLOW-UP
Scabies
Mite infestationfrom close contactwith infectedindividual orlinen/clothing.
Papules and pruritus “Itch/scratch” that mayinterrupt sleep
Small, inflamed papulesof linear “burrows” mostcommon on groin,genitals, fingers/toeswebbing
Usually noneindicated
Topical:
• Permethrins lotion orshampoo (Elimite/Nix)
• Also treat shipboard orhome contacts and washassociated clothing andlinen
F/U PRN
CHIEF COMPLAINT: SCALY
CONDITION &DEFINITION
KEY FEATURES DIFFERENTIATINGSIGNS & SYMPTOMS
DIFFERENTIATINGOBJECTIVE FINDINGS
COMMONDIAGNOSTIC TEST
TREATMENT FOLLOW-UP
Candidiasis (oral)
‘Thrush’ is a fungalinfection of the oralepithelium caused
by antibiotics,steroids, or immuno-suppression (AIDS).
White intra-oral plaquethat is easily scrapedoff
• History of antibiotic ororal topical steroids(like asthmatreatment) or HIV
infection• Pasty ‘cottage
cheese’ taste
White curd-like patchesthat appear like ‘cottagecheese’
• Potassiumhydroxide (KOHpreparation)microscopic eval
• Investigate causeif unknown
Topical antifungal:
Clotrimazole troches
OR
Oral Antifungal:
Fluconazole
F/U if notimproved in 14days
Pityriasis Rosea
Self-limiting skindisorder of unknowncause (may be viral).
Delicate, salmon-colored round or ovalpatches of fine whiteflakes
• Onset with “heraldspatch” 2-10 mmpink/tan oval patchfrequentlymisdiagnosed asringworm.
• Pruritus
“Heralds patch” withsalmon-colored round tooval patches withdelicate flaking; overtrunk and occasionallyextremities; “Christmastree” rash pattern onback.
Usually noneindicated
Reassurance – self-limiting, resolves in twoweeks to two months
F/U PRN
Psoriasis
Chronic, recurringskin disease of theepidermis; ofunknown cause(may be genetic).
Marked, silvery, flakingpatches or plaques
Gradual onsetexacerbated by stressand sunlight; nail pitting
Silvery pink scalypatches or plaques,classically on scalp,elbows and knees
Usually noneindicated
• High-potency topicalsteroids have someeffect
• Refer to MO
Refer to MO
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19–DERMATOLOGICAL
CHIEF COMPLAINT: SCALY (continued)
CONDITION &DEFINITION
KEY FEATURES DIFFERENTIATINGSIGNS &
SYMPTOMS
DIFFERENTIATINGOBJECTIVE FINDINGS
COMMONDIAGNOSTIC TEST
TREATMENT FOLLOW-UP
SeborrheicDermatitis
Chronic “dandruff”condition affectingmostly hairyregions.
Regional greasyscaling patches orplaques
• Chronic
• Waxing andwaning Sx
Superficial, greasy, flakypatch on scalp, eyebrows,face, chest, and groin
• Usually none indicated
• May have fungalcomponent
Topical:
Selenium sulfide shampoo(Selsun Blue) every day for2 weeks
F/U PRN.
Consider low-potency topicalsteroid cream;hydrocortisone1% if unimproved
Fungal
Tinea Capiti s
Fungal infection ofscalp.
Scaly patch onscalp
• Alopecia
• Pruritis of scalp
Round scaly patches withalopecia
Potassium hydroxide(KOH) preparationmicroscopic evaluation
Oral antifungal:
Refer to MO
Refer to MO
Tinea Corporis
Fungal infection offace, trunk, orextremities.
Scaly patch onbody
• “Ringworm”
• Pruritis of affectedarea
Annular, erythematous, scalypatch with central clearing
Potassium hydroxide(KOH) preparationmicroscopic evaluation
Anti fungal:
Clotrimazole 1% cream
F/U PRN
Tinea Cruris
Fungal infection ofgroin.
Scaly patch on
groin
• “Jock itch”
• Pruritis of groin
Sharply demarcated patch or
plaque with elevated, scalyborder (occasionally vesicularborder)
Potassium hydroxide
(KOH) preparationmicroscopic evaluation
Anti fungal: Clotrimazole
1% creamLoose-fitting under-clothesmay help
• F/U PRN.
• Considerbacterialerythrasma ifnot improving
Tinea Pedis
Fungal infection offoot.
Scaly patch on feet • “Athletes foot”
• Pruritis of foot/feet
Diffuse, not well- demarcatedscaly patches on sole or toewebs
Potassium hydroxide(KOH) preparationmicroscopic evaluation
Anti fungal: Clotrimazole1% cream and/or tolnaftate1% powder, solution, cream
Keep area dry, wear cleanand dry socks
F/U PRN
Tinea Unguium
Fungal infection ofnail.
Scaly nails “Onychomycosis” Nail exam: subungual scalydebris with yellowish nail
Potassium hydroxide(KOH) preparationmicroscopic evaluation
Oral antifungal:
Refer to MO
Refer to MO
Tinea Versicolor
Fungal infection ofthe skin.
Scaly patch onbody
• Finehypopigmentedsmall patches,usually multipleon trunk
• Mild pruritis ofaffected area
White, tan or pink patcheswith fine flaking border
Potassium hydroxide(KOH) preparationmicroscopic evaluation
Woods’ Lamp
Topical:
Selenium sulfide shampoo(Selsun Blue) every day for2 weeks.
F/U PRN
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20–DERMATOLOGICAL
CHIEF COMPLAINT: VESICULAR
CONDITION &
DEFINITION
KEY FEATURES DIFFERENTIATING SIGNS &
SYMPTOMS
DIFFERENTIATING
OBJECTIVE FINDINGS
COMMON
DIAGNOSTICTEST
TREATMENT FOLLOW-UP
Eczematous
Atopic Dermatit is
Recurrent eruptionsassociated withhistory of hay fever,asthma, dry skin oreczema.
• Papulovesicularpatch
• Pruritis isprominentsymptom
• Chronic history of same
• Scratching or oozing andcrusting may occur
Lichenified vesicularpatches with classicdistribution of flexuralarea of extremities
Usually noneindicated
Topical:
Hydrocortisone 1%cream
Antihistamine:
Hydroxyzine (Atarax) ordiphenhydramine(Benadryl) for itch
F/U if notimproved in 7days
Contact Dermatitis
Cutaneous reactionto irritant likechemical, product,metal, latex,clothing, soap,plant, etc.
• Papulovesicularpatch
• Severe pruritis.
Acute history of contact toexogenous plant, chemical ormetal; common offendingagents include poisonivy/oak/sumac
Wet, papulovesicularpatch with geometricoutline and sharpmargins
Usually noneindicated
Oral Steroid:
Prednisone (tapereddose)
Antihistamine:
Hydroxyzine (Atarax) ordiphenhydramine(Benadryl) for itch
F/U if notimproved in 7days
EczematousDermatitis orDyshidrosis
Recurrent eruptionsaffecting the handsand feet.
• Papulovesicularpatch
• Mild pruritis
Acute or chronic associatedwith excessive sweating,related to stress or irritation bynickel, chromate or cobalt
Papulovesicular patcheson hands or feet soles
(Some shoes havemetal that are causativeagent)
Usually noneindicated
Topical:
Hydrocortisone 1%cream
F/U PRN; usuallychronic; maydevelopsecondarybacterial infection
Infectious
Herpes Simplex
VirusRecurrent,incurable,contagious viraldisease. (see oraland genital)
Localized, grouped,
uniform lesion
• Acute or chronic. Primary
infection; fever, malaise,headache, regionaladenopathy.
• Recurrent lesions withprodrome of fever or localwarmth, burning, usually justprior to eruption
• Grouped “grape-like”
cluster of uniformvesicles that quicklybecome papules thatrupture & weep
• May be found on anybody location
• Usually recurs in samelocation
Tzanck Smear or
HSV antibody titers
Antiviral :
• Acyclovir (Zovirax) forbest results, take withfirst onset of Sx
• Good hygiene
• Patient education ontransmission. Condomuse if genital
IF not resolved in
14 days, contactMO for advice
Disease AlertReport requiredIF primary genitalinfection
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21–DERMATOLOGICAL
CHIEF COMPLAINT: VESICULAR (continued)
CONDITION &DEFINITION
KEY FEATURES DIFFERENTIATING SIGNS& SYMPTOMS
DIFFERENTIATINGOBJECTIVE FINDINGS
COMMONDIAGNOSTIC TEST
TREATMENT FOLLOW-UP
Infectious (cont)
Herpes Zoster
“Shingles” is alatent cutaneousvaricella virusinfection involving asingle dermatome Itis not infectious,though it may
cause primaryvaricella if notimmune.
Localized,unilateral, linear,dermatomal lesion
Acute prodrome of knife-likepain, pruritis prior to eruption;lesion lasting weeks tomonths with predominantcomplaint of pain
Groups of vesicles on anerythematous basesituated unilaterally alonga dematomal (nerve)distribution
Usually noneindicated
Antiviral:
Acyclovir (Zovirax)
Analgesic:
Acetaminophen ORibuprofen ORacetaminophen withcodeine (narcotic)
given short durationor as advised by MO
Lesion lasting weeksto months
Contact MO foradvice
Impetigo
Superficialcontagious skininfection caused by
Staphylococcusaureus, Group Abeta-hemolyticstreptococci orStreptoccusPyogenes
Localized crustedlesion
• Acute
• History of minor trauma toarea may be associatedwith disruption leading to
weeping lesion thatbecomes crusted
“Honey”-crusted lesionwith red base, usually onface, that may havemultiple new lesions
surrounding
Culture wound onthe advice of MO
Antibiot ic:
Dicloxacillin orcephalexin (Keflex)
Good hygiene
F/U if not improvedin 7 days
Smallpox
Highly contagious
and deadlyorthopox virus. Ithas beeneradicated throughaggressiveimmunizationprograms, thoughhas the potential foruse in bioterrorism.
Prodrome -regional
maculopapularrash
• Acute onset withoropharyngeal, facial, &
arm lesions spreading totrunk & legs
• Fever, headache,abdominal pain, vomiting,backache, & extrememalaise
After 1-2 days, cutaneouslesions become vesicular,
then pustular; unlikevaricella, all lesions are inthe same stage ofdevelopment on a givenbody part. After 8-9 daysall lesions becomecrusted.
Viral culture – notifylaboratory of
smallpox suspicion;highly contagious
Treatment isgenerally supportive,
with antibiotics forsecondary bacterialinfections. Antiviralshave never beenused clinically.
• CONTACT MOand Flight
Surgeon• Notify Command -
Disease AlertReport
• Be familiar withthe SVP.
http://www.smallpox.
army.mil/
http://www.smallpox/http://www.smallpox/
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22–DERMATOLOGICAL
CHIEF COMPLAINT: VESICULAR (continued)
CONDITION &
DEFINITION
KEY FEATURESDIFFERENTIATING
SIGNS & SYMPTOMS
DIFFERENTIATING
OBJECTIVE FINDINGS
COMMONDIAGNOSTIC
TEST
TREATMENT FOLLOW-UP
Infectious (cont)
Varicella
“Chickenpox” is ahighly contagiousviral disease,spread byrespiratory dropletsor direct contact.
Generalized maculesthat quickly develop topapules, rupture &crust
• Acute prodrome ofchills, fever, malaise,headache, sore throat,anorexia, dry cough
• Lesions first develop ontrunk, then to head andextremities
• Classic “crops” oflesions with newpapules developsimultaneously withruptured crusted lesions
• Pruritis
“Crops” of vesiclesdescribed as “dewdropon a rose petal” invarying stages ofdevelopment frommacules to papules tovesicles to crusted
lesions; first on trunk,then head andextremities
CBC otherwiseusually nothingindicated
Symptomatictreatment; Self-limiting though acourse of acyclovirmy shortenduration
Antiviral :
Acyclovir (Zovirax)
Bed rest
CONTACT MOfor advice
• Infectious from48 hoursbefore rash towhen alllesions crustedover
• Disease AlertReport required
• Heals withoutscar
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23–EENT
CHIEF COMPLAINT: RED EYE OR PAIN
CONDITION &
DEFINITION
KEY FEATURES DIFFERENTIATING
SIGNS & SYMPTOMS
DIFFERENTIATING
OBJECTIVE FINDINGS
COMMON
DIAGNOSTICTEST
TREATMENT FOLLOW-UP
Blepharitis
Inflammation of theeyelid by eitherseborrhea orstaphylococcalcause.
• Erythema of theeyelid margin
• Itchy, watery,burning sensation
SeborrheicBlepharitis: Dry flakesand oily secretion onthe lid margins
StaphyloccocalBlepharitis: Ulcerations
at base of eyelashesand photophobia
• Complete eye exam
• Erythema of lid marginthat may be ulcerated ifstaphylococcal infection
Usually noneindicated
• Clean eyelidmargin with babyshampoo (alsosee seborrheadermatitis)
• Forstaphylococcal:
Topicalophthalmic:Gentamycin ORerythromycinsolution/ointment
• No contact lensuse until resolved
F/U if not resolvedin 14 days
Chalazion
Non-infectious
meibomian glandocclusion causingswelling.
• Non-tendererythemicpapule of theeyelid
• Itchy, watery,burningsensation
Mild foreign bodysensation but usuallypainless
• Complete eye exam
• Swelling behind the lid
margin
Usually noneindicated
• Warm compressto promotedrainage 5-10minutes tid
• No contact lensuse until resolved
• No contact lensuse until resolved
F/U if not resolvedin 14 days
Chemical Bu rn toeye
Self explanatory.
• Erythema of theaffected part ofthe eye
• Itchy, watery,burningsensation
Determine causativeagent
• Complete eye exam
• Generalized erythema ofaffected area
• Assess for cornealabrasion with fluoresceinstain–epithelial defectshows brilliant green withfluorescent staining
• Usually noneindicated
• Fluoresceinstaining todetermineulceration orabrasion
• Immediateirrigation withcopious normalsaline for at least
10 minutes. Holdeyelid open.
• If alkali burn,irrigate for at least40 minutes andduring transport ifpossible
MEDEVAC
CONTACT MO orDuty FlightSurgeon
Emergencytransport toemergencydepartment orophthalmologistmust be considered
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24–EENT
CHIEF COMPLAINT: RED EYE OR PAIN (continued)
CONDITION &
DEFINITION
KEY FEATURES DIFFERENTIATING
SIGNS & SYMPTOMS
DIFFERENTIATING
OBJECTIVE FINDINGS
COMMON
DIAGNOSTIC TEST
TREATMENT FOLLOW-UP
Conjunctivitis, Al lergic
Inflammation of theconjunctiva.
• Erythema ofthe eyelid
• Bilateral Itchy,watery,burningsensation
• History of allergies,Rhinorrhea, itchy,watery eyes
• Seasonalenvironmentalconditions present
• Complete eye exam
• Different Palpebralconjunctiva withcobblestone-likeswelling
Usually noneindicated
Topical ophthalmic:
liquid tears
Oral Antihistamine:
Diphenhydramine(Benadryl), loratadine(Claritin), orFexofenadine(Allegra)
• Treat underlyingallergic symptoms
• No contact lensuse until resolved
F/U if notresolved in 14days
Conjunctivitis,Infectious
Contagious viral or
bacterial infection ofthe conjunctiva.
“Pink eye” refers tobacterial infection.
• Erythema ofthe eyelid
• Itchy, watery,
burningsensation
• Bacterial - may havehistory of inoculationor family memberwith “pink eye,”purulent dischargewith morningcrusting of lidmargin
• Viral – may haveassociated viralsymptoms withwatery discharge
• Complete eye exam
• Injected conjunctivaand margin edema
• Bacterial – crusteddischarge may or maynot be present
• Viral - may havepreauricularadenopathy
Usually noneindicated
Topical ophthalmic:
• Bacterial infection- Gentamicin OR
erythromycinsolution/ointment
• Viral infection –liquid tears
• Good hygiene
• No contact lensuse until resolved
F/U if notresolved in 7days
Corneal Abrasion
Breakdown in theepithelial barrier dueto an abrasive injuryor contact lenses.Most common eyeinjury.
Foreign body
sensation, tearing
• History of trauma or
contact lens irritation
• Severe pain andphotophobia
• Complete eye exam
• Consider tetracaine0.5% ophthalmicsolution to helpexamine eye
• Epithelial defect showsbrilliant green withfluorescein staining
Fluorescein staining
to confirm abrasion
Irrigation with normal
saline for at least 10minutes
Topical ophthalmic:
Gentamicin ORerythromycinsolution/ointment
• No contact lensuse until resolved
• Usually
resolves in 24hours
• If not resolvedin 24 hoursconsult MO
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25–EENT
CHIEF COMPLAINT: RED EYE OR PAIN (continued)
CONDITION &
DEFINITION
KEY FEATURES DIFFERENTIATING
SIGNS & SYMPTOMS
DIFFERENTIATING
OBJECTIVE FINDINGS
COMMON
DIAGNOSTIC TEST
TREATMENT FOLLOW-UP
Foreign Body oneye
Self explanatory
Foreign bodysensation, tearing
• History of trauma
• Mild to severe pain
• Photophobia
• Foreign bodysensation
• Tearing
• Complete eye exam
• Consider tetracaine0.5% ophthalmicsolution to helpexamine eye
• Foreign body may beimbedded andsometimes difficult to
find & may or may notcause abrasion
• Epithelial defect showsbrilliant green withfluorescein staining
Fluorescein stainingto determineabrasion
• Attempt tovisualize foreignbody and carefullyremove usingcotton-tip moistwith normal saline
• Irrigation withnormal saline for
at least 10minutes
• Topicalophthalmic: Entamicin ORerythromycinsolution/ointment
• No contact lensuse until resolved
• IF/U if notresolved in24 hours
• Reinforce eyeprotectionuse
Glaucoma
Closed-angleglaucoma is an acutedecreased outflow ofaqueous humorthrough pupil due toan anatomicallynarrow anteriorchamber increasing
intraocular pressure.(open-angle is a slowprogressive disease)
• Injectedconjunctivaand ocularpain
• May haveeyelid edema
• Acute blurredvision
• Frontal headache
• Lacrimation
• “Halos” aroundlights
• Possible nausea &vomiting
• Complete eye exam
• Increased intraocularpressure (IOP) to 50-65mmHg. IOP in uveitis isgenerally 35-45 mmHg
• Tonometry
• If no tonometry,red, painful eyewith visualhalos is‘warning’ sign
Emergency treatmentis required as theoptic nerve maybecome compressedby high intraocularpressure
• No contact lensuse until resolved
CONTACT MOor Duty FlightSurgeon
MEDEVAC
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26–EENT
CHIEF COMPLAINT: RED EYE OR PAIN (continued)
CONDITION &
DEFINITION
KEY FEATURES DIFFERENTIATING
SIGNS & SYMPTOMS
DIFFERENTIATING
OBJECTIVE FINDINGS
COMMON
DIAGNOSTICTEST
TREATMENT FOLLOW-UP
Hordeolum
Infection orinflammation ofeyelid hair follicleinternal or external(aka sty)
• Tendererythemicpapule oneyelid margin
• Itchy, watery,burningsensation
Sudden onset oflocalized tenderness oneyelid margin
• Complete eye exam
• Erythemic papule oneyelid margin
• Bacterial infection usuallyhas discharge in area
Usually noneindicated
• Warm compressto promotedrainage 5-10minutes tid
• No contact lensuse
• Bacterial infection:
gentamicin orerythromycinsolution/ointment
• No contact lensuse until resolved
F/U if notresolved in 7days
Hyphema
Blood in the anteriorchamber
May or may nothave erythema ofthe eyelid
• History of trauma orspontaneouspresentation
• Dull ache &
decreased vision
• Complete eye exam
• Blood in anteriorchamber, decreasedvisual acuity, intraocular
pressure may rise
Tonometry Think: concern forincreased intraocularpressure
Bed rest for 3-5 days
• No contact lensuse until resolved
CONTACT MOor Duty FlightSurgeon
Pinguecula
Benign ‘yellowish’colored lesion onbulbar conjunctivacaused by irritation
• Perceived asunsightly
• Asymptomatic
Eye irritation and patientconcern
• Complete eye exam
• Triangular, fleshy papuleover sclera/bulbarconjunctiva
Usually noneindicated
Reassurance
• No contact lensuse until resolved
• F/U PRN
• Consult withMO if in doubt
Pterygium
Benign ‘yellowish’colored lesionencroaching ontothe cornea causedby irritation
• Perceived asunsightly
• Asymptomatic
Eye irritation, visualchanges, & patientconcern
• Complete eye exam
• Triangular, fleshy growthof bulbar conjunctiva ontothe cornea; nasal side
Usually noneindicated
Reassurance
• No contact lensuse until resolved
• F/U PRN
• Consult withMO if indoubt. Referto optometristif change inacuity.
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27–EENT
CHIEF COMPLAINT: RED EYE OR PAIN (continued)
CONDITION &DEFINITION
KEY FEATURES DIFFERENTIATINGSIGNS & SYMPTOMS
DIFFERENTIATINGOBJECTIVE FINDINGS
COMMONDIAGNOSTIC TEST
TREATMENT FOLLOW-UP
Retinal Detachment
Self-explanatory. Thecause can be traumaor retinal tearcommon in highlymyopic [good near-sight (minus lens)]individuals
Decrease or lossof vision
• History of visualflashes of lights orsparks
• May be described asa “curtain falling” orcloudy or smoky infront of their eye
• Complete eye exam
• Detached retinaappears gray withwhite folds duringophthalmoscope exam
• Ophthalmoscope
• Tonometry
• Patch as directed
• Emergencytreatment isrequired
• No contact lensuse until resolved
CONTACT MOor Duty FlightSurgeon
MEDEVAC
SubconjunctivalHemorrhage
Blood under theconjunctiva
May or may nothave erythema ofthe eyelid
• Asymptomatic.
• History of venouspressure fromstraining
• Complete eye exam
• Blood under theconjunctiva may spillover into the lower lidmargin
Tonometry • No treatment isnecessary short oftreatment toassociated minortrauma if any.
• Treat underlyingillness if present
• No contact lensuse until resolved
F/U if notimproved in 14days
Uveitis
Acute inflammation ofthe uveal tract (iris,ciliary body andchoroids), increasingintraocular pressure
Injectedconjunctiva &ocular pain
• Acute blurred vision,deep ache & photo-phobia
• May have history oftrauma or inflam-matory condition
• Complete eye exam
• Dilated pupil, injectedflare along limbusborder
• Increased intraocularpressure to 35-45mmHg
• Tonometry
• If no tonometry, red,painful eye withphotophobia is‘warning’ sign.
Emergency treatmentis required as theoptic nerve maybecome compressedby high intraocularpressure
• No contact lensuse until resolved
CONTACT MOor FlightSurgeon
MEDEVAC
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28–EENT
CHIEF COMPLAINT: EARACHE
CONDITION &
DEFINITION
KEY FEATURES DIFFERENTIATING
SIGNS & SYMPTOMS
DIFFERENTIATING
OBJECTIVE FINDINGS
COMMON
DIAGNOSTIC TEST
TREATMENT FOLLOW-UP
Barotrauma
Ear pain or damagecaused by rapid changein pressure
Ear pain • History of trauma orrapid pressurechange
• Acute hearing loss
• Conductive hearing loss
• R/O TM perforation
• Weber or RinneTest
• Whisper test or Audiogram
• Self-limiting
• Decongestantor Valsalvamaneuver maybe helpful
F/U if notimproved in 7days
Cerumen Impaction
Cerumen is a natural
lubricant for the earcanal; accumulation ofcerumen can causeobstruction, thus hearingloss, tinnitus, andinfection.
• Ear pain and/orhearing loss
•
May beasymptomatic
• Bilateral or unilateralitchy sensation in earcanal
• Chronic Q-tip use inear canal causescerumen productionleading to impaction
TM not visible withirritated appearingexternal canal
Usually none indicated Emulsifying Agent :
Debrox• Ear irrigation
with warmsterile water
F/U if notimproved in 7day
Eustachian TubeDysfunction
ET equalized pressure inthe middle ear. Viralsymptoms and allergiesmay block tube withswelling.
Ear pain and/orhearing loss
Popping sensation inear
Normal TM Tympanometry.(normal peak thoughmay be diminished)
Decongestant:
Pseudoephedrine
F/U if notimproved in 7days
Mastoiditis
Infective process of themastoid air cells
Ear pain • History of recurrent orinadequate treat-mentof otitis media
• Feverish feeling
• Fever, bulging purulent& erythemic TM
• Postauricular edemaand tenderness
CBC & mastoidradiographs
Antibiot ics:
Ceftriaxone IV(Rocephen)
(consult with MOprior toadministering drug)
Emergencytreatment isrequired
CONTACT MOor Duty FlightSurgeon
MEDEVAC
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29–EENT
CHIEF COMPLAINT: EARACHE (continued)
CONDITION &
DEFINITION
KEY FEATURES DIFFERENTIATING
SIGNS & SYMPTOMS
DIFFERENTIATING
OBJECTIVE FINDINGS
COMMON
DIAGNOSTIC TEST
TREATMENT FOLLOW-UP
Otitis Externa
Infection of theexternal auditory canal
Ear pain • May have history ofswimming
• Itchy sensation inear canal
• May have otorrhea
• Tenderness with pinna‘tug’
• Edema and erythema ofexternal canal
• Normal TM
Usually none indicated Topical:
Corticosporin
F/U if notimproved in 7days;
R/OPseudamonas infectionwithpersistentsymptoms
Otitis Media
Infection of the middleear
Ear pain • History of viralsymptoms orEustachian tubedysfunction
• May have nasaldischarge, otorrhea,fever or dizziness
TM inflamed, non-mobile,bulging with decreasedlight reflex
Tympanometry Antibiot ics: Amoxicillin(Amoxil), orerythromycin(Emycin)
F/U if notimproved in 7days
Perforation ofTympanic Membrane
Self-explanatory
Ear pain andhearing loss
• History of trauma,
barotrauma, orinsertion of objectinto ear canal
• Bleeding from canal,hearing loss, tinnitus
TM perforated. Blood maybe present in canal
• Tympanometry
• Audiogram beforeand after treatment
• No specific
treatment• Keep ear dry
with ear plugsin shower
• No swimming
F/U if notimproved in 7days
Serous Otitis Media
Effusion of serousfluid in middle ear
Ear Pain • History of viral orallergy symptoms orEustachian tubedysfunction
• Popping sensationin ears
TM is relatively normal withfluid line or fluid bubblevisible
Tympanometry Decongestant:
Pseudoephedrine
F/U if notimproved in 7days
TemporomandibularJoint (TMJ)Syndrome
Pain in the TMJ thatmay be referred to theear; commonly causedby grinding of teeth
Ear or TMJ pain • Popping sensationin TMJ or ears
• Headache
• Normal ear exam
• May have tendernessand crepitus of TMJwith range of motiontest or mastication
Usually none indicated • Stressreduction maybe helpful
• Referral todental clinic
F/U PR
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30–EENT
CHIEF COMPLAINT: STUFFY NOSE
CONDITION &DEFINITION
KEY FEATURES DIFFERENTIATINGSIGNS & SYMPTOMS
DIFFERENTIATINGOBJECTIVE FINDINGS
COMMON DIAGNOSTICTEST
TREATMENT FOLLOW-UP
All ergic Rhini tis
Allergic response toairborne allergensaffecting the noseand eyes
• Nasalcongestion
• Seasonalallergiescommon in thespring whereperennialallergies maylast all year
• Watery, itchy eyesand nose, sneezing,clear nasal discharge
• Postnasal drip maycause cough
• Pale, boggyturbinates, conjunctivainjection
• May have dark circlesunder eyes
• Usually noneindicated
• CBC (eosinophilia)
• CT of sinus if Sxpersist
Antihistamine:
loratadine(Claritin), orfexofenadine(Allegra)
F/U PRN
Common Cold
Viral upperrespiratory infectionoccurring anytimeduring the year.(influenza is usuallyin winter months)
Nasal congestion. • General malaise andlow-grade fever
• Rhinorrhea, sorethroat, and cough
• Influenza has highfever with more acute& severe Sx
• Possible fever
• Nasal turbinate edemaand erythema withclear/white discharge
• Injected conjunctivaand throat
• Clear lungs
Usually none indicated Self limiting. Analgesic:
Acetaminophen oribuprofen
Decongestant:
Pseudoephedrineor combined withantihistamine
F/U if notimproved in7 days
Epistaxis
(Nosebleed):
• Anterior:Kiesselbach’splexus
• Posterior:posterior half ofroof of nasal
cavity• May be
idiopathic,traumatic ormedical cause
Stuffy nose • Bloody nose
• May have history ofaspirin or NSAID useor trauma
Bleeding from thenostril(s) and/or clot
Usually none indicated
• CBC
• CT of sinus if Sxpersist
Anter iorepistaxis:
Pinch nostrils forseveral minutes.Vasoconstrictorlike Afrin mayhelp.
Posteriorepistaxis: Pack
nostril withVaseline-coatedgauze
Refer foremergencyinterventionifunsuccessfulimmediatetreatment
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31–EENT
CHIEF COMPLAINT: STUFFY NOSE (continued)
CONDITION &DEFINITION
KEY FEATURES DIFFERENTIATINGSIGNS & SYMPTOMS
DIFFERENTIATINGOBJECTIVE FINDINGS
COMMONDIAGNOSTIC
TEST
TREATMENT FOLLOW-UP
Sinusitis
Inflammation orinfection of mucousmembranes ofparanasal sinus
Nasal congestion • Sinus pressure,facial pain orheadache
• May have yellow -green nasaldischarge, maxillarytoothache, fever ormalaise
• Turbinates areerythemic and swollen
• Face pain worse whenbending over (tilt test),sinus tenderness withpercussion
• May be unable to
transilluminate sinuses
• Usually noneindicated
• CT of sinus ifSx persist
• Reserveantibiotics forpatients that fail a7 day course ofdecongestantsand analgesics
• Antibiot ic: Amoxicillin-
clavulanate(Augmentin) orSeptra DS
F/U if notimproved in 7days orincreased feveror headache
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32–EENT
CHIEF COMPLAINT: SORE MOUTH/THROAT
CONDITION &
DEFINITION
KEY
FEATURES
DIFFERENTIATING
SIGNS & SYMPTOMS
DIFFERENTIATING
OBJECTIVE FINDINGS
COMMON
DIAGNOSTICTEST
TREATMENT FOLLOW-UP
Aphthous Ulcer
Mouth ulceration onbuccal mucosa referredto as “canker sore.”Cause is idiopathicthough may be related tostress or other moreserious condition ifrecurrent.
Mouth sore Painful ulcers White circular lesionssurrounded by anerythematous margin
Usually noneindicated
• OTC benzocainepreparations like
Anbesol andOragel
• Reassurance
• F/U PRN
• Refer to MO ifrecurrent
Epiglottitis
Inflammation andinfection of the epiglottis.More common inchildren.
Sore throat Fever, dysphagia,drooling, muffled voice,and may hold tripodposition (head forwardand tongue out)
• Inspiratory strider,cervical adenopathy
• Throat most likelyappears normal
• Do NOT use tongueblade to visualizethroat
• Blood culture
• Chest radiograph
• Throat cultureconducted ONLYin emergencyroom withtracheostomy kitavailable
Antibiot ics:
Ceftriaxone IV(Rocephen)
(consult with MOprior toadministering drug)
Emergencytreatment isrequired
CONTACT MO orDuty FlightSurgeon
MEDEVAC
Herpes Simplex Virus
Incurable, contagious,recurrent viral disease.HSV1 generallyassociated with oralsymptoms and HSV2genital symptoms thoughmay be mixed and notdistinguishable clinically.Referred to as “feverblister.” Recurrence maybe associated with sun-light, illness, or emotionalstress.
Mouth sore • May have prodromeof localized pain,warmth, burningusually just prior toirruption
• Occasional tenderadenopathy
• Headache, myalgia,or fever
• Primary infection maybe worst of Sx
• Primary infection:grouped “grape-likecluster of uniformvesicles onerythematous base;
lesions erode andcrust, last 2 to 6weeks
• Recurrent Infection:same as abovethough domeshaped lesionsrupture and crustlasting about 8 days
Tzanck Smear orHSV antibody titers
Antiviral:
Acyclovir (Zovirax)For best results,take with first onsetof Sx
• Patienteducation ontransmission
• Condom use ifgenital
• IF not resolvedin 14 dayscontact MO foradvice
• Disease AlertReport requiredIF primarygenital infectiononly
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36–CARDIOVASCULAR
CHIEF COMPLAINT: CHEST PAIN (continued)
CONDITION &
DEFINITION
KEY FEATURES DIFFERENTIATING
SIGNS & SYMPTOMS
DIFFERENTIATING
OBJECTIVEFINDINGS
COMMON
DIAGNOSTIC TEST
TREATMENT FOLLOW-UP
Cardiac (continued)
Pericarditis
Inflammation of thepericardium(fibroserous sacsurrounding theheart)
Acute onset ofchest pain
O – acute
P – relieved by leaningforward and sitting up
Q – dull, tight, pressing
R – substernal ache,radiating to back orshoulders
S – severe to vague
T – may have recent viralsyndrome
Shortness of breath,nausea, diaphoresis, &weakness may beassociated
• Appears anxious,diaphoretic, pallor,dyspnea
• Assess vitals,febrile, “friction rub”heart sound,
adventitious lungsounds
• ECG may haveST-segment“concave”elevation in mostleads creating a“smile face”
• CBC and Chestradiograph
Analgesics:
• Aspirin oribuprofen
• Oxygen PRN
• Comfortable rest.
• Emergencytreatment may benecessary
CONTACT MOor Duty FlightSurgeon.
• ConsiderMEDEVACas MI cannot
be ruled out
Non-Cardiac
Anxiety
Excessive worry,fear, nervousness,and hypervigilance.May be associatedwith adjustmentdisorder orgeneralized.
Chest pain may beassociated withstress or panicattack
Physical complaintsprompt patient to seekmedical attention; worry,insomnia, muscle tension,headache, fatigue, GIupset.
• Appears anxious,diaphoretic, pallor,dyspnea
• Mental healthinterview
• Assess vitals andR/O cardiac
involvement
• ECG is normal
• Objective AnxietyQuestionnaire.(Beck’s)
Acute Tx:
Antianxiety:hydroxyzine (Atarax)OR diazepam(Valium)
Chronic Tx:
Refer to MO
CONTACT MOor Duty FlightSurgeon IFdoubt
Costochondritis
“Tietze’s disease”is an inflammationof the rib cartilage/ligament/muscles.
Chest pain isexacerbated bycough or deepbreathing
History of physicalexertion or trauma tochest or ribs
Direct palpable chestwall tenderness ofcostochondralligament/muscle
ECG is normal Analgesics: Acetaminophen oribuprofen
Reassurance
CONTACT MOor Duty FlightSurgeon IFdoubt
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37–CARDIOVASCULAR
CHIEF COMPLAINT: CHEST PAIN (continued)
CONDITION &DEFINITION
KEY FEATURES DIFFERENTIATINGSIGNS & SYMPTOMS
DIFFERENTIATINGOBJECTIVE FINDINGS
COMMONDIAGNOSTIC TEST
TREATMENT FOLLOW-UP
Non-Cardiac (continued)GastroesophagealReflux Disease
Irritation caused byreflux of gastricsecretions into theespophagus (i.e.GERD). Excessiveuse of tobacco,alcohol, &
caffeinated productscan be contributingfactors
Chest pain andnausea may beassociated withmeal, exercise, orpatient restingsupine
• Epigastric “heartburn”
• Regurgitation causingbitter taste
• Symptoms relieved bysitting up or antacids
• May have naggingcough
• May have normalexam findings
• Assess for epigastrictenderness
• ECG is normal
• Antigen/antibodyfor H. pylori
Acute Tx:
H2 Inhibitor:Ranitidine (Zantac)
For chronic Tx orH. pylori refer toMO
CONTACT MO orDuty FlightSurgeon IF doubt
Pleuritis
Viral infectioncausinginflammation of thepleurae sacsurrounding the
lungs
Chest pain • Marked sharpstabbing pain withrespiration
• May have recent viralsyndrome
• Febrile
• Friction fremitus withrespiratory sounds
• ECG is normal
• Chestradiographs
Analgesics:
Aspirin or ibuprofen
• F/U if notimproved in 7days
• Consult withMO PRN
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38–CARDIOVASCULAR
CHIEF COMPLAINT: SYNCOPE
CONDITION &DEFINITION
KEY FEATURES DIFFERENTIATINGSIGNS & SYMPTOMS
DIFFERENTIATINGOBJECTIVE FINDINGS
COMMONDIAGNOSTIC TEST
TREATMENT FOLLOW-UP
Arrhythmia
Rhythm is just that;regular, coordinatedelectrical impulses.
Arrhythmia is loss ofheart rhythm, eithera regular or irregularabnormality.
Transient, suddenloss of conscious-ness that resolvesspontaneously
• May have history ofarrhythmia andfainting
• Palpitations andlightheadednessmay precedesyncope
• Age usually greaterthen 50
• Appears anxious,diaphoretic, pallor,dyspnea or normal
• Complete physicalexamination
• Orthostatic bloodpressure
• ECG is indicatedbut may benormal at time ofexam
• Refer to MO
• Evaluateurgency of case
CONTACT MO orDuty FlightSurgeon IF doubtor abnormal ECG
OrthostaticHypotension
Benign failure ofnormalcompensation forblood pressure dropreducing blood flowto brain due to
dehydration
Vasovagal syncope has similar endresult with differentmechanism of action
Transient, suddenloss of conscious-ness that resolvesspontaneously
• Brought on bydehydrationsecondary tovomiting, diarrhea,bleeding, diureticmedication,emotional stress,warm environment
• Palpitations andlightheadednessmay precedesyncope
• Appears anxious,diaphoretic, pallor,dyspnea or normal
• Complete physicalexamination
• Orthostatic bloodpressure
• ECG is indicatedbut may benormal at time ofexam
• Electrolyte
imbalance cancause ECGchanges
IV – NS or oral fluidreplenishment
CONTACT MO orDuty FlightSurgeon IF doubtor abnormal ECG
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39–CARDIOVASCULAR
CHIEF COMPLAINT: SYNCOPE (continued)
CONDITION &DEFINITION
KEY FEATURES DIFFERENTIATINGSIGNS & SYMPTOMS
DIFFERENTIATINGOBJECTIVE FINDINGS
COMMONDIAGNOSTIC TEST
TREATMENT FOLLOW-UP
Seizure
Paroxysmal hyperexcitation of theneurons in the brain;epilepsy is chronicrecurrent seizures
Compromisedmotor activity
• Partial Seizure – noloss ofconsciousness,though simple musclecontractions,paresthesias, loss ofbowel & bladder
• Petit Mal Seizure –sudden stopping of
motor function withblank stare
• Grand Mal Seizure –loss ofconsciousness, tonic-clonic musclecontractions, loss ofbowel & bladder;postictal period
Between seizuresphysical exam is normalthough may havebruising or trauma totongue just after
• CBC
• Chemical Panel
• Urinalysis
• Drug & alcoholscreening
• CT scan or MRI
• During seizure,maintain airwayand preventinjury
• Refer to MO
Seizure > 10minutes needsemergencyintervention!
Consult with MO orFlight Surgeon
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40–CARDIOVASCULAR
CHIEF COMPLAINT: VASCULAR SYMPTOMS
CONDITION &DEFINITION
KEY FEATURES DIFFERENTIATINGSIGNS & SYMPTOMS
DIFFERENTIATINGOBJECTIVE FINDINGS
COMMONDIAGNOSTIC TEST
TREATMENT FOLLOW-UP
Deep VeinThrombosis
Blood clot(s) in thecalf or femoral veinsresulting ininflammation
(e.g., DVT)
Leg pain Limb pain and swelling Calf tendernessswelling with increaseddiameter (notedifference betweenunaffected calf)
Positive Homan’ssign
• Support hose
• Refer to MO
• Evaluateurgency of case
CONTACT MO orDuty FlightSurgeon
Raynaud’s Disease
Vasospasm of thevessels of the digitsin response to coldor stress
Hand pain • Fingertips turnmottled white andred then cyanotic
• Tobacco useexacerbates Sx
• Normal examinationbetween attacks
• Cold challenge testwill reproduce Sx
Cold challenge test Caution patientabout coldexposure and tostop tobacco use
Refer to MO
Varicose Veins
Superficial veinswith incompetentvalves cause dilationof veins
Burning sensationand unsightlydiscoloration at site
Patient concern mostlyabout appearancethough extensive
varicosities haveconstant dull ache
Dilated, tortuous veinsof the medial anteriorankle, calf or thigh
Usually nothingindicated
Avoid prolongedstanding, and usesupport hose PRN
Refer to MO PRN
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41–RESPIRATORY
CHIEF COMPLAINT: COUGH
CONDITION &
DEFINITION
KEY FEATURES DIFFERENTIATING
SIGNS & SYMPTOMS
DIFFERENTIATING
OBJECTIVE FINDINGS
COMMON
DIAGNOSTIC TEST
TREATMENT FOLLOW-UP
Acu te
Bronchitis,Mycoplasma
Inflammatorycondition of thetracheobronchialtree caused by
mycoplasmpneumoniae (non-bacterial)
Non-productive,recurrent, barkingcough early, thenbecomesproductive
• Severe cough withpurulent sputumlate
• Sx persist for > 2weeks
• Fever, fatigue, and
possiblehemoptysis
• Low-grade fever
• Lung sounds: coarserhonchi and possiblyrales
Chest radiograph Cough suppressionwith expectorant:
Robitussin DM
Antibiot ic:
Erythomycin (E-Mycin)or Bactrim DS
Bed rest
F/U if notimproved in 7days
Bronchitis, Viral
Inflammatorycondition of thetracheobronchialtree caused by virus
Non-productive,recurrent, barkingcough
• Scant white to clearsputum
• May or may nothave fever
• Sx usually 7-10
days• Common in
smokers
Lung sounds: coarserhonchi and possiblyrales
Chest radiograph Cough suppressionwith expectorant:
Robitussin DM
F/U if notimproved in 7days
Influenza
“Flu” is a viralinfection that affectsthe nasopharynx,conjunctiva, and
respiratory tract,usually in wintermonths.
(common coldoccurs anytimeduring the year)
Non-productiveacute cough,usually worse atnight
Abrupt onset ofnonproductive coughwith high fever,malaise, headache,Rhinorrhea, sore throat,
& conjunctivitis
(Common cold has low-grade fever with lesssevere Sx and may notbe seasonal)
• High fever
• Nasal turbinateedema & erythemawith clear/whitedischarge
• Injected conjunctiveand throat. Clearlungs.
Chest radiograph Analgesic:
Acetaminophen oribuprophen
Cough suppressionwith expectorant:
Robitussin DM
• Self limiting
• Annual influenzavaccine
F/U if notimproved in 7days
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42–RESPIRATORY
CHIEF COMPLAINT: COUGH (cont inued)
CONDITION &DEFINITION
KEY FEATURES DIFFERENTIATINGSIGNS & SYMPTOMS
DIFFERENTIATINGOBJECTIVE FINDINGS
COMMONDIAGNOSTIC TEST
TREATMENT FOLLOW-UP
Acu te (cont inued)
Pneumonia,Bacterial
“Communityacquired”(outsidehospital/nursinghome) bacterialinfection of thelung
Streptococcuspneumoniae
• Productive,severe coughwith copiouspurulent sputum
• Usually worse atnight
• High fever
• Dark, thick, rustysputum
• Tachypnea, shakingchills, tachycardia,malaise, confusion
• Appears ill
• Febrile >100F/37.8C
• Pulse > 100
• Lung sounds: ralesand whispered
pectoriloquy
• Assessbronchophony &egophony
• Chest radiographwith lobarconsolidation
• Pulse Ox
• CBC
Note: Repeat chest x-ray in 4-6 weeks
Antibiot ic:
Ceftriaxone (Rocephin)Plus azithromycin(Zithromax)
Analgesic:
Acetaminophen or
ibuprofenCough suppressionwith expectorant:
Robitussin DM or withcodeine
• Consider oxygenand IV – NS
• Bed rest
CONTACT MO orDuty FlightSurgeon
Pneumonia,Mycoplasma
Atypicalpneumonia,“walkingpneumonia” is aninfection of thelung morecommon in the
summer monthsand in youngadults.
Mycoplasmapneumoniae
Non-productive, drycough
• Mild symptoms,sore throat, low-grade fever, sorethroat & malaise
• Headache usuallyalways present
• May appear ill
• Erythematous throat,fluid-line or bubblesbehind TM
• Lung sound: pleuralfriction rub
• Chest radiographwith bilateralpleural effusion
• Pulse Ox
• Consider RapidStrep & MonoSpot if sore throatsevere
Antibiot ic:
Azithromycin(Zithromax) orerythromycin (E-Mycin)
Analgesic:
Acetaminophen oribuprofen
Cough suppression
with expectorant:Robitussin DM or withcodeine
Bed rest
F/U if notimproved in 7days
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43–RESPIRATORY
CHIEF COMPLAINT: COUGH (cont inued)
CONDITION &
DEFINITION
KEY FEATURES DIFFERENTIATING
SIGNS & SYMPTOMS
DIFFERENTIATING
OBJECTIVE FINDINGS
COMMON
DIAGNOSTIC TEST
TREATMENT FOLLOW-UP
Acu te (cont inued)
Pneumonia, Viral
Viral infection ofthe lungs withrecent history ofcommon cold orinfluenza
Productive, mildcough
• Severe cough withwhite to clearsputum
• Fever & fatigue
• Recent history ofupper respiratory
viral illness
• Fever
• Tachycardia
• Usually has cervicaladenopathy
• Lung sounds: rales or
pleural friction rub
• Chest radiographwith peribronchialthickening andbilateral sparsinfiltrate
• Pulse Ox
Analgesic:
Acetaminophen oribuprophen
Coughsuppression withexpectorant:
Robitussin DM.
Bed rest
F/U if notimproved in 7days
Chronic
ChronicObstructivePulmonaryDisease
Permanent dilationand destruction ofthe alveolar ductsand bronchicaused by chroniclung irritation seenin ages > 40(occupational,cigarette smoking,or alpha1-
antirypsindeficiency)
Chronic coughingwith scant sputum
• Weight loss &dyspnea
• History of recurrent
bronchial infections
• Respiratory effort anduse of accessorymuscles, barrelchest, pursed lipbreathing
• Clubbing of fingers
• Change in weight
• Pulse Ox
• Peek flow beforeand after treatment
Bronchodilator:
Nebulized albuterol
Oxygen NC
CONTACT MOor Duty FlightSurgeon ifdoubt
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44–RESPIRATORY
CHIEF COMPLAINT: COUGH (cont inued)
CONDITION &DEFINITION
KEY FEATURES DIFFERENTIATINGSIGNS & SYMPTOMS
DIFFERENTIATINGOBJECTIVE FINDINGS
COMMONDIAGNOSTIC TEST
TREATMENT FOLLOW-UP
Chronic (continued)
GastroesophagealReflux Disease(GERD)
Irritation caused byreflux of gastricsecretions into theesophagus
Chronic, mildnagging cough andnausea
• Epigastric‘heartburn’
• Regurgitationcausing bitter taste
• Symptoms relievedby sitting up or
antacids• May have chest pain
• May have normalexam findings
• Assess forepigastrictenderness
• Complete HEENT,
CV, Respiratory, &GI Exam
• Antigen/antibodyfor H. pylori
• ECG is normal
Acute Tx:
H2 Inhibitor:Ranitidine (Zantac)
• For chronic Tx or H.pylori refer to MO
CONTACT MOor Duty FlightSurgeon IFdoubt
Tuberculosis “TB” is primarily alung infectioncaused by inhalationof tubercle bacillifrom close contact
with actively infectedperson
Chronic cough • Productive yellow/green sputum thatprogresses
• Prominent featuresare chronic “notfeeling well” with
drenching nightsweats
• Hemoptysis is lateSx
• History of closecontact with infectedperson
Lung sounds: rales inupper lobes withwhispered pectoriloquy
• PPD (PPDconverter doesnot necessarilymean activedisease (may bepast exposure),
though all withactive disease arepositive)
• CBC
• Sputum culturewith acid-fastsmear x 3 (culturetakes 3-6 wks)
• Chest radiograph:multi-noduleinfiltrate in apicallobe and hilaradenopathy
• Multi drug therapyis required
• Direct observationtherapyrecommended
• Consult with MO.
CONTACT MOor Duty FlightSurgeon
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45–RESPIRATORY
CHIEF COMPLAINT: DIFFICULT BREATHING
CONDITION &
DEFINITION
KEY FEATURES DIFFERENTIATING
SIGNS & SYMPTOMS
DIFFERENTIATING
OBJECTIVE FINDINGS
COMMON
DIAGNOSTIC TEST
TREATMENT FOLLOW-UP
Anaphylax is
Immune hyper-sensitivity reactionto an antigen(insect, food,medication)
IgE mediated
Acute laboredtachypnea, cough,and wheeze
• History of exposure
• May have Urticariaand angioedema ofthe face withcyanosis
• Obvious distressrequiring immediatecare
• ABCs fi rs t
• Lung sounds:rhonchi and wheeze
• Vitals: hypotension
•
Complete HEENT,CV, respiratory, skinexam
• Pulse Ox
• Peak Flow beforeand after Tx
Bronchodilator:
Epinephrine 1:10000.3 to 0.5 mg IM and
Nebulized albuterol;
oxygen, IV – NS
Antihistamine: Diphenhydramine(Benadryl)
Oral steroid: Prednisone may beindicated to preventrecurrence
CONTACT MO orDuty FlightSurgeon
• IF reaction tovaccine,completeVAERS Report
Asthma
Disorder of thetracheobronchialtree with reversibleairway obstruction(bronchospasmwith inflammatoryprocess)
Acute laboredtachypnea, cough,and wheeze
• History of asthma
• Prolongedexpiratory wheeze
brought on byexposure trigger
• May have cyanosis
• Obvious distressrequiring immediatecare
•
ABCs fi rs t • Lung sounds:
expiratory wheeze
• Pulse Ox
• Peak Flow beforeand after Tx
Bronchodilator:
Epinephrine 1:10000.3 to 0.5 mg IM and
Nebulized albuterol;oxygen, IV – NS
Oral steroid: Prednisone may beindicated to preventrecurrence
CONTACT MO orDuty FlightSurgeon
Pneumothorax,Spontaneous
Sudden collapseof lung mostcommon in young,tall, thin men(primary) orpersons whosmoke(secondary)
• Acute laboredtachypnea,
cough, andwheeze
• Sx may besubtle
• History of smoking,vigorous exercises
• Sharp chestdiscomfort that isworse withbreathing
• Asymmetrical chestmovements and
decreased lungsounds
• Just listening to thelungs makes the Dx
• Pulse Ox
• Chest radiograph
• Oxygen
• Emergency
treatment isrequired
CONTACT MO orDuty Flight
SurgeonMEDEVAC
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46–RESPIRATORY
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CHIEF COMPLAINT: ABDOMINAL PAIN
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47–GASTROINTESTINAL
CONDITION &DEFINITION
KEY FEATURES DIFFERENTIATINGSIGNS & SYMPTOMS
DIFFERENTIATINGOBJECTIVE FINDINGS
COMMONDIAGNOSTIC TEST
TREATMENT FOLLOW-UP
Appendici tis Acute inflammationof the vermiformappendix
Nausea, vomiting,constipation & fever•
Early, colicky toconstant pain inepigastrium orperiumbilical; RLQlater
• Vomiting after pain& pain worse withmovement
•
RLQ involuntaryguarding
• RLQ reboundtenderness; painmay be referred(Rovsing’s sign)
• Pain withpsoas/obturatormaneuver (Psoas –Obturator sign)
•
CBC• UA
•
Prompt referralto ER or directhospitaladmission
• Emergencytreatment isrequired
CONTACT MO orDuty FlightSurgeon
MEDEVAC
Cholecystitis
Acute inflammationof the gallbladder
Nausea, vomiting,loose stool, andfever
• Colicky to constantpain at RUQ toinferior angle ofright scapula
• Brought on by fattyfoods. Morecommon infemales
• May have dark
urine, light stool,and/or jaundice
RUQ tender with deeppalpation duringinspiration (Murphy’sSign)
• CBC
• UA
• LFT
• Gallbladderultrasound
Prompt referral toER or directhospital admission
CONTACT MO orDuty FlightSurgeon
MEDEVAC
Constipation(symptom)
Difficulty passingstool or diminishedfrequency ofdefecation. May besymptom of otherconditions
Nausea • Diffuse cramps
• Difficulty expellingfeces; less frequentdefecation thennormal for patient
• Abdomen bloatedand tender
• Hyperactive bowlsounds
• Labs directedtowards cause
• MO mayrecommendrectal exam foroccult blooddetection
Stool so ftener: Docusate sodium(Colase)
• Increase waterintake
• Increase dietary
fiber AFTERrelief of Sx
• F/U if notimproved in 24hours
• Consult withMO PRN
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48–GASTROINTESTINAL
CHIEF COMPLAINT: ABDOMINAL PAIN (cont inued)
CONDITION &DEFINITION
KEY FEATURES DIFFERENTIATINGSIGNS & SYMPTOMS
DIFFERENTIATINGOBJECTIVE FINDINGS
COMMONDIAGNOSTIC TEST
TREATMENT FOLLOW-UP
Diarrhea (symptom)
Acute diarrhea isabnormal andincreasedfrequency andliquid stoolconsistency.
May be symptom of
other conditions.Symptoms lasting> 2 weeks =chronic diarrhea.
Nausea, vomiting,fever
• Diffuse cramps
• Abnormal andincreasedfrequency andliquid stoolconsistency
• Diffuse, abdominaltender
• May have poor skinturgor indicatingdehydration
• CBC
• UA
• Stool culture andova/parasite maybe indicated
• MO mayrecommend rectalexam for occult
blood detection
Antidiarrheal :
Loperamide(Immodium)
Antibiot ics may beindicated
• Increase waterintake; considerIV normal saline if
dehydrated
• NO solids x 24hours thenBRATS diet x 24hours
• Consider cause
F/U if notimproved in 72hours or chronicsymptoms,CONTACT MOand or DutyFlight Surgeon.
Diverticulitis
Inflamed diverticula(outpouchings ofthe mucosathrough themuscular wall ofthe intestine)
Nausea, vomiting,fever, anorexia, andconstipation ordiarrhea
Intermittent chronicpain, usually LLQ
LLQ tenderness,tympanic sound onpercussion
• CBC
• UA• MO may
recommend rectalexam for occultblood detection
Bowel spasm relief: Dicyclomine (Bentyl)
Antibiot ic : Metronidazole(Flagyl) PLUSciprofloxacin (Cipro)
CONTACT MOor Duty FlightSurgeon
Food Poisoning
Bacterial causefrom contaminatedfood
• Nausea
• Vomiting
• Fever• Diarrhea
• Onset of nausea,vomiting & diarrheawithin 12–24 hours
of eating
• Diffuse cramps
• Diffuse abdominaltender
•
May have poor skinturgor indicatingdehydration
• CBC
• Stool culture may
be indicated• MO may
recommend rectalexam for occultblood detection
Antibiot ic : Ciprofloxacin (Cipro)
•
Increase waterintake; considerIV normal saline ifdehydrated
• NO solids x 24hours thenBRATS diet x 24hours
F/U if notimproved in 24hours
CHIEF COMPLAINT: ABDOMINAL PAIN (cont inued)
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49–GASTROINTESTINAL
CHIEF COMPLAINT: ABDOMINAL PAIN (cont inued)
CONDITION &DEFINITION
KEY FEATURES DIFFERENTIATINGSIGNS & SYMPTOMS
DIFFERENTIATINGOBJECTIVE FINDINGS
COMMONDIAGNOSTIC TEST
TREATMENT FOLLOW-UP
Gastroenteritis, Acu te
Viral cause ofvomiting anddia