Family Medicine Excellent Differential Diagnosis Listing

8/12/2019 Family Medicine Excellent Differential Diagnosis Listing

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TABLE OF CONTENTS



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



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



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



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.




DERMATOLOGICAL

CHIEFCOMPLAINT

CONDITION HS3 Post‘A’ School

HS2 IDHS ‘C’School

Anthrax (cutaneous) A J M

Cellulitis A J M

Drug Reaction A J M

Furuncle A J M

Urticaria A J M

Erythema

Viral Exanthemas(measles, mumps,rubella)

A M

MolluscumContagiosum

A MGrowths

Wart (common) A J M

Acne Vulgaris A

J M

Insect bite/sting(nonvenomous)

A M

Miliaria A M

Pseudofolliculitis,Barbae

A M

Inflammatory

Scabies A M

Candidiasis(oral) A M

Pityriasis Rosea A M

Psoriasis A M

Seborrheic Dermatitis A M

Tinea Capitis A M

Tinea Corporis A J M

Tinea Cruris A J M

Tinea Pedis A J M

Tinea Unguium A M

Scaly

Tinea Versicolor A J M

DERMATOLOGICAL, Continued

CHIEFCOMPLAINT



Atopic Dermatitis A J M

Contact Dermatitis A J M

Eczema (dyshidrosis) A J M

Herpes Simplex Virus A M

Herpes Zoster A J M

Impetigo A M

Smallpox A J M

Vesicular

Varicella (chickenpox) A J M




EYES, EARS, NOSE, AND THROAT

CHIEFCOMPLAINT



Blepharitis A J M

Chalazion A M

Chemical Burn A M

Conjunctivitis, Allergic A J M

Conjunctivitis, Infectious A J M

Corneal Abrasion A J M

Foreign Body A M

Glaucoma A M

Hordeolum A J M

Hyphema A J M

Pinguecula A M

Pterygium A M

Retinal Detachment A M

SubconjunctivalHemorrhage

A J M

Red Eye

Uveitis A M

Barotrauma A M

Cerumen Impaction A J M

Eustachian Tube

Dysfunction

A J M

Mastoiditis A M

Otitis Externa A J M

Otitis Media A J M

Perforation A J M

Earache

Serous Otitis Media A J M

EYES, EARS, NOSE, AND THROAT, Conti nued

CHIEFCOMPLAINT



Earache,continued

Temporomandibular JointSyndrome

A M

Allergic Rhinitis A J M

Common Cold A J M

Epistaxis A J M

Stuffy Nose

Sinusitis A J M

Aphthous Ulcer A J M

Epiglottitis A M

Herpes Simplex Virus A M

Laryngitis A M

Mononucleosis A M

Peritonsillar Abscess A M

Pharyngitis, Bacterial A J M

Pharyngitis, Viral A J M

Sore Throat

Salivary Stone A M




CARDIOVASCULAR

CHIEFCOMPLAINT



Acute CoronarySyndrome (ACS)

A J M

Angina Pectoris A J M

Cardiac ChestPain

Pericarditis A M

Anxiety (see Mental

Health–Feeling Downor Worried)

A M

Costochondritis A J M

GastroesophagealReflux Disease(GERD– seeRespiratory–ChronicCough)

A J M

Non-CardiacChest Pain

Pleuritis A

J M

Arrhythmia A M

OrthostaticHypotension

A M

Syncope

Seizure (seeNeurological –AlteredMental Status)

A M

Deep Vein Thrombosis A M

Raynaud’s Disease A M Vascular

Varicose Veins A M

RESPIRATORY

CHIEFCOMPLAINT



Bronchitis,Mycoplasma

A M

Bronchitis, Viral A J M

Influenza A J M

Pneumonia, Bacterial A J M

Pneumonia,Mycoplasma

A J M

Acute Cough

Pneumonia, Viral A J M

Chronic ObstructivePulmonary Disease

A M

GastroesophagealReflux Disease

A J M

ChronicCough

Tuberculosis A J M

Anaphylaxis A J M

Asthma A J M DifficultBreathing

Pneumothorax,Spontaneous

A M




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




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




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




MENTAL HEALTH

CHIEF

COMPLAINT

CONDITION HS3 Post

‘A’School

HS2 IDHS ‘C’

School

Adjustment Disorder A M

Anxiety A M

Depression A M

Feeling Down orWorried

Suicidal Ideation A M




This page is intentionally blank.



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



14–DERMATOLOGICAL

CHIEF COMPLAINT: ERYTHEMA (continued)

CONDITION &

DEFINITION

KEY FEATURES DIFFERENTIATING

SIGNS & SYMPTOMS

DIFFERENTIATING

OBJECTIVE FINDINGS

COMMON

DIAGNOSTIC TEST

TREATMENT FOLLOW-UP

Furuncle

Pus-filled masscaused bystaphylococcusaureus or MRSA

• Localized erythema

• Fever is rare

Papule or nodule, firmor fluctuant; painful andwarm to touch

• Localized red (rubor)

• Tender (dolor)

• Warm (calor)

• Papule or nodule(tumor)


• Culture lesion

• CBC.

• Patient contactsmay also becontaminated withMRSA

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

• Incise and drain iffluctuant lesion

• Large wound mayrequire Iodoform

packing – repackdaily or PRN

• F/U Every24 hoursuntilresolved

• If NOTresolved in7 days orsevere,

contact MO

Urticaria

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

are unknown.

Generalized, confluent,pruritic maculopapularrash

• Recent history ofingestion of drug orfood associated withgeneralized rash

• Ask about over-the-counter or herb use

• Aspirin (salicylate) ismost common cause

• General distribution ofwheals or hives inpatches

• Respiratory distress

Usually noneindicated

Antihistamine:

Hydroxyzine (Atarax) ordiphenhydramine(Benadryl)

• Avoid cause

• Respiratory distress

will need emergenttreatment (seeanaphylaxis)

F/U PRN.

Chronicconditionsrefer to MO



15–DERMATOLOGICAL

CHIEF COMPLAINT: ERYTHEMA (continued)

CONDITION &

DEFINITION


SIGNS & SYMPTOMS

DIFFERENTIATING

OBJECTIVE FINDINGS

COMMON

DIAGNOSTIC TEST

TREATMENT FOLLOW-UP

Viral Exanthemas

Measles, mumps,and rubella arecontagious viraldiseases

• Generalized orregional erythemicmaculopapular rash

• May have fever,malaise, myalgia,headache andlymphadenopathy

Measles

• Coryza

• Cough

• Conjunctivitis

• Koplik’s Spots (white)on bucal mucosa

•

Rash spreads fromface to trunk andextremities

Mumps

• Parotid gland pain andswelling, 15% withmeningeal signs

• Maculopapular rashless common

Rubella

• Childhood disease

• Petechiae of softpalate

• Rosy red oval or roundmacules

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

• Skin exam: asdescribed by history


• Complete HEENT, CVand respiratory exams

• CBC

• R/OMononucleosis

Antipyret ic: Acetaminophen

• Otherwise,symptomatic Tx

• Ensure MMRvaccination is up-to-date

If not improvedin 7 days,consult with MOPRN



16–DERMATOLOGICAL

CHIEF COMPLAINT: GROWTHS

CONDITION &

DEFINITION


SIGNS & SYMPTOMS

DIFFERENTIATING

OBJECTIVE FINDINGS

COMMON

DIAGNOSTIC TEST

TREATMENT FOLLOW-UP

MolluscumContagiosum

• Contagious viraldisease

• In children it istransmitted fromfomites

• In adults it is

transmitted fromfomites, butprimarily sexuallyor intimate contact

Individual orgrouped papules

Usually an incidental andasymptomatic finding bythe patient

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

• The lesions are firmand centrallyumbilicated

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

• BCC usually havetelangiectasia andusually found on face

• Self limiting inmost cases

• Cryotherapy orcantharidinapplication maybe indicated

• Good hygiene

• Condom use if

genital

F/U PRN

Wart, common

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

direct contact; humanpapilloma virus

Individual papule

(also see genitalwarts)

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

black dots• No skin lines through

lesion as corns do

“Cauliflower” flesh-colored papules thatbecome dome- shapedgrowths

Usually nothingindicated

• Self limiting inmost cases

• Cryotherapy orsalicylic acid

patch

• F/U PRN.

• Therapy mayrequirerepeated

applicationevery twoweeks



17–DERMATOLOGICAL

CHIEF COMPLAINT: INFLAMMATORY

CONDITION &

DEFINITION


SIGNS & SYMPTOMS

DIFFERENTIATING

OBJECTIVE FINDINGS

COMMON

DIAGNOSTIC TEST

TREATMENT FOLLOW-UP

Acne Vulgar is

Inflammatorydisorder of thepilosebaceousglands.

Few or multiplepapules, pustules ornodules on face, chestor back

Closed comedonesand/or open comedones

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


Topical: Benzyl peroxidegel

• Apply after washingwith mild soap andwater twice per day

• F/U PRN

• Chronicconditionsrefer to MO

Insect Bite/Sting

(non-venomous)

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

Irritative bites: localizedinflamed papule

• Other varied reactionsmay be localized,

toxic systemic, orallergic systemic

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

• Irritative bites: localerythema, edema,

and pain• Complete thorough

skin exam and reviewof systems

Usually noneindicated unless

related conditionssuspected

• Symptomatic treatment

• Related conditions like

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

• F/U PRN

• Chronic

conditionsrefer to MO

Miliaria

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

Regionalized papulesand pruritus

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

back


Topical: Hydrocortisone1% lotion to affectedarea.

Cool environment

F/U PRN

PseudofolliculitisBarbae

Inflammatoryresponse to aningrown hair.

Papules on beard area Difficulty shaving; “razorbumps”

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


Topical: Benzyl peroxidegel

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

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

F/U PRN



18–DERMATOLOGICAL

CHIEF COMPLAINT: INFLAMMATORY (continued)



DIFFERENTIATINGOBJECTIVE FINDINGS

COMMONDIAGNOSTIC

TEST

TREATMENT FOLLOW-UP

Scabies

Mite infestationfrom close contactwith infectedindividual orlinen/clothing.

Papules and pruritus “Itch/scratch” that mayinterrupt sleep

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


Topical:

• Permethrins lotion orshampoo (Elimite/Nix)

• Also treat shipboard orhome contacts and washassociated clothing andlinen

F/U PRN

CHIEF COMPLAINT: SCALY





TREATMENT FOLLOW-UP

Candidiasis (oral)

‘Thrush’ is a fungalinfection of the oralepithelium caused

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

White intra-oral plaquethat is easily scrapedoff

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

infection• Pasty ‘cottage

cheese’ taste

White curd-like patchesthat appear like ‘cottagecheese’

• Potassiumhydroxide (KOHpreparation)microscopic eval

• Investigate causeif unknown

Topical antifungal:

Clotrimazole troches

OR

Oral Antifungal:

Fluconazole

F/U if notimproved in 14days

Pityriasis Rosea

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

Delicate, salmon-colored round or ovalpatches of fine whiteflakes

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

• Pruritus

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


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

F/U PRN

Psoriasis

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

Marked, silvery, flakingpatches or plaques

Gradual onsetexacerbated by stressand sunlight; nail pitting

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


• High-potency topicalsteroids have someeffect

• Refer to MO

Refer to MO



19–DERMATOLOGICAL

CHIEF COMPLAINT: SCALY (continued)


KEY FEATURES DIFFERENTIATINGSIGNS &

SYMPTOMS



TREATMENT FOLLOW-UP

SeborrheicDermatitis

Chronic “dandruff”condition affectingmostly hairyregions.

Regional greasyscaling patches orplaques

• Chronic

• Waxing andwaning Sx

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

• Usually none indicated

• May have fungalcomponent

Topical:

Selenium sulfide shampoo(Selsun Blue) every day for2 weeks

F/U PRN.

Consider low-potency topicalsteroid cream;hydrocortisone1% if unimproved

Fungal

Tinea Capiti s

Fungal infection ofscalp.

Scaly patch onscalp

• Alopecia

• Pruritis of scalp

Round scaly patches withalopecia

Potassium hydroxide(KOH) preparationmicroscopic evaluation

Oral antifungal:

Refer to MO

Refer to MO

Tinea Corporis

Fungal infection offace, trunk, orextremities.

Scaly patch onbody

• “Ringworm”

• Pruritis of affectedarea

Annular, erythematous, scalypatch with central clearing


Anti fungal:

Clotrimazole 1% cream

F/U PRN

Tinea Cruris

Fungal infection ofgroin.

Scaly patch on

groin

• “Jock itch”

• Pruritis of groin

Sharply demarcated patch or

plaque with elevated, scalyborder (occasionally vesicularborder)

Potassium hydroxide

(KOH) preparationmicroscopic evaluation

Anti fungal: Clotrimazole

1% creamLoose-fitting under-clothesmay help

• F/U PRN.

• Considerbacterialerythrasma ifnot improving

Tinea Pedis

Fungal infection offoot.

Scaly patch on feet • “Athletes foot”

• Pruritis of foot/feet

Diffuse, not well- demarcatedscaly patches on sole or toewebs


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

Keep area dry, wear cleanand dry socks

F/U PRN

Tinea Unguium

Fungal infection ofnail.

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


Oral antifungal:

Refer to MO

Refer to MO

Tinea Versicolor

Fungal infection ofthe skin.

Scaly patch onbody

• Finehypopigmentedsmall patches,usually multipleon trunk

• Mild pruritis ofaffected area

White, tan or pink patcheswith fine flaking border


Woods’ Lamp

Topical:

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

F/U PRN



20–DERMATOLOGICAL

CHIEF COMPLAINT: VESICULAR

CONDITION &

DEFINITION

KEY FEATURES DIFFERENTIATING SIGNS &

SYMPTOMS

DIFFERENTIATING

OBJECTIVE FINDINGS

COMMON

DIAGNOSTICTEST

TREATMENT FOLLOW-UP

Eczematous

Atopic Dermatit is

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

• Papulovesicularpatch

• Pruritis isprominentsymptom

• Chronic history of same

• Scratching or oozing andcrusting may occur

Lichenified vesicularpatches with classicdistribution of flexuralarea of extremities


Topical:

Hydrocortisone 1%cream

Antihistamine:

Hydroxyzine (Atarax) ordiphenhydramine(Benadryl) for itch


Contact Dermatitis

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


• Severe pruritis.

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

Wet, papulovesicularpatch with geometricoutline and sharpmargins


Oral Steroid:

Prednisone (tapereddose)

Antihistamine:

Hydroxyzine (Atarax) ordiphenhydramine(Benadryl) for itch


EczematousDermatitis orDyshidrosis

Recurrent eruptionsaffecting the handsand feet.


• Mild pruritis

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

Papulovesicular patcheson hands or feet soles

(Some shoes havemetal that are causativeagent)


Topical:

Hydrocortisone 1%cream

F/U PRN; usuallychronic; maydevelopsecondarybacterial infection

Infectious

Herpes Simplex

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

Localized, grouped,

uniform lesion

• Acute or chronic. Primary

infection; fever, malaise,headache, regionaladenopathy.

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

• Grouped “grape-like”

cluster of uniformvesicles that quicklybecome papules thatrupture & weep

• May be found on anybody location

• Usually recurs in samelocation

Tzanck Smear or

HSV antibody titers

Antiviral :

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

• Good hygiene

• Patient education ontransmission. Condomuse if genital

IF not resolved in

14 days, contactMO for advice

Disease AlertReport requiredIF primary genitalinfection



21–DERMATOLOGICAL

CHIEF COMPLAINT: VESICULAR (continued)


KEY FEATURES DIFFERENTIATING SIGNS& SYMPTOMS



TREATMENT FOLLOW-UP

Infectious (cont)

Herpes Zoster

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

cause primaryvaricella if notimmune.

Localized,unilateral, linear,dermatomal lesion

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

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


Antiviral:

Acyclovir (Zovirax)

Analgesic:

Acetaminophen ORibuprofen ORacetaminophen withcodeine (narcotic)

given short durationor as advised by MO

Lesion lasting weeksto months

Contact MO foradvice

Impetigo

Superficialcontagious skininfection caused by

Staphylococcusaureus, Group Abeta-hemolyticstreptococci orStreptoccusPyogenes

Localized crustedlesion

• Acute

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

weeping lesion thatbecomes crusted

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

surrounding

Culture wound onthe advice of MO

Antibiot ic:

Dicloxacillin orcephalexin (Keflex)

Good hygiene

F/U if not improvedin 7 days

Smallpox

Highly contagious

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

Prodrome -regional

maculopapularrash

• Acute onset withoropharyngeal, facial, &

arm lesions spreading totrunk & legs

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

After 1-2 days, cutaneouslesions become vesicular,

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

Viral culture – notifylaboratory of

smallpox suspicion;highly contagious

Treatment isgenerally supportive,

with antibiotics forsecondary bacterialinfections. Antiviralshave never beenused clinically.

• CONTACT MOand Flight

Surgeon• Notify Command -

Disease AlertReport

• Be familiar withthe SVP.

http://www.smallpox.

army.mil/

http://www.smallpox/

http://www.smallpox/



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



23–EENT

CHIEF COMPLAINT: RED EYE OR PAIN

CONDITION &

DEFINITION


SIGNS & SYMPTOMS

DIFFERENTIATING

OBJECTIVE FINDINGS

COMMON

DIAGNOSTICTEST

TREATMENT FOLLOW-UP

Blepharitis

Inflammation of theeyelid by eitherseborrhea orstaphylococcalcause.

• Erythema of theeyelid margin

• Itchy, watery,burning sensation

SeborrheicBlepharitis: Dry flakesand oily secretion onthe lid margins

StaphyloccocalBlepharitis: Ulcerations

at base of eyelashesand photophobia

• Complete eye exam

• Erythema of lid marginthat may be ulcerated ifstaphylococcal infection


• Clean eyelidmargin with babyshampoo (alsosee seborrheadermatitis)

• Forstaphylococcal:

Topicalophthalmic:Gentamycin ORerythromycinsolution/ointment

• No contact lensuse until resolved

F/U if not resolvedin 14 days

Chalazion

Non-infectious

meibomian glandocclusion causingswelling.

• Non-tendererythemicpapule of theeyelid

• Itchy, watery,burningsensation

Mild foreign bodysensation but usuallypainless


• Swelling behind the lid

margin


• Warm compressto promotedrainage 5-10minutes tid



F/U if not resolvedin 14 days

Chemical Bu rn toeye

Self explanatory.

• Erythema of theaffected part ofthe eye


Determine causativeagent


• Generalized erythema ofaffected area

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

• Usually noneindicated

• Fluoresceinstaining todetermineulceration orabrasion

• Immediateirrigation withcopious normalsaline for at least

10 minutes. Holdeyelid open.

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

MEDEVAC

CONTACT MO orDuty FlightSurgeon

Emergencytransport toemergencydepartment orophthalmologistmust be considered



24–EENT

CHIEF COMPLAINT: RED EYE OR PAIN (continued)

CONDITION &

DEFINITION


SIGNS & SYMPTOMS

DIFFERENTIATING

OBJECTIVE FINDINGS

COMMON

DIAGNOSTIC TEST

TREATMENT FOLLOW-UP

Conjunctivitis, Al lergic

Inflammation of theconjunctiva.

• Erythema ofthe eyelid

• Bilateral Itchy,watery,burningsensation

• History of allergies,Rhinorrhea, itchy,watery eyes

• Seasonalenvironmentalconditions present


• Different Palpebralconjunctiva withcobblestone-likeswelling


Topical ophthalmic:

liquid tears

Oral Antihistamine:

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

• Treat underlyingallergic symptoms


F/U if notresolved in 14days

Conjunctivitis,Infectious

Contagious viral or

bacterial infection ofthe conjunctiva.

“Pink eye” refers tobacterial infection.

• Erythema ofthe eyelid

• Itchy, watery,

burningsensation

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

• Viral – may haveassociated viralsymptoms withwatery discharge


• Injected conjunctivaand margin edema

• Bacterial – crusteddischarge may or maynot be present

• Viral - may havepreauricularadenopathy


Topical ophthalmic:

• Bacterial infection- Gentamicin OR

erythromycinsolution/ointment

• Viral infection –liquid tears

• Good hygiene



Corneal Abrasion

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

Foreign body

sensation, tearing

• History of trauma or

contact lens irritation

• Severe pain andphotophobia


• Consider tetracaine0.5% ophthalmicsolution to helpexamine eye

• Epithelial defect showsbrilliant green withfluorescein staining

Fluorescein staining

to confirm abrasion

Irrigation with normal

saline for at least 10minutes

Topical ophthalmic:

Gentamicin ORerythromycinsolution/ointment


• Usually

resolves in 24hours

• If not resolvedin 24 hoursconsult MO



25–EENT


CONDITION &

DEFINITION


SIGNS & SYMPTOMS

DIFFERENTIATING

OBJECTIVE FINDINGS

COMMON

DIAGNOSTIC TEST

TREATMENT FOLLOW-UP

Foreign Body oneye

Self explanatory

Foreign bodysensation, tearing

• History of trauma

• Mild to severe pain

• Photophobia

• Foreign bodysensation

• Tearing


• Consider tetracaine0.5% ophthalmicsolution to helpexamine eye

• Foreign body may beimbedded andsometimes difficult to

find & may or may notcause abrasion

• Epithelial defect showsbrilliant green withfluorescein staining

Fluorescein stainingto determineabrasion

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

• Irrigation withnormal saline for

at least 10minutes

• Topicalophthalmic: Entamicin ORerythromycinsolution/ointment


• IF/U if notresolved in24 hours

• Reinforce eyeprotectionuse

Glaucoma

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

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

• Injectedconjunctivaand ocularpain

• May haveeyelid edema

• Acute blurredvision

• Frontal headache

• Lacrimation

• “Halos” aroundlights

• Possible nausea &vomiting


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

• Tonometry

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

Emergency treatmentis required as theoptic nerve maybecome compressedby high intraocularpressure


CONTACT MOor Duty FlightSurgeon

MEDEVAC



26–EENT


CONDITION &

DEFINITION


SIGNS & SYMPTOMS

DIFFERENTIATING

OBJECTIVE FINDINGS

COMMON

DIAGNOSTICTEST

TREATMENT FOLLOW-UP

Hordeolum

Infection orinflammation ofeyelid hair follicleinternal or external(aka sty)

• Tendererythemicpapule oneyelid margin


Sudden onset oflocalized tenderness oneyelid margin


• Erythemic papule oneyelid margin

• Bacterial infection usuallyhas discharge in area


• Warm compressto promotedrainage 5-10minutes tid

• No contact lensuse

• Bacterial infection:

gentamicin orerythromycinsolution/ointment



Hyphema

Blood in the anteriorchamber

May or may nothave erythema ofthe eyelid

• History of trauma orspontaneouspresentation

• Dull ache &

decreased vision


• Blood in anteriorchamber, decreasedvisual acuity, intraocular

pressure may rise

Tonometry Think: concern forincreased intraocularpressure

Bed rest for 3-5 days



Pinguecula

Benign ‘yellowish’colored lesion onbulbar conjunctivacaused by irritation

• Perceived asunsightly

• Asymptomatic

Eye irritation and patientconcern


• Triangular, fleshy papuleover sclera/bulbarconjunctiva


Reassurance


• F/U PRN

• Consult withMO if in doubt

Pterygium

Benign ‘yellowish’colored lesionencroaching ontothe cornea causedby irritation

• Perceived asunsightly

• Asymptomatic

Eye irritation, visualchanges, & patientconcern


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


Reassurance


• F/U PRN

• Consult withMO if indoubt. Referto optometristif change inacuity.



27–EENT






TREATMENT FOLLOW-UP

Retinal Detachment

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

Decrease or lossof vision

• History of visualflashes of lights orsparks

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


• Detached retinaappears gray withwhite folds duringophthalmoscope exam

• Ophthalmoscope

• Tonometry

• Patch as directed

• Emergencytreatment isrequired



MEDEVAC

SubconjunctivalHemorrhage

Blood under theconjunctiva

May or may nothave erythema ofthe eyelid

• Asymptomatic.

• History of venouspressure fromstraining


• Blood under theconjunctiva may spillover into the lower lidmargin

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

• Treat underlyingillness if present



Uveitis

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

Injectedconjunctiva &ocular pain

• Acute blurred vision,deep ache & photo-phobia

• May have history oftrauma or inflam-matory condition


• Dilated pupil, injectedflare along limbusborder

• Increased intraocularpressure to 35-45mmHg

• Tonometry

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

Emergency treatmentis required as theoptic nerve maybecome compressedby high intraocularpressure


CONTACT MOor FlightSurgeon

MEDEVAC



28–EENT

CHIEF COMPLAINT: EARACHE

CONDITION &

DEFINITION


SIGNS & SYMPTOMS

DIFFERENTIATING

OBJECTIVE FINDINGS

COMMON

DIAGNOSTIC TEST

TREATMENT FOLLOW-UP

Barotrauma

Ear pain or damagecaused by rapid changein pressure

Ear pain • History of trauma orrapid pressurechange

• Acute hearing loss

• Conductive hearing loss

• R/O TM perforation

• Weber or RinneTest

• Whisper test or Audiogram

• Self-limiting

• Decongestantor Valsalvamaneuver maybe helpful


Cerumen Impaction

Cerumen is a natural

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

• Ear pain and/orhearing loss

•

May beasymptomatic

• Bilateral or unilateralitchy sensation in earcanal

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

TM not visible withirritated appearingexternal canal

Usually none indicated Emulsifying Agent :

Debrox• Ear irrigation

with warmsterile water

F/U if notimproved in 7day

Eustachian TubeDysfunction

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

Ear pain and/orhearing loss

Popping sensation inear

Normal TM Tympanometry.(normal peak thoughmay be diminished)

Decongestant:

Pseudoephedrine


Mastoiditis

Infective process of themastoid air cells

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

• Feverish feeling

• Fever, bulging purulent& erythemic TM

• Postauricular edemaand tenderness

CBC & mastoidradiographs

Antibiot ics:

Ceftriaxone IV(Rocephen)

(consult with MOprior toadministering drug)

Emergencytreatment isrequired


MEDEVAC



29–EENT

CHIEF COMPLAINT: EARACHE (continued)

CONDITION &

DEFINITION


SIGNS & SYMPTOMS

DIFFERENTIATING

OBJECTIVE FINDINGS

COMMON

DIAGNOSTIC TEST

TREATMENT FOLLOW-UP

Otitis Externa

Infection of theexternal auditory canal

Ear pain • May have history ofswimming

• Itchy sensation inear canal

• May have otorrhea

• Tenderness with pinna‘tug’

• Edema and erythema ofexternal canal

• Normal TM

Usually none indicated Topical:

Corticosporin

F/U if notimproved in 7days;

R/OPseudamonas infectionwithpersistentsymptoms

Otitis Media

Infection of the middleear

Ear pain • History of viralsymptoms orEustachian tubedysfunction

• May have nasaldischarge, otorrhea,fever or dizziness

TM inflamed, non-mobile,bulging with decreasedlight reflex

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


Perforation ofTympanic Membrane

Self-explanatory

Ear pain andhearing loss

• History of trauma,

barotrauma, orinsertion of objectinto ear canal

• Bleeding from canal,hearing loss, tinnitus

TM perforated. Blood maybe present in canal

• Tympanometry

• Audiogram beforeand after treatment

• No specific

treatment• Keep ear dry

with ear plugsin shower

• No swimming


Serous Otitis Media

Effusion of serousfluid in middle ear

Ear Pain • History of viral orallergy symptoms orEustachian tubedysfunction

• Popping sensationin ears

TM is relatively normal withfluid line or fluid bubblevisible

Tympanometry Decongestant:

Pseudoephedrine


TemporomandibularJoint (TMJ)Syndrome

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

Ear or TMJ pain • Popping sensationin TMJ or ears

• Headache

• Normal ear exam

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

Usually none indicated • Stressreduction maybe helpful

• Referral todental clinic

F/U PR



30–EENT

CHIEF COMPLAINT: STUFFY NOSE




COMMON DIAGNOSTICTEST

TREATMENT FOLLOW-UP

All ergic Rhini tis

Allergic response toairborne allergensaffecting the noseand eyes

• Nasalcongestion

• Seasonalallergiescommon in thespring whereperennialallergies maylast all year

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

• Postnasal drip maycause cough

• Pale, boggyturbinates, conjunctivainjection

• May have dark circlesunder eyes


• CBC (eosinophilia)

• CT of sinus if Sxpersist

Antihistamine:

loratadine(Claritin), orfexofenadine(Allegra)

F/U PRN

Common Cold

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

Nasal congestion. • General malaise andlow-grade fever

• Rhinorrhea, sorethroat, and cough

• Influenza has highfever with more acute& severe Sx

• Possible fever

• Nasal turbinate edemaand erythema withclear/white discharge

• Injected conjunctivaand throat

• Clear lungs

Usually none indicated Self limiting. Analgesic:

Acetaminophen oribuprofen

Decongestant:

Pseudoephedrineor combined withantihistamine

F/U if notimproved in7 days

Epistaxis

(Nosebleed):

• Anterior:Kiesselbach’splexus

• Posterior:posterior half ofroof of nasal

cavity• May be

idiopathic,traumatic ormedical cause

Stuffy nose • Bloody nose

• May have history ofaspirin or NSAID useor trauma

Bleeding from thenostril(s) and/or clot

Usually none indicated

• CBC


Anter iorepistaxis:

Pinch nostrils forseveral minutes.Vasoconstrictorlike Afrin mayhelp.

Posteriorepistaxis: Pack

nostril withVaseline-coatedgauze

Refer foremergencyinterventionifunsuccessfulimmediatetreatment



31–EENT

CHIEF COMPLAINT: STUFFY NOSE (continued)




COMMONDIAGNOSTIC

TEST

TREATMENT FOLLOW-UP

Sinusitis

Inflammation orinfection of mucousmembranes ofparanasal sinus

Nasal congestion • Sinus pressure,facial pain orheadache

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

• Turbinates areerythemic and swollen

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

• May be unable to

transilluminate sinuses


• CT of sinus ifSx persist

• Reserveantibiotics forpatients that fail a7 day course ofdecongestantsand analgesics

• Antibiot ic: Amoxicillin-

clavulanate(Augmentin) orSeptra DS

F/U if notimproved in 7days orincreased feveror headache



32–EENT

CHIEF COMPLAINT: SORE MOUTH/THROAT

CONDITION &

DEFINITION

KEY

FEATURES

DIFFERENTIATING

SIGNS & SYMPTOMS

DIFFERENTIATING

OBJECTIVE FINDINGS

COMMON

DIAGNOSTICTEST

TREATMENT FOLLOW-UP

Aphthous Ulcer

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

Mouth sore Painful ulcers White circular lesionssurrounded by anerythematous margin


• OTC benzocainepreparations like

Anbesol andOragel

• Reassurance

• F/U PRN

• Refer to MO ifrecurrent

Epiglottitis

Inflammation andinfection of the epiglottis.More common inchildren.

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

• Inspiratory strider,cervical adenopathy

• Throat most likelyappears normal

• Do NOT use tongueblade to visualizethroat

• Blood culture

• Chest radiograph

• Throat cultureconducted ONLYin emergencyroom withtracheostomy kitavailable

Antibiot ics:

Ceftriaxone IV(Rocephen)

(consult with MOprior toadministering drug)

Emergencytreatment isrequired


MEDEVAC

Herpes Simplex Virus

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

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

• Occasional tenderadenopathy

• Headache, myalgia,or fever

• Primary infection maybe worst of Sx

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

lesions erode andcrust, last 2 to 6weeks

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

Tzanck Smear orHSV antibody titers

Antiviral:

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

• Patienteducation ontransmission

• Condom use ifgenital

• IF not resolvedin 14 dayscontact MO foradvice

• Disease AlertReport requiredIF primarygenital infectiononly



33–EENT

CHIEF COMPLAINT: SORE MOUTH/THROAT (continued)

CONDITION &

DEFINITION


SIGNS & SYMPTOMS

DIFFERENTIATING

OBJECTIVE FINDINGS

COMMON

DIAGNOSTICTEST

TREATMENT FOLLOW-UP

Laryngitis

Inflammation of themucosa of the larynxor vocal cords maybe associated withexcessive voice useor virus

Sore throat • Voice hoarseness mainfeature

• If viral, fever, malaise,difficult swallowing,regionallymphadenopathy maybe present

Exam may be normal orhave slight pharyngealerythema


• Supportive care

• Strict voice rest fora few days or untilresolving


Mononucleosis

Contagious infectioncaused by theEpstein-Barr virus.Spread by person topersonoropharyngeal route

Gradual onset ofsore throat, fatigueand malaise

• Headache, fever,malaise, fatigue

• Sx generally lastinglonger than 2 weeks (anormal course forcommon viralsyndromes)

• May have generalizedmaculopapular rash

• Appears ill and isfebrile

• Palatal petechiae iskey feature withwhite membrane ontonsils, posteriorcervical adenopathy,hepatic or splenicenlargement

• Rapid Strep test(30% with monoalso have strepthroat)

• Mono SpotCBC

• Consider EBV,LFT and throatculture

• Supportive care.Recovery maytake weeks.Maintain healthydiet and rest

• Avoid ‘contact’sports

• Good hygiene

• Consult MOor Duty FlightSurgeon

• Follow up ifnot improvedin 30 days

Peritonsillar Abscess

Bacterial cellulites ofperitonsillar area.Initiates in tonsil andspreads tosurrounding softtissue.

Severe sore throatand difficultyswallowing

Fever with markedtrismus (difficultyopening mouth)

Virtually alwaysunilateral and “hotpotato voice”

• Appears ill and isfebrile

• Pharyngealerythema, tonsildisplaced mediallywith unilateral neckswelling

CT of neck orultrasound canconfirm diagnosis

Antibiot ic:

Penicillin IV orceftriaxone IV(Rocephen)

(consult with MO priorto administering drug)

Emergency treatment

is required. (Incision& drainage ofabscess completed inemergency room)


MEDEVAC



34–EENT

CHIEF COMPLAINT: SORE MOUTH/THROAT (continued)



DIFFERENTIATINGOBJECTIVE

FINDINGS

COMMONDIAGNOSTIC

TEST

TREATMENT FOLLOW-UP

Pharyngitis,Bacterial

Infection of throat bygroup A beta-hemolyticstreptococci; otherorganisms can causebacterial infection,

but they are notdiscussed here.

Also referred to astonsillopharyngitis

Severe sore throat • Acute onset

• Describes halitosis,fever, difficultyswallowing, chills,malaise & headache

• Usually NO commoncold symptoms or cough

• May appear ill andis febrile

• Triad: pharyngealerythema (beefyred), tonsillarexudate, cervicaladenopathy

• Rapid Strep

• Throat culture ifrapid strepnegative

Antibiot ic:

Penicillin VK

• Saline gargle

• New toothbrush

• Good hygiene

• Family may havesame Sx –considertesting/treatment

• F/U if notimproved in 7days

• Tonsillarhypertrophymay be presentand concern forairway

obstruction

Pharyngitis, Viral

Viral infection of thethroat (also seemono-nucleosis)

Acute onset ofsore throat andmalaise

• Feverish, difficultyswallowing, chills,malaise, andheadache

• Coryza and commoncold symptoms usuallysuggest viral, notbacterial infection

• Fever

• Rhinorrhea

• Viral conjunctivitis

•

Pharyngealerythema

• Nonproductivecough

Rapid Strep • Supportive care

• Saline gargle

• Good hygiene

F/U if not improvedin 7-14 days

Salivary Stone

Calcium saltsaccumulate insalivary glandscausing parotid,submandibular orsublingual ductobstruction.

Swelling and painof the salivarygland

Localized pain is keyfeature mostly after eating

The stone may be feltby palpation of theduct/gland in themouth

If stone is notapparent on exam,give patient lemon

juice, hard candy(something tostimulate saliva).

Reproduction of Sxis diagnostic.

• Manualmanipulation(massage) ofduct/gland mayhelp stoneextraction

• Antibioticsindicated ifassociatedbacterial infectionpresent


• Watch forsecondary

infection





36–CARDIOVASCULAR

CHIEF COMPLAINT: CHEST PAIN (continued)

CONDITION &

DEFINITION


SIGNS & SYMPTOMS

DIFFERENTIATING

OBJECTIVEFINDINGS

COMMON

DIAGNOSTIC TEST

TREATMENT FOLLOW-UP

Cardiac (continued)

Pericarditis

Inflammation of thepericardium(fibroserous sacsurrounding theheart)

Acute onset ofchest pain

O – acute

P – relieved by leaningforward and sitting up

Q – dull, tight, pressing

R – substernal ache,radiating to back orshoulders

S – severe to vague

T – may have recent viralsyndrome

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

• Appears anxious,diaphoretic, pallor,dyspnea

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

adventitious lungsounds

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

• CBC and Chestradiograph

Analgesics:

• Aspirin oribuprofen

• Oxygen PRN

• Comfortable rest.

• Emergencytreatment may benecessary

CONTACT MOor Duty FlightSurgeon.

• ConsiderMEDEVACas MI cannot

be ruled out

Non-Cardiac

Anxiety

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

Chest pain may beassociated withstress or panicattack

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

• Appears anxious,diaphoretic, pallor,dyspnea

• Mental healthinterview

• Assess vitals andR/O cardiac

involvement

• ECG is normal

• Objective AnxietyQuestionnaire.(Beck’s)

Acute Tx:

Antianxiety:hydroxyzine (Atarax)OR diazepam(Valium)

Chronic Tx:

Refer to MO

CONTACT MOor Duty FlightSurgeon IFdoubt

Costochondritis

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

Chest pain isexacerbated bycough or deepbreathing

History of physicalexertion or trauma tochest or ribs

Direct palpable chestwall tenderness ofcostochondralligament/muscle

ECG is normal Analgesics: Acetaminophen oribuprofen

Reassurance




37–CARDIOVASCULAR

CHIEF COMPLAINT: CHEST PAIN (continued)





TREATMENT FOLLOW-UP

Non-Cardiac (continued)GastroesophagealReflux Disease

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

caffeinated productscan be contributingfactors

Chest pain andnausea may beassociated withmeal, exercise, orpatient restingsupine

• Epigastric “heartburn”

• Regurgitation causingbitter taste

• Symptoms relieved bysitting up or antacids

• May have naggingcough

• May have normalexam findings

• Assess for epigastrictenderness

• ECG is normal

• Antigen/antibodyfor H. pylori

Acute Tx:

H2 Inhibitor:Ranitidine (Zantac)

For chronic Tx orH. pylori refer toMO

CONTACT MO orDuty FlightSurgeon IF doubt

Pleuritis

Viral infectioncausinginflammation of thepleurae sacsurrounding the

lungs

Chest pain • Marked sharpstabbing pain withrespiration

• May have recent viralsyndrome

• Febrile

• Friction fremitus withrespiratory sounds

• ECG is normal

• Chestradiographs

Analgesics:

Aspirin or ibuprofen


• Consult withMO PRN



38–CARDIOVASCULAR

CHIEF COMPLAINT: SYNCOPE





TREATMENT FOLLOW-UP

Arrhythmia

Rhythm is just that;regular, coordinatedelectrical impulses.

Arrhythmia is loss ofheart rhythm, eithera regular or irregularabnormality.

Transient, suddenloss of conscious-ness that resolvesspontaneously

• May have history ofarrhythmia andfainting

• Palpitations andlightheadednessmay precedesyncope

• Age usually greaterthen 50

• Appears anxious,diaphoretic, pallor,dyspnea or normal

• Complete physicalexamination

• Orthostatic bloodpressure

• ECG is indicatedbut may benormal at time ofexam

• Refer to MO

• Evaluateurgency of case

CONTACT MO orDuty FlightSurgeon IF doubtor abnormal ECG

OrthostaticHypotension

Benign failure ofnormalcompensation forblood pressure dropreducing blood flowto brain due to

dehydration

Vasovagal syncope has similar endresult with differentmechanism of action

Transient, suddenloss of conscious-ness that resolvesspontaneously

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

• Palpitations andlightheadednessmay precedesyncope

• Appears anxious,diaphoretic, pallor,dyspnea or normal


• 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



39–CARDIOVASCULAR

CHIEF COMPLAINT: SYNCOPE (continued)





TREATMENT FOLLOW-UP

Seizure

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

Compromisedmotor activity

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

• Petit Mal Seizure –sudden stopping of

motor function withblank stare

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

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

• CBC

• Chemical Panel

• Urinalysis

• Drug & alcoholscreening

• CT scan or MRI

• During seizure,maintain airwayand preventinjury

• Refer to MO

Seizure > 10minutes needsemergencyintervention!

Consult with MO orFlight Surgeon



40–CARDIOVASCULAR

CHIEF COMPLAINT: VASCULAR SYMPTOMS





TREATMENT FOLLOW-UP

Deep VeinThrombosis

Blood clot(s) in thecalf or femoral veinsresulting ininflammation

(e.g., DVT)

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

Positive Homan’ssign

• Support hose

• Refer to MO

• Evaluateurgency of case


Raynaud’s Disease

Vasospasm of thevessels of the digitsin response to coldor stress

Hand pain • Fingertips turnmottled white andred then cyanotic

• Tobacco useexacerbates Sx

• Normal examinationbetween attacks

• Cold challenge testwill reproduce Sx

Cold challenge test Caution patientabout coldexposure and tostop tobacco use

Refer to MO

Varicose Veins

Superficial veinswith incompetentvalves cause dilationof veins

Burning sensationand unsightlydiscoloration at site

Patient concern mostlyabout appearancethough extensive

varicosities haveconstant dull ache

Dilated, tortuous veinsof the medial anteriorankle, calf or thigh


Avoid prolongedstanding, and usesupport hose PRN

Refer to MO PRN



41–RESPIRATORY

CHIEF COMPLAINT: COUGH

CONDITION &

DEFINITION


SIGNS & SYMPTOMS

DIFFERENTIATING

OBJECTIVE FINDINGS

COMMON

DIAGNOSTIC TEST

TREATMENT FOLLOW-UP

Acu te

Bronchitis,Mycoplasma

Inflammatorycondition of thetracheobronchialtree caused by

mycoplasmpneumoniae (non-bacterial)

Non-productive,recurrent, barkingcough early, thenbecomesproductive

• Severe cough withpurulent sputumlate

• Sx persist for > 2weeks

• Fever, fatigue, and

possiblehemoptysis

• Low-grade fever

• Lung sounds: coarserhonchi and possiblyrales

Chest radiograph Cough suppressionwith expectorant:

Robitussin DM

Antibiot ic:

Erythomycin (E-Mycin)or Bactrim DS

Bed rest


Bronchitis, Viral

Inflammatorycondition of thetracheobronchialtree caused by virus

Non-productive,recurrent, barkingcough

• Scant white to clearsputum

• May or may nothave fever

• Sx usually 7-10

days• Common in

smokers

Lung sounds: coarserhonchi and possiblyrales

Chest radiograph Cough suppressionwith expectorant:

Robitussin DM


Influenza

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

respiratory tract,usually in wintermonths.

(common coldoccurs anytimeduring the year)

Non-productiveacute cough,usually worse atnight

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

& conjunctivitis

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

• High fever

• Nasal turbinateedema & erythemawith clear/whitedischarge

• Injected conjunctiveand throat. Clearlungs.

Chest radiograph Analgesic:

Acetaminophen oribuprophen

Cough suppressionwith expectorant:

Robitussin DM

• Self limiting

• Annual influenzavaccine




42–RESPIRATORY

CHIEF COMPLAINT: COUGH (cont inued)





TREATMENT FOLLOW-UP

Acu te (cont inued)

Pneumonia,Bacterial

“Communityacquired”(outsidehospital/nursinghome) bacterialinfection of thelung

Streptococcuspneumoniae

• Productive,severe coughwith copiouspurulent sputum

• Usually worse atnight

• High fever

• Dark, thick, rustysputum

• Tachypnea, shakingchills, tachycardia,malaise, confusion

• Appears ill

• Febrile >100F/37.8C

• Pulse > 100

• Lung sounds: ralesand whispered

pectoriloquy

• Assessbronchophony &egophony

• Chest radiographwith lobarconsolidation

• Pulse Ox

• CBC

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

Antibiot ic:

Ceftriaxone (Rocephin)Plus azithromycin(Zithromax)

Analgesic:

Acetaminophen or

ibuprofenCough suppressionwith expectorant:

Robitussin DM or withcodeine

• Consider oxygenand IV – NS

• Bed rest


Pneumonia,Mycoplasma

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

summer monthsand in youngadults.

Mycoplasmapneumoniae

Non-productive, drycough

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

• Headache usuallyalways present

• May appear ill

• Erythematous throat,fluid-line or bubblesbehind TM

• Lung sound: pleuralfriction rub

• Chest radiographwith bilateralpleural effusion

• Pulse Ox

• Consider RapidStrep & MonoSpot if sore throatsevere

Antibiot ic:

Azithromycin(Zithromax) orerythromycin (E-Mycin)

Analgesic:


Cough suppression

with expectorant:Robitussin DM or withcodeine

Bed rest




43–RESPIRATORY


CONDITION &

DEFINITION


SIGNS & SYMPTOMS

DIFFERENTIATING

OBJECTIVE FINDINGS

COMMON

DIAGNOSTIC TEST

TREATMENT FOLLOW-UP

Acu te (cont inued)

Pneumonia, Viral

Viral infection ofthe lungs withrecent history ofcommon cold orinfluenza

Productive, mildcough

• Severe cough withwhite to clearsputum

• Fever & fatigue

• Recent history ofupper respiratory

viral illness

• Fever

• Tachycardia

• Usually has cervicaladenopathy

• Lung sounds: rales or

pleural friction rub

• Chest radiographwith peribronchialthickening andbilateral sparsinfiltrate

• Pulse Ox

Analgesic:

Acetaminophen oribuprophen

Coughsuppression withexpectorant:

Robitussin DM.

Bed rest


Chronic

ChronicObstructivePulmonaryDisease

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

antirypsindeficiency)

Chronic coughingwith scant sputum

• Weight loss &dyspnea

• History of recurrent

bronchial infections

• Respiratory effort anduse of accessorymuscles, barrelchest, pursed lipbreathing

• Clubbing of fingers

• Change in weight

• Pulse Ox

• Peek flow beforeand after treatment

Bronchodilator:

Nebulized albuterol

Oxygen NC

CONTACT MOor Duty FlightSurgeon ifdoubt



44–RESPIRATORY






TREATMENT FOLLOW-UP

Chronic (continued)

GastroesophagealReflux Disease(GERD)

Irritation caused byreflux of gastricsecretions into theesophagus

Chronic, mildnagging cough andnausea

• Epigastric‘heartburn’

• Regurgitationcausing bitter taste

• Symptoms relievedby sitting up or

antacids• May have chest pain

• May have normalexam findings

• Assess forepigastrictenderness

• Complete HEENT,

CV, Respiratory, &GI Exam


• ECG is normal

Acute Tx:


• For chronic Tx or H.pylori refer to MO


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

with actively infectedperson

Chronic cough • Productive yellow/green sputum thatprogresses

• Prominent featuresare chronic “notfeeling well” with

drenching nightsweats

• Hemoptysis is lateSx

• History of closecontact with infectedperson

Lung sounds: rales inupper lobes withwhispered pectoriloquy

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

though all withactive disease arepositive)

• CBC

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

• Chest radiograph:multi-noduleinfiltrate in apicallobe and hilaradenopathy

• Multi drug therapyis required

• Direct observationtherapyrecommended

• Consult with MO.




45–RESPIRATORY

CHIEF COMPLAINT: DIFFICULT BREATHING

CONDITION &

DEFINITION


SIGNS & SYMPTOMS

DIFFERENTIATING

OBJECTIVE FINDINGS

COMMON

DIAGNOSTIC TEST

TREATMENT FOLLOW-UP

Anaphylax is

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

IgE mediated

Acute laboredtachypnea, cough,and wheeze

• History of exposure

• May have Urticariaand angioedema ofthe face withcyanosis

• Obvious distressrequiring immediatecare

• ABCs fi rs t

• Lung sounds:rhonchi and wheeze

• Vitals: hypotension

•

Complete HEENT,CV, respiratory, skinexam

• Pulse Ox

• Peak Flow beforeand after Tx

Bronchodilator:

Epinephrine 1:10000.3 to 0.5 mg IM and

Nebulized albuterol;

oxygen, IV – NS

Antihistamine: Diphenhydramine(Benadryl)

Oral steroid: Prednisone may beindicated to preventrecurrence


• IF reaction tovaccine,completeVAERS Report

Asthma

Disorder of thetracheobronchialtree with reversibleairway obstruction(bronchospasmwith inflammatoryprocess)

Acute laboredtachypnea, cough,and wheeze

• History of asthma

• Prolongedexpiratory wheeze

brought on byexposure trigger

• May have cyanosis

• Obvious distressrequiring immediatecare

•

ABCs fi rs t • Lung sounds:

expiratory wheeze

• Pulse Ox

• Peak Flow beforeand after Tx

Bronchodilator:

Epinephrine 1:10000.3 to 0.5 mg IM and

Nebulized albuterol;oxygen, IV – NS

Oral steroid: Prednisone may beindicated to preventrecurrence


Pneumothorax,Spontaneous

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

• Acute laboredtachypnea,

cough, andwheeze

• Sx may besubtle

• History of smoking,vigorous exercises

• Sharp chestdiscomfort that isworse withbreathing

• Asymmetrical chestmovements and

decreased lungsounds

• Just listening to thelungs makes the Dx

• Pulse Ox

• Chest radiograph

• Oxygen

• Emergency

treatment isrequired

CONTACT MO orDuty Flight

SurgeonMEDEVAC



46–RESPIRATORY

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CHIEF COMPLAINT: ABDOMINAL PAIN



47–GASTROINTESTINAL





TREATMENT FOLLOW-UP

Appendici tis Acute inflammationof the vermiformappendix

Nausea, vomiting,constipation & fever•

Early, colicky toconstant pain inepigastrium orperiumbilical; RLQlater

• Vomiting after pain& pain worse withmovement

•

RLQ involuntaryguarding

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

• Pain withpsoas/obturatormaneuver (Psoas –Obturator sign)

•

CBC• UA

•

Prompt referralto ER or directhospitaladmission



MEDEVAC

Cholecystitis

Acute inflammationof the gallbladder

Nausea, vomiting,loose stool, andfever

• Colicky to constantpain at RUQ toinferior angle ofright scapula

• Brought on by fattyfoods. Morecommon infemales

• May have dark

urine, light stool,and/or jaundice

RUQ tender with deeppalpation duringinspiration (Murphy’sSign)

• CBC

• UA

• LFT

• Gallbladderultrasound

Prompt referral toER or directhospital admission


MEDEVAC

Constipation(symptom)

Difficulty passingstool or diminishedfrequency ofdefecation. May besymptom of otherconditions

Nausea • Diffuse cramps

• Difficulty expellingfeces; less frequentdefecation thennormal for patient

• Abdomen bloatedand tender

• Hyperactive bowlsounds

• Labs directedtowards cause

• MO mayrecommendrectal exam foroccult blooddetection

Stool so ftener: Docusate sodium(Colase)

• Increase waterintake

• Increase dietary

fiber AFTERrelief of Sx

• F/U if notimproved in 24hours

• Consult withMO PRN




CHIEF COMPLAINT: ABDOMINAL PAIN (cont inued)





TREATMENT FOLLOW-UP

Diarrhea (symptom)

Acute diarrhea isabnormal andincreasedfrequency andliquid stoolconsistency.

May be symptom of

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

Nausea, vomiting,fever

• Diffuse cramps

• Abnormal andincreasedfrequency andliquid stoolconsistency

• Diffuse, abdominaltender

• May have poor skinturgor indicatingdehydration

• CBC

• UA

• Stool culture andova/parasite maybe indicated

• MO mayrecommend rectalexam for occult

blood detection

Antidiarrheal :

Loperamide(Immodium)

Antibiot ics may beindicated

• Increase waterintake; considerIV normal saline if

dehydrated

• NO solids x 24hours thenBRATS diet x 24hours

• Consider cause

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

Diverticulitis

Inflamed diverticula(outpouchings ofthe mucosathrough themuscular wall ofthe intestine)

Nausea, vomiting,fever, anorexia, andconstipation ordiarrhea

Intermittent chronicpain, usually LLQ

LLQ tenderness,tympanic sound onpercussion

• CBC

• UA• MO may

recommend rectalexam for occultblood detection

Bowel spasm relief: Dicyclomine (Bentyl)

Antibiot ic : Metronidazole(Flagyl) PLUSciprofloxacin (Cipro)


Food Poisoning

Bacterial causefrom contaminatedfood

• Nausea

• Vomiting

• Fever• Diarrhea

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

of eating

• Diffuse cramps

• Diffuse abdominaltender

•

May have poor skinturgor indicatingdehydration

• CBC

• Stool culture may

be indicated• MO may

recommend rectalexam for occultblood detection

Antibiot ic : Ciprofloxacin (Cipro)

•

Increase waterintake; considerIV normal saline ifdehydrated

• NO solids x 24hours thenBRATS diet x 24hours

F/U if notimproved in 24hours










TREATMENT FOLLOW-UP

Gastroenteritis, Acu te

Viral cause ofvomiting anddiarrhea. Irritantslike medications andalcohol can causenausea and vomitingreferred to asgastritis.

• Nausea

• Vomiting

• Malaise

• Fever

• Diarrhea

• Onset of nausea,vomiting anddiarrhea within 48-72 hours of feelingill

• Diffuse cramps

• Nausea, betterafter vomiting orbowel movement

May have normal exam CBC • Increase waterintake

• NO solids x 24hours thenBRATS diet x24 hours


GastroesophagealReflux Disease(GERD)

Irritation caused byreflux of gastricsecretions into theesophagus

Nausea • Epigastric‘heartburn’

• Regurgitationcausing bitter taste.Symptoms relievedby sitting up orantacids.

• May have naggingcough

• May have normalexam findings.

Assess forepigastrictenderness

• Complete HEENT,CV, Respiratory, &GI Exam


• ECG to R/O“cardiac chestpain”

Acute Tx:


For chronic Tx orH. pylori refer toMO


Hepatitis

Viral hepatitis is aninflammatorydisease of the livercaused by a distinctgroup of viruses(HAV and HBV arediscussed here)

• Fever

• Jaundice

• Anorexia

• Nausea

• Malaise

• Myalgia

• HAV – may beinfectious 2 wksbefore Sx and 1 wkafter. Caused bycontaminated foodand water

•

HBV - may beinfectious for 6 wksbefore Sx andunpredictable after.Caused by sexualcontact or bloodproducts

• Jaundice skin andsclera

• RUQ tendernesswith splenic and/orliver enlargement

• CBC

• LFT

• Serologic markerfor specific type ofhepatitis

HAV – Immuneglobulin. Also Txintimate contacts

HBV – Hepatitis Bimmune globulinand start HBvaccine inunvaccinated and

booster invaccinated. Also Txsexual contacts

CG member shouldbe vaccinated withboth HA and HBvaccines


CHIEF COMPLAINT ABDOMINAL PAIN ( ti d)




CHIEF COMPLAINT: ABDOMINAL PAIN (continued)





TREATMENT FOLLOW-UP

Hernia, Abdominal

An abnormalopening orweakness in theabdominal muscularwall allowingprotrusion ofabdominal viscus(Inguinal hernia –

see GU conditions)

May beasymptomatic orhave mild pain

• If reducible orirreducible: maycomplain of a softbulge at the site

• If strangulated:colicky abdominalpain, nausea andvomiting,abdominal

distention

• Visual exam notingsize and supplenessof the mass

• Reducible = able topush mass in

• Irreducible = unableto push mass in

• Strangulated =

irreducible,discolored, painful;do not reduce

None indicated Gently reducehernia if possible,and if notconsideredstrangulated

CONTACT MOor Duty FlightSurgeon IF indoubt

If strangulatedhernia,MEDEVAC

Irritable BowlSyndrome

Chronic abdominalpain, with altereddiarrhea/constipationand gaseousness inthe absence ofdetectable pathology

• Nausea

• Vomiting

• Diarrhea orconstipation

• Gas

• Predominatealternating diarrheaand constipationwithout blood instool

•

Possible stressorsin life

• no weight loss

May have vagueabdominal tenderness >left

• CBC

• ESR

• Stool culture,hemoccult, ovaand parasites

• MO mayrecommendrectal exam foroccult blooddetection

Bowl spasmrelief:

Dicyclomine(Bentyl)

Treat for

constipation ordiarrhea


Pancreatitis, Acute

Inflammation of thepancreas caused by

trauma, virus, cysts,drugs (steroids,sulfa, NSAID), ductobstruction, alcohol

• Nausea

• Vomiting

• Fever

• Jaundice

• Dark urine

• Sudden, severeepigastric painradiating to mid-

back• Hypotension

• Bluish flank (GrayTurner’s sign)

• Bluish periumbilical

(Cullen’s sign)

• Mild jaundiced

• Crackles in lungs

• Epigastric tenderness

• Frothy dark urine

• Complete bloodchemistry test

• CBC

• UA

• Ultrasound or CT

• IV – NS AnalgesicsPRN:

Acetaminophenor ibuprofen

• Otherwise NPOas directed byMO.


MEDEVAC

CHIEF COMPLAINT ABDOMINAL PAIN ( ti d)




CHIEF COMPLAINT: ABDOMINAL PAIN (continued)





TREATMENT FOLLOW-UP

Peptic UlcerDisease

Erosion of gastricmucosa. Duodenal> gastric

• Nausea

• Vomiting

• Melena

• Abdominalcramping

• Duodenal Ulcer:nocturnal pain,heartburn, betterwith food/antacids

• Gastric Ulcer:heartburn or backpain, worse w/ food

Epigastric tendernessthough exam may beunremarkable

• CBC

• MO mayrecommend rectalexam for occultblood detection

Acute Tx:


Chronic Tx:

Refer to MO


CHIEF COMPLAINT: ABDOMINAL PAIN Female Specif ic




CHIEF COMPLAINT: ABDOMINAL PAIN Female Specif ic





TREATMENT FOLLOW-UP

Ectopic Pregnancy

Implantation of fertileegg in fallopian tube,cervix, or ovary

• Nausea

• Vomiting(morningsickness)

• Mild or severeunilateral pelvicor referred pain

• Amenorrhea orabnormal uterinebleeding

• Determine lastmenses andmenses history;sexual contact

• Unilateral lowerquadrant or pelvictendernessexacerbated bymovement

• Shock (cool, clammy,pallor, hypotension,tachycardia)

HCG Positive whenpatient is pregnant

(R/O pregnancy inall females withabdominal pain orabnormal uterinebleeding)

• IV – NS

• Otherwise NPOas directed byMO



MEDEVAC

Endometriosis

Abnormal growth ofendometrial tissueoutside the uterus

• Nausea

• Vomiting

• Mild or severepelvic or referredpain

• Dyspareunia

• Dysmenorrheal

• Determine lastmenses andmenses history;sexual contact.

Vague to diffuseabdominal or pelvictenderness

HCG Negative (R/Opregnancy in allfemales withabdominal pain orabnormal uterinebleeding)

Analgesics PRN:

Acetaminophen,ibuprofen orcombination of both

(Tylenol 1000 mgPLUS Motrin 800mg)

This is a chronicconditionrequiring referralto MO for work-up and Tx

Ovarian Cyst Associated with orwithout ovulation, acyst may causedysmenorrhea orrupture releasingblood/fluid andsevere pain.

Note: Mittelschmerzis a self-limiting mid-cycle pelvic painassociated withovulation.

• Nausea• Vomiting

• Mild or severepelvic or referredpain

• Dysmenorrhea• Determine last

menses andmenses history;sexual contact.

• Unilateral lowerquadrant or pelvictenderness;exacerbated bymovement

• Abdominal rigidity =possible surgical case

HCG Negative (R/Opregnancy in allfemales withabdominal pain orabnormal uterinebleeding)

Goal is todetermine urgencyof case.

If non-emergentcase:

Analgesics PRN:

Acetaminophen,ibuprofen orcombination of both

(Tylenol 1000 mgPLUS Motrin 800mg)

Otherwise:

• IV – NS

• NPO as directedby MO

• Transport


Emergent case =MEDEVAC






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CHIEF COMPLAINT: SEXUALLY TRANSMITTED DISEASE



55–GENITOURINARY





TREATMENT FOLLOW-UP

Chancroid

Contagious bacterialinfection of genitalscaused byHaemophilus ducreyi

Ulceration ongenitals

• Sexual historyusually has multiplepartners; travel todeveloping country

• Painful ulceration ongenitals withinguinal adenopathythat may progress toabscess (bubo)

• The HS/IDHSconducts visual GUexam withchaperone

• Tender ulceratedgenital lesion withinguinal adenopathythat may haveabscessdevelopment

• Female pelvic examby MO may beindicated

STD Screening PRN:(test for H. ducreyi not available in US)

• HIV

• RPR (syphilis)

• Chlamydia

• Gonorrhea

• HSV antibody

• Pap smear (HPV)

Antibiot ic :

Ceftriaxone(Rocephin) IM orerythromycin(E-mycin)

• Tx for partner(s)also

• Encouragecondom use


Disease AlertReport

ChlamydiaTrachomatis

Contagiousintracellular parasite.

Most common STD.

Scant white to clearurethral or vaginaldischarge

• Possible history ofsexual contact

• Females may beasymptomatic


•

Discharge may notbe visible


STD Screening PRN:

• HIV

• RPR (syphilis)

• Chlamydia

• Gonorrhea

• HSV antibody

• Pap Smear (HPV)

Antibiot ic :

Doxycycline or Azithromycin

Tx for partner(s)

alsoEncourage condomuse


Disease AlertReport

Condyloma Acuminata

Contagious viralinfection of the

genitals/anus causedby human papillomavirus

Wart-like growth ongenitals or anus


• Pruritus

•

Dysuria


• Cauliflower-likeclusters of papuleson genitals or anus


STD Screening PRN:

• HIV

• RPR (syphilis)

• Chlamydia• Gonorrhea

• HSV antibody

• Pap Smear (HPV)

• Refer to MO



Disease AlertReport

CHIEF COMPLAINT: SEXUALLY TRANSMITTED DISEASE (continued)



56–GENITOURINARY

( )





TREATMENT FOLLOW-UP

Gonorrhea

Contagious bacterialinfection caused byNeisseriagonorrhoeae (gram-negative diplococus)

Purulent urethral orvaginal discharge


• Males with severepyuria and dysuria

• Female withmoderated vaginalpruritus andburning


• Discharge apparenton genitals andunderwear or sheets

• Female pelvic examby MO may be

indicated

STD Screening PRN:

• HIV

• RPR (syphilis)

• Chlamydia

• Gonorrhea

• HSV antibody

• Pap Smear(HPV)

Antibiot ic:

Ceftriaxone(Rocephin) IM

Tx for partner(s)also

Encouragecondom use

CONTACT MO orDuty FlightSurgeon IF doubt

Disease AlertReport

Herpes SimplexVirus

Recurrent, incurable,contagious viraldisease (see oral andskin)

Localized,grouped, uniformlesion on genitals.(may be found onother body parts)


• Acute or chronic

• Primary infection;fever, malaise,headache, regionaladenopathy

• Recurrent lesionswith prodrome offever or localwarmth, burning,usually just prior toeruption


• Grouped “grape-like”cluster of uniformvesicles quicklybecome papulesthat rupture andweep and may befound on any bodylocation

• Usually recurs insame location


STD Screening PRN:

• HIV

• RPR (syphilis)

• Chlamydia

• Gonorrhea

• HSV antibody

• Pap Smear(HPV)

• Tzanck Smear

Antiviral :

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

• Good hygiene;patient

education ontransmission

• Condom use ifgenital

• F/U if notresolved in 14days, contactMO for advice

• Disease AlertReportrequired IFprimary genitalinfection only




57–GENITOURINARY





TREATMENT FOLLOW-UP

Human Immuno-deficiency Virus(HIV)

Retrovirus thatinfects/kills CD4lymphocytesresulting in patientprone toopportunistic

infections andmalignanciesleading to acquiredImmunodeficiencysyndrome (AIDS)

Flu-like or mono-nucleosis-likecomplaint

• Sexual, drug, andblood transfusionhistory helpful

• May beasymptomatic orearly fever,myalgia, headache,malaise, and rash

• Initial Sx may be

mild and self-limiting

• As diseaseprogresses, generallymphadenopathychronic diarrhea,weight loss, andrecurrent nightsweats develop.

• Head to toe physical ifsuspected

Note the following:

• Vitals

• Weight Hx

• Oral thrush or ulcers

• Lymphadenopathy

• Lung crackles

• Cardiac murmur/gallop

• Hepatomegaly

• Splenomegaly

• Skin lesions

• Female pelvic exam byMO may be indicated

STD Screening PRN:

• HIV

• RPR (syphilis)

• Chlamydia

• Gonorrhea

• HSV antibody

• Pap Smear(HPV)

• CBC

• If HIV ELISA ispositive, confirmwith Western Blot

• Refer to MO

• Counsel on life-style changes

• Immunize:pneumonia,influenza,tetanusbooster,hepatitis A and

B vaccines


• Disease AlertReport

• Notify HealthDepartmentfor patient

contactinvestigation

Lymphogranuloma

Venerum

Systemic,contagiousintracellular parasiteaffecting theinguinal lymphnodes. (virulentChlamydia

trachomatis)

• Primary Stage:Painless papules,on externalgenitalia

• Secondary:inguinal nodeenlargement ishallmark.

• Fever

• Foreign travel to Africa, South America, Haiti,Jamaica, East Asia,and Indonesia withhistory of sexualcontact

• Travel history is key

to diagnosis

• Rare in U.S.

• The HS/IDHS conductsvisual GU exam withchaperone

• Possible papules onexternal genitalia orunilateral tenderinguinal nodeenlargement – maydrain


STD Screening PRN:

• HIV

• RPR (syphilis)

• Chlamydia

• Gonorrhea

• HSV antibody

• Pap Smear

(HPV)• CBC

Antibiot ics:

Doxycycline

Encourage condomuse


Disease AlertReport




58–GENITOURINARY





TREATMENT FOLLOW-UP

Pediculosis

Infestation of thescalp (capitis), body(corporis), or pubicarea (pubis) byparasite(lice/crab/louse)

Acute onset ofintense pruritis inaffected hair areas

• Possible history ofsexual contact withinfestation exposure

• “Itch/scratch”interrupts sleep

• Complete skin exam andvisual GU exam withchaperonee

• Papules, erythema, inhair areas of groin orscalp; nits or eggcapsules that appear aswhitish structures on hairfilaments

• None usuallyindicated

• STD screeningmay be indicatedPRN

Topical:

Permethrin lotion orshampoo(Elimite/Nix)

Also treatshipboard or homecontacts and washassociated clothingand linen

• F/U PRN

• Eggs notdestroyed mayhatch with asecondinfestation in 2weeks

Syphilis

Contagiousspirochete diseasecaused byTreponemapallidum. Theclinical stages ofsyphilis, if

untreated, areprimary, secondary,latent, and tertiary.

Primary painlessulceration ongenitals may besubtle


• Onset 1-2 weeksafter exposure;primary lesion self-limiting in 7-10 days;secondary lesion isgeneralized rash

• Fever, malaise

• Tertiary syphilisinvolves latentneurologic symptoms

• Primary non-tenderulcerated (button-like)genital lesion, inguinaladenopathy; secondarylesion is generalizednon-tender

• Erythematous macularrash that also involves

soles and palms

• Tertiary syphilis involveslatent neurologicsymptoms


STD Screening PRN:

• HIV

• RPR (syphil is)

• Chlamydia

• Gonorrhea

• HSV antibody

•

Pap Smear (HPV)• If Rapid Plasma

Reagin (RPR) ispositive, confirmwith fluorescenttreponemalantibody absorption(FTA-ABS).

Antibiot ic:

• Penicillin Gbenzathine IM 2.4mil units ORDoxycycline 100mg bid x 14 days(for patientsallergic to

penicillin inprimary andsecondaryinfection)


CONTACT MOor Duty FlightSurgeon IF doubt.

Disease AlertReport




59–GENITOURINARY





TREATMENT FOLLOW-UP

Trichomoniasis

Contagiousflagellated protozoainfection caused byTrichomonasvaginalis. Thoughreferred to asvaginalis, may befound in males as

well as females.

Mild urethral orvaginal pruritus

• Sexual historyusually revealsmultiple partners

• Females withvaginal dischargeand “rancid” odor

• Males may havedysuria anddischarge, but may

be asymptomatic

• The HS/IDHS conductsa visual GU exam withchaperone

• Females with copiousyellow to green vaginalfrothy discharge withrancid odor. Malesmay have mild urethraldischarge.


• Cherry red cervix

Urinalysis:

• Wet mount –motile organisms

• Vaginal pH > 6.0(normal around4.0)

STD Screening PRN:

• HIV• RPR (syphilis)

• Chlamydia

• Gonorrhea

• HSV antibody

• Pap Smear(HPV)

Antibiot ic:

Metronidazole(Flagyl)

Encourage condomuse


CHIEF COMPLAINT: MALE COMPLAINT



60–GENITOURINARY


COMMONFEATURES

DIFFERENTIATINGSIGNS & SYMPTOMS



TREATMENT FOLLOW-UP

Epididymitis

• Infection orinflammation of theepididymis

• Common causesare coliformbacteria and ductalobstruction

• For young males

(<35 yo) considerN. gonorrheae orChlamydiatrachomotis

Testicular painand/or scrotalswelling

• Possible fever

• Consider STD ifpatient is under 35y/o

• The HS/IDHSconducts a visual GUexam with chaperone

• Testicular tendernessmoresuperior/posterior andelevation of testiclemay decrease pain(Prehn’s sign)

• May have scrotaledema and erythema

• Urinalysis – mayhave pyuria

• If suspected,complete STDscreening forChlamydia andGonorrhea

Antibiot ics:

Septra DS if NOT anSTD

• For gonorrhea:Ceftriaxone(Rocephin) IM

• For chlamydia: Doxycycline or

Azithromycin


• Disease AlertReport if STD

Hydrocele, Acute

Fluid accumulationin the serous liningcovering the testicle

and epididymis(tunica vaginalis)


• Scrotum may feelheavy

• May have fluctuationin the size of the

scrotum

• The HS/IDHSconducts a visual GUexam with chaperonee

• Swelling of the

scrotum

Transillumination-light passes throughthe hydrocele causinga red glow

(IF light does notpass through solid,firm mass = tumors =carcinoma untilproven other-wise)

If mass clearlytransilluminates,reassure patient, thoughmay not be self-limiting

& referral to MO isindicated.


Inguinal Hernia

An abnormalopening or

weakness in theabdominal muscularwall allowingprotrusion ofabdominal viscus(hernia, abdominal –see GI conditions)

May beasymptomaticor have mild

pain

• If reducible orirrreducible: Maycomplain of a soft

bulge at the site• If strangulated:

colicky abdominalpain, nausea andvomiting, abdominaldistention

• The HS/IDHSconducts a visual GUexam with chaperonee

• Reducible = able topush mass in

• Irreducible = unable topush mass in

• Strangulated =Irreducible, discolored,painful; do not reduce

None indicated If not consideredstrangulated, gentlyreduce hernia

CONTACT MOor Duty FlightSurgeon IF

doubt If strangulatedhernia,MEDEVAC

CHIEF COMPLAINT: MALE COMPLAINT (continued)



61–GENITOURINARY


COMMONFEATURES




TREATMENT FOLLOW-UP

Prostatitis, Acute

Infection orinflammation ofthe prostate gland.Usually caused byascending urethralinfection of coliform bacteria ornon-bacterialchronic cause.

Lower back andperineal pain

• Urinary frequency,urgency minorfeature

• Nocturia may bepresent

• The HS/IDHSconducts a visualGU exam withchaperone

• Digital rectal examby MO is indicated =tender, boggyprostate (IF prostatehard with nodules or

mass = tumor =carcinoma untilproven otherwise)

•

• Urinalysis – mayhave leukocytes

• Subtle symptomswith lower backpain (also seerenal calculi) inthe absence ofSTD Sx, providedirection for Tx

• Prostate Specific Antigen (PSA)

Antibiot ic:

Ciprofloxacin (Cipro)or Septra DS

Treat for 30 days

F/U if notimproving in 14days

TesticularTorsion

The twisting of thetestis andspermatic cordresulting in acuteischemia of testis


• History of trauma orexcessive physicalactivity just beforesymptoms

• Nausea and/or

vomiting


• Scrotum enlarged,

red, edematous• Testis may appear

high in scrotum withtenderness

• Elevating scrotumincreases pain

• Cremasteric reflexabsent

• Urinalysis –normal

• Do not delayemergency Tx forurinalysis if high

suspicion


• Torsion usuallyrotates inward.

For de-torsion, thetestis is rotatedoutward. Morethan one rotationmay be needed.Pain reductionguides progress.


MEDEVAC

If de-torsionfails,emergencysurgery isrequired tosave testis.Salvage dropsto 20% in 6-8hrs and near

0% in 12 hrs.

CHIEF COMPLAINT: MALE COMPLAINT (continued)



62–GENITOURINARY


COMMON

FEATURES




TREATMENT FOLLOW-UP

Urinary TractInfection (UTI)

Infection of theurinary tract orbladder.Uncommon inmales. Cause maybe ascendinginfection of

coliform bacteriaor STD.

Dysuria; urinaryfrequency andurgency.

• Consider causesthat introduce coliform bacteria asurinary infection

• Suprapubicdiscomfort

• The HS/IDHSconducts a visualGU exam withchaperone.

• CVA tendernessusually not present

• Digital rectal examby MO is indicated ifneed to R/O

prostatitis.

• Urinalysis - mayhave leukocyteand nitrites

• If suspected,complete STDscreening PRN,consideringChlamydia orGonorrhea

Antibiot ic:

Septra DS orciprofloxacin(Cipro)


Varicocele

A collection oflarge veins,usually on the leftscrotum, causedby venous valvedilation.


Feeling of heaviness inthe testicle(s)


• Visible swelling orpalpable “bag ofworms” in scrotum

Urinalysis – normal Analgesic:

Ibuprofen oracetaminophen fordiscomfort PRN.

Athletic support forscrotum

May requirereferral to MO IFdoubt

CHIEF COMPLAINT: FEMALE COMPLAINT

CONDITION & COMMON DIFFERENTIATING DIFFERENTIATING COMMON TREATMENT FOLLOW UP



63–GENITOURINARY


COMMONFEATURES




TREATMENT FOLLOW-UP

Bacterial Vaginosis A bacterial infectionof the vagina and/orvulva commonlycaused byGardnerellavaginalis.

Not STD.

• Mild vaginal

• Pruritis

• Dysuria

• Dyspareunia

• History ofvaginal/vulvairritation

• A grayish to cleardischarge withunique “fishy”vaginal odor



Urinalysis

• Wet mount – cluecell

• KOH ‘whiff test’with amine/fishyodor

Antibiot ic:Metronidazole(Flagyl)


Bartholin’s Cyst

Mucus-filledglandular cyst of theBartholin’s glandoccurring on eitherside of the vaginalopening; causeunknown, thoughmay be due tovaginal irritation.

Not STD.

• Mild vaginal

pruritis• Dysuria

• Dyspareunia

• Usually starts

asymptomatic, ascyst grows larger itbecome very painfulwith sitting

• If untreated, maydevelop into anabscess

• The HS/IDHS

conducts a visualGU exam withchaperone

• Lump or mass at theintroitus

Note: any drainage orsigns of infection =abscess.

• Urinalysis –

normal• Dx made with

physicalexamination

DDX:

• Skene’s Duct Cyst – duct obstructionat distal urethra

• Vulvar Inclusion

Cyst – ductobstruction atsebaceous glandof epidermis

Warm compresses

to area is mainstayof Tx

Analgesic:Ibuprofen oracetaminophen fordiscomfort PRN.

If the cyst becomesabscess considerantibiotics;Cephalexin (Keflex)

CONTACT MO

or Duty FlightSurgeon IFdoubt

Candidiasis, Volvo-vaginal

Yeast-like fungalinfection of the vulvaor vagina. Caused

by Candidaalbicans. Not STD.

Vulvar-vaginalpruritis

• White, malodorousdischarge

• Patient may relaythat symptomssimilar to past yeastinfections

• The HS/IDHSconducts a visualGU exam withchaperonee

• Cheesy discharge

with white plaqueson erythematousbase

• Urinalysis –normal

• KOH prep withpseudohyphaeand budding

spores

Anti fungal:

Clotrimazole 1%vaginal cream orfloxurindine(Diflucan)


CHIEF COMPLAINT: FEMALE COMPLAINT (continued)



64–GENITOURINARY


COMMONFEATURES




TREATMENT FOLLOW-UP

Urinary TractInfection (UTI)

Infection of theurinary tract orbladder. Cause maybe ascendinginfection of coli formbacteria or STD

Dysuria; urinaryfrequency andurgency

• Suprapubicdiscomfort

• Patient may relaythat symptomssimilar to pastinfections

• The HS/IDHSconducts a visualGU exam withchaperonee

• CVA tendernessusually not present

• Urinalysis - mayhave leukocyteand nitrites

• If suspected, STDscreening PRN,consideringChlamydia orGonorrhea

Antibiot ic:



CHIEF COMPLAINT: HEMATURIA


COMMONFEATURES




TREATMENT FOLLOW-UP

Glomerulonephritis, Acu te

Inflammation of theglomeruli of the kidney.

More common inyoung adults.

Hematuria • History of recentstreptococcalinfection or otherinfection

• Oliguria, edema,and weight gain

• Complete physicalexam

• May havehypertension

• Urinalysis – Bloodand protein (noleukocytes ornitrites)

• CBC

• Renal FunctionTest

CONTACT MO orDuty FlightSurgeon fordirections.

F/U with MO forproper work-up

Pyelonephritis, Acute

Bacterial infection ofthe kidney; may lead tobacteremia,progressing to septicshock and death if

untreated

Hematuria • Fever

• Flank pain

• Shaking chills

• Urinary urgency

• Frequency

• Dysuria

• Malaise,• Myalgia

• Anorexia

• Nausea

• Vomiting

• Diarrhea

• Headache

• Suprapubic pain


• Febrile

• Tachycardia

• CVA tenderness

• Urinalysis – Bloodand protein PLUSleukocytes, &nitrites

• Urine culture ->100,000 CFU/ml.

• CBC

• Renal ultrasoundor spiral CT

Antibiot ic:


Analgesic:

Acetaminophen(NSAIDSmetabolized inkidney)

Increase fluids, SIQx 72 hours


F/U if noimprovement in24 hrs; considerhospitalizationand MEDEVAC

CHIEF COMPLAINT: HEMATURIA, (continued)

CONDITION & COMMON DIFFERENTIATING DIFFERENTIATING COMMON TREATMENT FOLLOW-UP



65–GENITOURINARY


COMMONFEATURES




TREATMENT FOLLOW UP

Renal Calculi“Kidney stones” arecrystallized minerals,commonly calcium oruric acid that forms inthe urinary tractsystem.

Hematuria,though may

just present asflank pain

• May have history ofkidney stones,family history ofkidney stones

• Pain originates inflank though mayradiate togroin/testicles/supra-pubic or labia

• May havediaphoresis,tachycardia,nausea, vomiting

• Patient appearsanxious and unableto sit; paces thefloor.

• May have CVAtenderness thoughno fever unlesskidney infection alsopresent

• Urinalysis – Bloodand acidic (<7pH)or alkalytic(>7pH). Normalurine pH is around7.0

• Spiral CT ofkidneys

Analgesic:Ketorolac (Toradol)or morphine IM/IV

Oral Analgesic: Tramadol (Ultram)Tx nausea PRN.

IV – NS

‘Catch’ urine to find

stone


MEDEVAC PRN



66–GENITOURINARY


CHIEF COMPLAINT: MENSES COMPLAINT



67–GYNECOLOGICAL

CONDITION &

DEFINITION


SIGNS & SYMPTOMS

DIFFERENTIATING

OBJECTIVE FINDINGS

COMMON

DIAGNOSTIC TEST

TREATMENT FOLLOW-UP

DysfunctionalUterine Bleeding

This is abnormaluterine bleedingcaused by hormoneimbalance.

Other causes ofabnormal uterinebleeding includeanovulation;pregnancy-related,malignancies,infection, masses,tumors, or cysts.

Lower abdominalpain and crampingwith dysfunctionaluterine bleeding.

Dysfunctional uterinebleeding is morefrequent than typicalmenses; > 7 days ofheavy menses OR lessthen 21 days apart ORirregular bleedingbetween menses.

Ask about “possibility of

pregnancy”

• The HS/IDHSconduct anabdominal exam

• History alone mayelicit tentativediagnosis ofdysfunctionaluterine bleeding

• Refer to MO for

pelvic exam

• HCG Negative (R/O pregnancyin all femaleswith abdominalpain or uterinebleeding)

• If HCG ispositive, patientis pregnant.

Consider ectopicpregnancy orthreatenedabortion whichare emergentconditions.

• CBC• Urinalysis, and

other tests PRN

OralContraceptivePill:

Take tid for 3 days,then once daily forthree months toprevent recurrence.

Consult with MOprior to treatment


Dysmenorrhea,Primary

Primary: cramps,lower abdominalpain that occursbefore or duringmenses caused byexcessprostaglandinrelease. Secondary

dysmenorrhea haspathologic cause.

“Crampy” lowerabdominal pain

Pain is intermittent orconstant and may beassociated withmoodiness, fatigue,headache, bloating andnausea.

• The HS/IDHSconduct anabdominal exam

• History alone mayelicit diagnosis

• Refer to MO forpelvic exam

• CBC

• Urinalysis

• Dysmenorrheaworkup: wetmount, pap,cultures,ultrasound

Analgesic :

• Ibuprofen 800mg tid.

• May addacetaminophen1000 mg tid forseverediscomfort




68–GYNECOLOGICAL


CHIEF COMPLAINT: NECK PAIN



69–MUSCULOSKELETAL

CONDITION &

DEFINITION

COMMON

FEATURES

DIFFERENTIATING

SIGNS & SYMPTOMS

DIFFERENTIATING

OBJECTIVE FINDINGS

COMMON

DIAGNOSTIC TEST

TREATMENT FOLLOW-UP

Cervical MuscleStrain

A ‘strain’ can referto muscle andligamentousinjury, thoughhere, generally,strain refers tomuscle injury. The

term strain andsprain are ofteninterchangeable.

Pain alongtrapezius and/orsternocleidomastoidmuscles

O – trauma orspontaneous

P – extreme movementor spasm makes worse

Q – dull ache

R – nonradicular

S – mild to moderate

T – constant

Tension headache maybe associated

Insp: symmetrical w/oatrophy/deformity/discolor

Palp: tenderness atparaspinous andtrapezius muscle

ROM: active - limited;passive - full

Stability: yes

Motor: 5/5 strengthsSense: normal

No bony tenderness

Radiograph indicatedif trauma

Analgesic/NSAID:

Ibuprofen

• Ice initially,then moist heat

• Rest

• May last 1-2weeks

•

ROM exerciseswhen acutepain subsides


HerniatedCervical Disk

Rupture of theinter-vertebral discwith protrusion ofthe nucleuspulposus in thespinal canal.

HNP = HerniatedNucleus Pulposus

Neck pain may beprominent, thoughmay present asdeltoid or handnumbness also.

O – acute trauma orpast trauma

P – worse w/ extension;better w/ rest

Q – dull to sharp ache

R – radiculopathy indeltoid or hand


T – intermittent

Tension headache maybe associated.


Palp: tenderness atcervical disk (C5/6/7)

ROM: active - limited;

passive - limitedStability: stable

Motor: 3/5 strengths(neck and grip)

Sense: distal sensationin hand may diminish

Distraction Test less pain;Compression Test morepain

• Radiographindicated iftrauma

• MRI to confirmHNP

Analgesic/NSAID:

Ibuprofen

• Moist heat

• Bed Rest for 1-2 days

• ROM exerciseswhen acutepain subsides

• Chronicproblem

• If notimproving, referto MO


If in doubt,

CONTACT theMO

CHIEF COMPLAINT: SHOULDER PAIN





CONDITION &

DEFINITION

COMMON

FEATURES

DIFFERENTIATING

SIGNS & SYMPTOMS

DIFFERENTIATING

OBJECTIVE FINDINGS

COMMON

DIAGNOSTIC TEST

TREATMENT FOLLOW-UP

Bicepital TendonRupture,Proximal

The tendonrupture is morecommon in olderadults and oftenassociated withchronic shoulder

pathology.

Involves proximalbicepital tendon,though may begeneralized pain

O – acute trauma orforce on muscle

P – worse w/ onset;better over time

Q – sudden sharp ache

R – nonradicular


T – worse w/ onset

Often a result of a trivialevent

Insp: asymmetrical withbulge deformity distally &may have ecchymosis

Palp: early tendernessproximally, then no pain

ROM: active - full;passive - full

Stability: stable


The bulge can beaccentuated bycontraction of biceps


Analgesic/NSAID:

Ibuprofen

• ProgressiveROM exercises

• Nonsurgicaltreatment iseffective

• Distal rupture

may requiresurgicalintervention

CONTACT MOor Duty FightSurgeon foradvice

BicepitalTendonitis

Inflammation ofthe tendoncaused byrepetitivemovement ortrauma

Involves anteriorbicipital groove,though may be

generalized pain

O – overuse

P – worse w/ use;better w/ rest

Q – dull ache

R – nonradicular


T – intermittent orconstant

Often concurrent withsubacromial bursitis


Palp: tenderness overbicipital groove.

ROM: active - full;passive - full

Stability: pain, weaknesswith Yergason’s Test

Motor: 4/5 strengths

Sense: normal


Analgesic/NSAID:

Ibuprofen

No overhead reachfor 3-4 days,consider sling toprevent reach


CHIEF COMPLAINT: SHOULDER PAIN (continued)





CONDITION &

DEFINITION

COMMON

FEATURES

DIFFERENTIATING

SIGNS & SYMPTOMS

DIFFERENTIATING

OBJECTIVE FINDINGS

COMMON

DIAGNOSTIC TEST

TREATMENT FOLLOW-UP

ImpingementSyndrome

A chronicinflammationcausing fibrosis ofthe tendon or ananatomical tiltingof the acromionprocess

Chronicgeneralizedshoulder painexacerbated byoverhead reach

O – chronic overuse orpast trauma

P – worse w/ overheadlifting or ball throwing;better w/ rest

Q – dull ache

R – nonradicular



Past history of rotatoror acromion jointtrauma


Palp: tenderness overthe glenohumeral joint

ROM: active - limited;passive - limited

Stability: pain, weaknessw/ abduction > 90 degree


Chronic cases may resultin atrophy of rotator cuffmuscles

Failed conservativetreatment requiresreferral to orthopedicsurgeon. MRI isindicated then.

Analgesic/NSAID:

Ibuprofen

• CodmanExercises

• Avoid overheadreaching

• If notimproving, refer

to MO; steroidinjections maybe indicated


Rotator CuffTear

Four musclescompose therotator cuff. Thesupraspinatus ismost ofteninvolved in a tear.Cause of tear maybe acute injury,though commonlyit is related to old,

degenerativeinjury.

Chronic painassociated withspecific past injury;acute presentationis also possible

O – chronic w/ pasttrauma or night pain

P – worse w/ overheadlifting or ball throwing;better w/ rest

Q – dull ache

R – nonradicular



Past history of rotatoror acromion jointtrauma


Palp: tenderness overthe glenohumeral joint


Stability: pain, weaknessw/ Drop Arm Test


Sense: normal

Chronic cases may resultin atrophy of rotator cuffmuscles.

Failed conservativetreatment requiresreferral to orthopedicsurgeon. MRI isindicated then.

Analgesic/NSAID:

Ibuprofen• Codman

Exercises

• Avoid overheadreaching

• If notimproving, referto MO; steroidinjections maybe indicated


CHIEF COMPLAINT: SHOULDER PAIN (continued)





CONDITION &

DEFINITION

COMMON

FEATURES

DIFFERENTIATING

SIGNS & SYMPTOMS

DIFFERENTIATING

OBJECTIVE FINDINGS

COMMON

DIAGNOSTIC TEST

TREATMENT FOLLOW-UP

SubacromialBursitis

Inflammation ofthe bursae, thefluid-filled sac ofthe acromionprocess

Involves anterioraspect of lateralshoulder, thoughmay be generalizedpain

O – acute trauma oroveruse

P – worse w/ use;better w/ rest

Q – dull ache

R – nonradicular


T – intermittent or

constant

Often concurrent withbicipital tendonitis


Palp: tenderness atanterior/inferior acromion


Stability: yes


Sense: distal sensationin hand may diminish.

Arm maximally flexed forpalpation


Analgesic/NSAID:

Ibuprofen

• CodmanExercises

• If not improving,refer to MO;steroid injectionsmay be indicated


CHIEF COMPLAINT: ELBOW PAIN






COMMONFEATURES




TREATMENT FOLLOW UP

Bursitis,Olecranon

Inflammation ofthe bursae, thefluid-filled sac ofthe olecranonprocess

Acute pain ondorsal aspect withdramatic swelling isthe most commonpresentation

O – acute swelling(trauma) is mostcommon. Infection mayalso be acute (cellulitis).

P – worse w/ attempt toput on shirt; better w/rest

Q – dull ache

R – nonradicularS – mild to moderate


Gradual swelling is dueto chronic inflammation

Insp: asymmetrical w/oatrophy/discolor.Dramatic fluctuantswelling.

Palp: tenderness overthe dorsal olecranon


Stability: stableMotor: 4/5 strengths

Sense: normal

See cellulitis -if infectionsuspected

• Usually nothingindicated

• Radiographindicated iftrauma

• Aspiration of fluidmay be boththerapeutic anddiagnostic. Fluidshould beanalyzed andcultured.

Analgesic:

Ibuprofen

• RICE

• Self-limiting

• Reassurance

F/U if notimproved in 7days or signs ofinfection

Epicondylitis,

Medial/Lateral

A chronic irritation(not inflammation)causing fibrosis ofthemuscles/tendon

just distal to theepicondyle

Gradual elbowpain. Lateralepicondylitis ismost common.

O – gradual pain with

history of overuse

P – worse w/ wristextension or rotation;better w/ rest

Q – dull ache

R – nonradicular



Lateral more commonthan medial symptoms

Insp: symmetrical w/o

atrophy/deformity/discolor

Palp: tenderness justdistal to epicondyle

ROM: active – full;passive – full; Lateral =pain with wrist extension

Stability: stable


Sense: normal

Medial = pain with wristflexion


Analgesic:


• ROM Exercisesand isometricsqueezing ofrubber ball

• If not improving,refer to MO;steroid injections

may be indicated


CHIEF COMPLAINT: WRIST PAIN






COMMONFEATURES




TREATMENT FOLLOW UP

Carpal TunnelSyndrome

Compression ofthe median nervedue to repetitivemovement of thewrist (forexample, typing)

Vague, gradual oracute ache in wristor hand

O – vague pain withhistory of overuse

P – worse w/ sleep &repetitive action; betterw/ rest

Q – dull ache

R – radicular referral tothenar, thumb, index

and middle fingersS – mild to moderate

T – intermittent

Insp: asymmetrical w/thenar atrophy w/odeformity/discolor

Palp: tenderness andradiation; Positive Tinel’sand Phalen’s Tests

ROM: active – full;passive – full

Stability: stableMotor: 3/5 strengths

Sense: decreasedsensation to thenar,thumb, index, and middlefingers


Analgesic:

Ibuprofen

• Modify repetitivemovementactivities

• Night splint helpprevent fullflexion of wrist

during sleep

F/U if notimproved in 30days or worse,refer to MO

Ganglion Cyst

Cystic structure

that arises fromthe capsule of the

joint synovialsheath andcontains thick,clear, mucinousfluid

Painful, localizedmass on dorsal or

volar surface ofwrist

O – gradual with orwithout pain, may have

history of overuseP – worse w/ activitiesof frequent movement;better w/ rest

Q – dull ache

R – non-radicularunless median nerveinvolved


T – intermittent

Insp: asymmetrical w/oatrophy/discolor. Lump

on dorsal or volar aspectPalp: tenderness overfluctuant mass


Stability: stable


Sense: normal unlessmedian nerve involved


• Reassurance isusually

adequate• If activities of

daily living(picking uppaper/glass) arecompromised,refer to MO forpossibleaspiration ofmass

F/I if notimproved in 30

days or worse,refer to MO

CHIEF COMPLAINT: WRIST PAIN (continued)





DEFINITION FEATURES SIGNS & SYMPTOMS OBJECTIVE FINDINGS DIAGNOSTIC TEST

Scaphoid WristFracture

Most common fxof the wristcaused by fall onoutstretchedhand. Importantbecause offrequency and

Scaphoid onlyhas proximalblood supply.Untreated fracturecan lead toosteonecrosis.

Acute wrist painafter trauma

O – acute associatedwith trauma

P – worse w/ gripping;better w/ rest

Q – dull ache

R – nonradicular


T – intermittent

Insp: asymmetrical w/oatrophy/deformity/discolor

Palp: tenderness at(snuffbox) dorsalScaphoid bone

ROM: active – limited;passive – full

Stability: stable


• Radiographindicated if trauma

• Fracture may notbe visible on initialradiographs andmust be repeatedif pain persistsbeyond 2-3 weeks

Analgesic:

Acetaminophenwith codeine for 7days (short term).

• When in doubt,treat as fracture.Short arm splintand immobilizethumb (thumbspica cast).

• Contact MO


CHIEF COMPLAINT: FINGER PAIN






Paronychia

Infection of thetissue aroundfingernail. (calleda “Felon” iffingertip involved).Staphylococcusaureus is themost common

cause.

Acute pain at distalphalanx along edgeof nail

O – acute w/ history oftrauma vague pain.

P – worse w/ palpationto lesion; better w/ rest

Q – dull ache

R – nonradicular

S – moderate to sever

T – constant

Insp: asymmetrical w/localized red (rubor),tender (dolor), warm(calor), fluctuant swelling(tumor) along lateraledge on nail.

Palp: very tender


Stability: stable


Sense: intact

Culture if unsure orsuspect MRSA

Antibiot ic:

Cephalexin(Keflex)

I and D as directedby MO

Follow up every24 hours untilresolved.

If not resolved in7 days;

CONTACT MO



CHIEF COMPLAINT: KNEE PAIN


COMMONFEATURES




TREATMENT FOLLOW-UP





Bursitis, Patellar

Inflammation ofthe bursae (fluid-filled sac), causedby repetitivekneeling. Thereare several bursaof the knee thatmay be involved.

Knee pain withdirect pressure orafter prolongedsitting or kneeling

O – may or may notpresent as pain. May

just be swelling.

P – worse after sitting orkneeling; better w/activity

Q – dull ache

R – nonradicular


T – intermittent

The patient will befeverish if infected.

Insp: w/o atrophy/discolor. Swelling maybe evident

Palp: tenderness overbursae


Stability: stable


Sense: normal

An infected bursae willshow signs of infection.


Note: infected(septic) and goutyknees will present asa swollen, painfulknee in the absence of trauma and will

require MOconsultation fordiagnostic approach.

Analgesic:

Ibuprofen

No kneeling for 7-10 days

If not improved in14 days or signsof infection orgouty, refer toMO.

CollateralLigament Tear

(Lateral/Medial)

The medialligament is mostcommonly injuredand related tovalgus force as ina football clippinginjury.

Acute knee painwithout initialswelling

O – acute pain withoutinitial swelling

P – worse w/

ambulation; better afterswelling reduces

Q – sharp ache

R – nonradicular

S – severe

T – constant;ambulation limitationmay be 24-48 hrs afterswelling progresses

Insp: slight swellingwith possibleecchymosis

Palp: tender overligament

ROM: active – limited;passive – limited

Stability: instable,positive valgus/varusstress test


Sense: normal

Radiograph indicatedto rule out fracture

Note: Unlike thelateral, the medialcollateral ligamentattaches to themeniscus and injuryto either can affectthe other.

Analgesic:

Ibuprofen

• RICE andcrutches

• Immobilize for2-3 days, thenregular, gentleROM exercises

• Usually non-surgical. ROMexercises andstrengthening

are important torecovery

If not improved in14 days; consultwith MO

CHIEF COMPLAINT: KNEE PAIN (continued)


COMMONFEATURES




TREATMENT FOLLOW-UP





CruciateLigament Tear (Anter./Posterior)

The anteriorcruciate ligamentis the prime kneestabilizer andmore likely to beinjured. A tear

results from atwisting or hyper-extension of theknee joint.

Acute and severeknee pain andswelling associatedwith trauma

O – sudden pain maybe associated with anaudible pop

P – worse w/ambulation; better afterswelling reduces

Q – sharp ache

R – nonradicular

S – severeT – constant

Pain develops over 24hrs as swelling worsens

Insp: marked swellingwith possibleecchymosis

Palp: tender knee


Stability: instable;positive Drawer Sign


Initially, knee may betoo swollen to examine

• Radiographindicated to ruleout fracture

• MRI, althoughquite sensitive todetecting tears,rarely arenecessary unlessdiagnosis is

allusive or surgeryis indicated

Analgesic:

Ibuprofen

• RICE andcrutches


• If not correctedby surgery,ROM exercisesandstrengtheningare important torecovery

Consult with theMO

Meniscal Tear

(Lateral/Medial)The menisci arefibrocartilaginouspads that act asshock absorbers.Significant twistingcan injury themeniscus, thoughin older patients,minimal or no

trauma can causeinjury.

Acute trauma mayresult in a ‘lockingsensation’ withflexion

O – Insidious, even withtrauma. No initialswelling

P – worse w/ lockingsensation or squatting;better with rest

Q – sharp ache

R – nonradicular

S – mild

T - intermittent

Insp: may have slightswelling otherwisenormal

Palp: tender along jointline


Stability: stable,positive McMurray testwith painful click


Sense: normal

• Radiograph

indicated to ruleout fracture

• Diagnosis may beallusive and MRIis quite sensitiveto detecting tears

Analgesic:

Ibuprofen• RICE and

crutches


• Surgery may beindicated


CHIEF COMPLAINT: KNEE PAIN (continued)


COMMONFEATURES




TREATMENT FOLLOW-UP





PatellofemoralSyndrome

Vague painassociated withrunning orclimbing stairs,usually in youngerpatients. Causecan be articular

surfaceirregularities orpatellarmalalignment.

Diffuse knee painwith running andmay have crepituswith squatting

O – insidious

P – worse w/ prolongedsitting or running; betterwith rest

Q – dull ache

R – nonradicular

S – mild

T - intermittent


Palp: nontender,though crepitus withmovement


Stability: Stable.Positive Patellar Grindtest


Sense: normal


• Q-anglemeasurement canbe helpful todeterminingmalalignment.

Analgesic:

Ibuprofen

Continue activitybut change to lowimpact orswimming untilresolved

F/U if notimproved in 2-3months

Popliteal Cyst

A “Baker cyst” is acystic structure

that arises fromthe capsule of the

joint synovialsheath associatedwith arthritis ordegeneration ofthe meniscus

Cyst may bepainless andpresent as swelling

behind the knee

O – gradual and may bepainless w/ just patientcomplaint of swelling

behind the kneeP – worse if cystruptures; better afterswelling reduces

Q – dull ache

R – nonradicular

S – slight to mild

T – intermittent

Insp: asymmetrical w/swelling in poplitealfossa w/o atrophy or

discoloration.Palp: tender ornontender poplitealmass.


Stability: stable thoughmay have positiveMcMurray if meniscus iscause


Sense: normal

Transillumination, orshining a light throughthe cyst, can

demonstrate that themass is filled withfluid

• Observationunless the cystbecomes large

and painful• NSAIDs for

minordiscomfort

• Treatment isdirected at thecause. Refer toMO PRN

F/U PRN

CHIEF COMPLAINT: ANKLE PAIN


COMMONFEATURES




TREATMENT FOLLOW-UP

http://www.nlm.nih.gov/medlineplus/ency/article/003103.htm

http://www.nlm.nih.gov/medlineplus/ency/article/003103.htm




Ach il les TendonRupture

Usually the tendonruptures justproximal tocalcaneus, andmore common inmiddle-aged menwho play quick,

stop-and-gosports.

Sudden, severecalf pain

O – sudden w/audible‘pop’ and pain mayresolve quickly

P – worse w/ambulation; better withrest

Q – sudden sharp thendull ache

R – nonradicular

S – moderate to severe

T – constant

Insp: asymmetrical w/calf swelling andecchymosis

Palp: tender


Stability: unstable w/positive Thompson test(no plantar flexion w/calf squeeze)


Sense: normal

Usually nothingindicated.

Analgesic:

Ibuprofen PRN

• Initially RICE

• Immediatereferral toMO required

• There aresurgical and

non-surgicalapproachesrequiring anorthopedicevaluation


MEDEVAC

Ankle Sprain

Most commonankle ligament

sprain is the lateralanterior talofibularligament (ATFL)caused by aninversion injury.

The rare aversioninjury involves themedial deltoidligaments.

• Acute ankle painassociated withtrauma

• Ability toambulate andweight-bearhelps determineseverity

O – sudden andswelling may not beimmediate

P – worse w/ambulation; better withrest


R – nonradicular


T – constant

Insp: asymmetrical w/swelling andecchymosis

Palp: tender at ATFLTenderness at baseof 5

th metatarsal may

indicate fracture.


Stability: unstable w/positive Drawers sign


Sense: normal

Radiograph indicatedto rule out fracture ifpatient unable toweight-bear, or ifthere is markedswelling.

Analgesic:

Ibuprofen

• RICE and

crutches


• Severe sprainsmay require acast ororthopedic bootfor 2-3 weeks


CHIEF COMPLAINT: FOOT PAIN


COMMONFEATURES




TREATMENT FOLLOW-UP




5TH

MetatarsalFracture

The fifthmetatarsal is atthe base of thesmall toe, and theproximal end,where the fractureoccurs, is in the

mid-portion of thefoot.

These fracturesoccur after forcedinversion with thefoot and ankle inplantar flexion,causing thetendon to pull off apiece of the bone.

Patients whosustain a fracturehave pain over thismiddle/outsidearea of their foot

O – trauma (after aninversion injury)

P – walking andprolonged standingaggravate thesymptoms


R – nonradicular


T – constant,aggravated byprolonged standing,walking or activity

Insp: ecchymosis andswelling at the site

Palp: tenderness at thebase of the fifthmetatarsal. Fullevaluation of the distalfibula and lateralligamentous structuresmust be included in the

assessment.Stability: stable


Sense: normal

• Radiographs areindicated withinitial evaluation

• Weight-bearingradiographsindicated iftreatmentunsuccessful

Analgesic:

Ibuprofen

• Options includeelastic wrapping,ankle splints andlow-profilewalking boots orcasts

• Weight bearing isallowed astolerated

• Treatment shouldbe continued untilsymptoms abate--usually within sixweeks

F/U if notimproving in 6weeks

Heel Spur

Soft, bendabledeposits ofcalcium that arethe result oftension andinflammation inthe plantar fascia

attachment to theheel.

Dull ache that isfelt most of thetime with episodesof a sharp pain inthe center of theheel or on theinside margin ofthe heel.

O – first ambulation

P – worse w/ fistambulation; better withtime, though returnsover course of day


R – nonradicular


T – constant,aggravated byprolonged standing


Palp: tender atcalcaneal tuberosity


Stability: stable


Sense: normal

• Radiographs notindicated withinitial evaluation


Analgesic:

Ibuprofen

• Heel cushion ordonut

• Avoid highimpact exerciseor work

F/U if notimproving in 3-6months

CHIEF COMPLAINT: FOOT PAIN (continued)


COMMONFEATURES




TREATMENT FOLLOW-UP




Plantar Fasciitis

Degenerative tearof fascial originfrom thecalcaneus. Thismay beassociated with aheel spur.

• Acute orChronic archpain

• Usually notrauma; worseon firstambulation angradually getsbetter

throughout day

O – first ambulation

P – worse w/ fistambulation; better withtime throughout day

Q – dull ache

R – nonradicular


T – constant


Palp: tender at medialcalcaneal tuberosityand distally alongplantar fascia


Stability: stable


Sense: normal

• Radiographs notindicated withinitial evaluation


Analgesic:

Ibuprofen

Heel cup (raiseheel slightly todecrease strain onplantar fascia) orOTC orthotic insert

F/U if notimproved in 3-6months

CHIEF COMPLAINT: TOE PAIN


COMMONFEATURES




TREATMENT FOLLOW-UP




Ingrown Toenail

The toenailabnormally growsinto nail bed andmay involveinfection of thetissue aroundtoenail.

Staphylococcus

aureus is the mostcommon organisminvolved

Acute pain at distalphalanx alongedge on nail

O – Insidious

P - worse w/ palpationto lesion; better w/ rest

Q – dull ache

R – nonradicular

S – moderate to sever

T – constant

Insp: asymmetrical w/localized red (rubor),tender (dolor), if infectedwill also be warm (calor),and swollen (tumor)along lateral edge onnail

Palp: very tender

ROM: active – full;

passive – fullStability: stable


Sense: normal

Culture if unsure orsuspect MRSA

Soak the foot inwarm water 4 timesa day, preferablywith Epsom salts.

If infected:

Antibiot ic:

Cephalexin(Keflex)

•

Painmanagement,no boots

• Partial toenailremoval asdirected by MO

Follow up every24 hours untilresolved

IF not resolved in7 days;CONTACT MO

CHIEF COMPLAINT: LEG PAIN



DIFFERENITIATINGOBJECTIVE FINDINGS


TREATMENT FOLLOW-UP




Shin Splints

A general namegiven to pain atthe front of thelower leg relatedto inflammation ofthe periosteum ofthe tibia due totraction forces on

the musclesattached. Causedby training toohard or running inill-fitting or worn-out footwear.

Lower leg pain overinside of the shin

O – gradual onset

P - worse with running;better w/o activity

Q – dull ache

R – nonradicular


T – intermittent

Insp: w/o atrophy/discolor, deformity. Mayhave slight swelling.

Palp: tenderness overanterior tibia (shin)


Stability: stable



Note: If symptomsappear persistent,radiographs mayindicate stressfracture.

Analgesic:

Ibuprofen

Wear properfootwear andlessen the impactof training

F/U if notimproved in 14days; or refer toMO




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CHIEF COMPLAINT: ALTERED MENTAL STATUS(though any neurological condition can have AMS, the CC here is categorized by common presenting features)

CONDITION &

DEFINITION

COMMON

FEATURES

DIFFERENTIATING

SIGNS & SYMPTOMS

DIFFERENTIATING

OBJECTIVE FINDINGS

COMMON

DIAGNOSTIC TEST

TREATMENT FOLLOW-UP



87–NEUROLOGICAL


Alcoho l Intoxicati on

Physically and/orpsychologically relianton alcohol. Alcoholabuse may besituational or chronic.

Alcohol dependencyis a chronic, life-time

diagnosis.

• Acute intoxication

• Cognitive deficit

• Sloppy speech,alcohol on breath

• Nausea and vomiting

• Headache

• Happy, sad or angryaffect

(Note: diabetic

emergencies mayappear asintoxication)

• Appears intoxicated

• The classic chronicalcoholic may appearwith poor hygiene,spider angiomas onskin, ‘red faced’, ‘pot’belly, thin extremities.

Ask:

C = cut down need?

A = annoyed by drink?

G = guilty about drink?

E = eye opener need?

Reasonable bloodalcohol concentration(BAC) is <0.06%.

(1 drink = 0.03%BAC: 12 oz of 4%beer, 1.5 oz of 40%shot, or 6 oz of 11%

wine)

Note: 5 drinks/2.5 hrs= 0.15 BAC= intoxication/delirium

Acute Tx:

• Time

• Avoid stimulantslike caffeine

• Monitor

• Severe casesmay require MO

consultation.

Chronic Tx:

Refer to MO

Refer to CDAR

Note: MNM-0013is:

Maturity = Mod.

Zero illegal drink

Zero DUI

1 drink per hour

3 drinks per 24hours

Never leave drinkunattended

Cerebrovascular Acc ident (CVA)

Infarction orhemorrhage in thebrain caused byischemia, trauma oranticoagulation. Mostcommon in age > 45.

Acute cognitivedeficit

• Slurred speech

• Motor and sensorydeficits

• Headache may begradual or sudden

• Patient able to easilyclose both eyes butunable to completely

smile. Facialweakness does notinclude forehead as itdoes in Bell’s Palsy.

• Complete physicalexamination includingneurological

• CBC

• Blood chemistries

• Blood glucose• RPR

• Urinalysis

• ECG

• CT of head

Acute Tx:

Aspirin 650 mg bid

Chronic Tx:

Refer to MO

CONTACT MOor Duty FlightSurgeon.

MEDEVAC

CHIEF COMPLAINT: ALTERED MENTAL STATUS(though any neurological condition can have AMS, the Chief Complaint is categorized by common presenting features)

CONDITION &

DEFINITION

COMMON

FEATURES

DIFFERENTIATING

SIGNS & SYMPTOMS

DIFFERENTIATING

OBJECTIVE FINDINGS

COMMON

DIAGNOSTIC TEST

TREATMENT FOLLOW-UP



88–NEUROLOGICAL


Seizure

Paroxysmalhyperexcitation ofthe neurons in thebrain. Epilepsy ischronic recurrentseizures.

Compromisedmotor activity

• Partial Seizure – no lossof consciousness,though simple musclecontractions,paresthesias, loss ofbowel & bladder

• Petit Mal Seizure –sudden stopping of

motor function withblank stare

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

Between seizures,physical exam isnormal, though mayhave bruising or traumato tongue just after.

• CBC

• Chemical Panel

• Urinalysis

• Drug & alcoholscreening

• CT scan or MRI

• During seizure,maintain airwayand preventinjury.

• Refer to MO

Seizure > 10minutes needemergencyintervention!

Consult with MOor Flight Surgeon

CHIEF COMPLAINT: HEADACHE


COMMONFEATURES


DIFFERENTIATINGOBJECTIVE

FINDINGS


TREATMENT FOLLOW-UP



89–NEUROLOGICAL

FINDINGS

Emergent

Hemorrhage,Subarachnoid

Hemorrhage withinthe subarachnoidspace of the braincaused by trauma oranticoagulation

Acute cognitivedeficit withsudden, severeheadache

• Sudden, severeheadache. Reports“worst headache oflife”

• Nausea, vomiting

• Altered consciousness

• May have visual andneurological deficiency

• Appears with alteredlevel ofconsciousness

• Increased BP

• Tachycardia

• Complete physical

examinationincludingneurological

• CBC


• Blood glucose

• RPR

• Urinalysis

•

ECG• CT of head

• Oxygen

• IV- NS

• Comfortable rest

Emergency

treatment is required


MEDEVAC

HypertensionEmergency

Severe hyper-tensionwith potential tocause target organdamage (brain,

cardio-vascularsystem, and kidneys)

Normal mentalstatus withheadache

• May be asymptomaticor have a headachewith blurred vision

• Nausea and maybevomiting

• Marked increasedBP with a diastolic of>120 (>210/>120) and bounding pulse

• Fundoscopic =papilledema

• Complete physicalexaminationincludingneurological

• CBC


• Urinalysis

• ECG

• Spiral CT of

kidneys

Antihypertensive: Nitroprusside IV; BPmust be reducedwithin 1 hour

Emergency

treatment is required


MEDEVAC

Meningitis

Bacterial or viralinfection/inflammationof the covering of thebrain and spinal cord.

Cause is mainlybacterial or viral.Cause must beidentified becausetreatments aredifferent.

• Acute severeheadache witha fever

• May havecognitive deficit

• Fever

• Gradual or suddenheadache with neckpain and stiffness

• Photophobia

• Occasional rash

• Febrile

• Nuchal rigidity onflexion only

• Positive Kernig’s orBrudzinski’s sign

• Fundoscopic =papilledema

• Complete physicalexaminationincludingneurological

• CBC

• Lumbar Puncture

• CT of head

Acute Tx:

Determine cause:

• If bacterial, IVantibiotics asdirected

• If viral, IVanalgesics asdirected

Emergencytreatment is required


MEDEVAC

CHIEF COMPLAINT: HEADACHE (continued)


COMMONFEATURES



COMMONDIAGNOSTIC

TEST

TREATMENT FOLLOW-UP



90–NEUROLOGICAL

Non-Emergent

Cluster Headache

Excruciating unilateralperiorbital or temporalpain typically in men.Cause unknown, thoughsuggests hypothalamicdisorder.

Normal mentalstatus with sharp,boring headache

• Rhinorrhea

• Ipsilateral lacrimation

• Unilateral headachecentered around orbitand lasting 30-120minutes in clusters

over 4-12 weeks with1-2 per day.

• Appears un-rested,and in pain



• If uncertain, CTor MRI of head

• Acute Tx: Ergotamines (NOTwith sulfa allergy):Sumatriptan SQ(Imitrex) or Midrin,oxygen, IV NS ifdyhydrated

• Chronic Tx –referto MO

F/U if notimproved in 24hrs refer to MO

Sinusitis

Inflammation or infectionof mucous membranesof paranasal sinus

• Normal mentalstatus with dull,functionalheadache

• NasalCongestion

• Sinus pressure, facialpain or headache

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

malaise.

• Turbinates areerythematic andswollen

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

percussion

• May be unable totransilluminate sinuses



Antibiot ic:

Amoxicillin-clavulanate(Augmentin) orSeptra DS

• Reserve antibioticsfor patients that faila 7 day course ofdecongestants andanalgesics

• If severe pain, treatsooner

F/U if notimproved in 7days orincreased feveror headache

CHIEF COMPLAINT: HEADACHE (continued)


COMMONFEATURES




TREATMENT FOLLOW-UP

Non-Emergent (continued)



91–NEUROLOGICAL

Non Emergent (continued)

Tension Headache

Diffuse bilateraloccipital or band-likepain usuallyassociated with stress(episodic) and may bechronic in nature

Normal mentalstatus with dull,functionalheadache

Bilateral occipital orband-like head pain ismost common, thoughmay be a generalizedpain.

• Normal physicalfinding



• If uncertain, CT orMRI of head

Analgesics: Acetaminophen(Tylenol) orNSAIDS

• Stress reductionor evaluateworkplaceergonomics

F/U PRN

Vascular Headache

Migraine headache isa diffuse severeunilateral pain. Exactcause is unknownthough a disturbanceof cerebral blood flowprecipitated by food,

alcohol, BCP,menses, fatigue,excess sleep, hunger,stress or relief ofstress is involved.65% with positivefamily history of same.

Normal mentalstatus with severe,throbbingheadache

• Unilateral headache,preceded by aura,gradually intense andthrobbing

• Associated nausea,vomiting,photophobia, blurredvision are very

common

• Appears un-rested, inpain and may havefacial flushing duringattack



• If uncertain, CT orMRI of head

• Acute TX Ergotamines(NOT with su lfaallergy):Sumatriptan SQ(Imitrex) orMidrin, oxygen, IVNS if dyhydrated

• Chronic TX –referto MO


CHIEF COMPLAINT: VERTIGO


COMMONFEATURES




TREATMENT FOLLOW-UP

Benign Positional Vertigo with body • Vertigo associated • Dix-Hallpike Barany • Usually nothing Antiemetics: F/U if not



92–NEUROLOGICAL

gVertigo

Vertigo occurs withcertain headpositions. Causeassociated withotoconial crystals thatstimulate semicircularcanal hair cells

g yposition changes

Vertigo associatedwith positionalchanges. Usuallyoccurs when supineor acute change inbody position.

• May have recent HOviral infection

Dix Hallpike BaranyManeuver positive(with + nystagmus)



• CT or MRI if tumoris suspected

Meclozine improved in 24hours

Labyrinthitis

Inflammation of thevestibular labyrinth ofthe inner ear

Vertigo withnausea andvomiting

Gradual, severe vertigowith bilateral tinnitusand associated nausea,and vomiting

• Dix-HallpikeManeuver negative




Antiemetics:meclozine

• Hydration forvomiting


Meniere’s Disease

Disease of the inner

ear in which there isincreased endolymph,which createsincreased pressure inthe inner ear

Vertigo. symptomsmay be vague

• Periodic, sudden,severe attacks of

vertigo with unilateraltinnitis and hearingloss

• Occasional nausea,vomiting



• Diagnosis ofexclusion may

require rule out ofother conditions


Antiemetics:Meclozine


Motion Sickness

Normal response toabnormal erratic or

rhythmic motions.Chronic symptomswithout relief ofstimulus can bedebilitating

Vertigo orlightheadednessand nausea

Motion stimulus.Symptoms may includenausea, vomiting,yawing, salivation, andhyperventilation.


• Complete physical

examination includingneurological


Antiemetics:Meclozine,preferably prior totravel

Hydration forvomiting


CHIEF COMPLAINT: FACIAL NEUROPATHY


COMMONFEATURES




TREATMENT FOLLOW-UP

Bell’s Palsy Facial flaccidity • Sudden onset of • Patient not able to Usually nothing Keep affected eye CONTACT MO



93–NEUROLOGICAL

Facial muscleweakness caused byinflammation of theseventh cranialnerve (facial nerve).Complete resolutionwithin 6 weeks.Cause unknownthough may beassociated withherpes.

y

flaccidity of one sideof the face

• May have loss ofhearing

• May have history of oractive herpes lesionon face

close affected eyelid

• Unable to completelysmile

• Facial weaknessincludes forehead

• Complete physicalexamination includingneurological.

y gindicated

ymoist with eyedrops or ophthalmicointment

or Duty FlightSurgeon

Cerebrovascular Acc ident (CVA)

Infarction orhemorrhage in thebrain cause byischemia, trauma oranticoagulation.Most common in age> 45.

• Facialflaccidity

• Acutecognitivedeficit

• Slurred speech, motorand sensory deficits

• Headache may begradual or sudden.

• Patient able to easilyclose both eyes butunable to completelysmile

• Facial weakness doesnot include foreheadas it does in Bell’sPalsy


• CBC


• Blood glucose

• RPR

• Urinalysis

• ECG

• CT of head

• Acute TX: Aspirin650 mg bid

• Chronic Tx:Refer to MO


MEDEVAC

CHIEF COMPLAINT: FACIAL NEUROPATHY (continued)


COMMONFEATURES




TREATMENT FOLLOW-UP

Trigeminal Facial pain in • Pain burst for several Patient may present • MRI for all patients Carbamazepine CONTACT MO



94–NEUROLOGICAL

Neuralgia

“Tic douloureux’ is asyndrome ofparoxysms oflancinating facialpain in thedistribution of one ormore division of thefifth (trigeminal)nerve. Caused bycompression to thetrigeminal nerve in90% of cases.Rarely an aneurysm.

clusters seconds then remits

• Attack brought on bymild trigger such aslight touch or draft ofair

asymptomatic or havepain on one side of facewith light touch

to exclude masslesions or centraldemyelination

• Dental pathologymay be cause–dental exam willhelp rule out

(Tegretol) works in75% of cases.

or Duty FlightSurgeon

CHIEF COMPLAINT: FEELING DOWN OR WORRIED





TREATMENT FOLLOW-UP

Adjustment

Disorder

T i t

Patient may present

with somaticcomplaints caused by

Patient usually presents

with depressed moodassociated with feelings

• May appear anxious

or depressed:preoccupied by

• R/O anxiety and

depression

A i t

• Self-limiting

• Improvementh th t

CONTACT MO

and/or DutyFlight Surgeon



95–MENTAL HEALTH

Transient,situationalmaladjustmentdue to specialstress (significantlife stressor)

complaints caused byexcessive worry orlow mood

associated with feelingsof being in hopelesssituation. Thoughts areoften dominated by theproblems thatprecipitate the episode.

preoccupied byproblems thatprecipitate theepisode; military/sealife, homesick

• AnxietyQuestionnaire andDepressionQuestionnaire

when the stressis removed oradaptive copingmechanismemployed

Flight SurgeonIF doubt

Anxiety

Excessive worry,

fear, nervousness,& hyper vigilance.May be associatedwith adjustmentdisorder orgeneralized.

Patient may presentwith somatic

complaints caused byexcessive worry

• Physical complaintsprompt patient to seek

medical attention;worry, insomnia,muscle tension,headache, fatigue, GIupset.

• Chest pain may beassociated with stressor panic attack.

• Appears anxious,diaphoretic, pallor,

dyspnea

• If presenting withchest pain - ECG is

normal• Anxiety

Questionnaire

Acute Tx:

Antianxiety:

Hydroxyzine(Atarax), ordiazepam (Valium)

Chronic Tx:

Refer to MO

CONTACT MOand/or Duty

Flight SurgeonIF doubt

Depression Abnormalemotional state;sadness, rejection,worthlessness,despair, anddiscouragement.May be associatedwith adjustmentdisorder or major

depression.

Patient may presentwith somaticcomplaints caused bylow mood

FIVE of the followingcriteria daily for TWOweeks:

• Sleep more/less

• Interest down

• Guilt dominant

• Energy down

• Concentration down

• Appetite more/less

• Psychomotor loss

• Libido down

• Suicidal ideation

• Appears sad,unkempt, tearful,minimal eye contact,slow movements

DepressionQuestionnaire

(SIGECAPS)

• Listen• Encourage

proper diet, dailyexercise,pursuingpleasurableinterest, minimalalcoholconsumption;exercise is

proven to reducedepression

• Refer to MO

• IF suicidal: referto suicidalideation

CONTACT MOand/or DutyFlight SurgeonIF doubt

CHIEF COMPLAINT: FEELING DOWN OR WORRIED (continued)




COMMONDIAGNOSTIC

TEST

TREATMENT FOLLOW-UP

Suicidal Ideation Patient may present See anxiety and May appear anxious Suicide Risk Suicidal thoughts • CONTACT MO



96–MENTAL HEALTH

Suicidal Ideation

Self destructivethoughts or acts;

three types:

• successful(death)

• attempt

•

gesture

Thoughts & plansabout suicide areideation.

Patient may presentwith somaticcomplaints caused byexcessive worry orlow mood.

• See anxiety anddepression above

• ASK: “Do you want tohurt yourself?” or “Doyou have a plan tohurt yourself?”

• May appear anxiousor depressed. Seeanxiety anddepression above

• Mental HealthInterview

Suicide RiskQuestionnaire

(SADPERSON)

• Suicidal thoughts ALONE requireimmediatehealthcareintervention

• Obtain assistance

• Establish a ‘NoHarm Safety

Plan’

• CONTACT MOand/or DutyFlight Surgeon

• Follow unitSOP, i.e.,suicide ideationpolicy

• Contact

command

ICD CODES, ABBREVIATED VERSION

CONDITION CODE

Dermatological

Erythema due to Anthrax 692.4

Erythema due to a Drug Reaction (internal) 693 0



97–ICD 9 CODES

Erythema due to a Drug Reaction (internal) 693.0

Erythema due to a Drug Reaction (contact) 692.3

Erythema/Urticaria 708.9

Wart (common) 078.10

Acne Vulgaris 706.1

Tinea Corporis 110.5

Tinea Cruris 110.3

Tinea Pedis 110.4

Tinea Versicolar 111.0

Atopic Dermatitis 691.8

Contact Dermatitis 692.9

Eczema (dyshidrosis) 705.81

Herpes Zoster 053.9

Smallpox 050.9

Varicella (chickenpox) 052.9


HEENT

Blepharitis 373.00

Allergic Conjunctivitis 372.05



98–ICD 9 CODES

Infectious Conjunctivitis 372.30

Corneal Abrasion 918.1

Subconjunctival Hemorrhage 372.72

Cerumen Impaction 380.4

Eustachian Tube Dysfunction 381.81

Otitis Externa 380.10

Otitis Media 382.9

Perforation (ear) 384.20

Serous Otitis Media 381.01

Allergic Rhinitis 477.9

Upper Respiratory Infection 465.9

Common Cold 460.0

Epistaxis 784.7

Sinusitis (Acute) 461.9

Viral Pharyngitis 462


Gastrointestinal

Appendicitis 541

Constipation 564.00



99–ICD 9 CODES

Diarrhea 787.91

Food Poisoning 005.9

Acute Gastroenteritis (viral) 008.8

Gastroesophageal Reflux Disease (GERD) 530.81

Peptic Ulcer Disease 533.90

Ectopic Pregnancy 633.90

Genitourinary

Vulvovaginal Candidiasis 112.1

Dysmenorrhea 625.3

Urinary Tract Infection (including cystitis) 599.0

Epididymitis 604.90

Inguinal Hernia 550.90

Acute Prostatitis 601.0

Testicular Torsion 608.20

Pyelonephritis 590.80

Renal Calculii 592.0


Genitourinary, continued

Chancroid 009.0

Chlamydia 079.98

Gonorrhea 098.0



100–ICD 9 CODES

Gonorrhea 098.0

Herpes Simplex Virus II (HSV II) 054.9

Human Immunodeficiency Virus (HIV) (symptomatic) 042

Human Immunodeficiency Virus (HIV) asymptomatic) V08

Pediculosis 132.9

Syphilis 097.9

Cardiovascular

Acute Coronary Syndrome (ACS) (AMI) 411.1

Angina Pectoris 413.9

Costochondritis 733.6

Pleuritis 511.0

Respiratory

Bronchitis, Viral 466.0

Bronchitis, Acute 466.0

Influenza 487.1

Pneumonia, Bacterial 482.9


Respiratory, continued

Pneumonia, Mycoplasmal 483.0

Pneumonia, Viral 480.9

Tuberculosis 011.9



101–ICD 9 CODES

Anaphylaxis 995.0

Asthma 493.90

Musculoskeletal

Neck - Cervical Muscle Strain 847.0

Herniated Cervical Disk – Neck 722.0

HNP – Herniated Nucleus Pulposus 722.2

Shoulder – Bicepital Tendon Rupture, Proximal 840.8

Shoulder – Biceptial Tendonitis 726.12

Shoulder – Subacromial Bursitis 726.19

Elbow – Epicondylitis, Media 726.31

Elbow – Epicondylitis, Lateral 726.32

Elbow – Epicondylitis, Olecranon 726.33

Wrist – Carpal Tunnel Syndrome 354.0

Wrist – Scaphoid Wrist Fracture 814.01

Lower back – Mechanical muscular strain 846.9


Musculoskeletal, continued

Knee – Bursitis, Patellar 726.64

Ankle – Ankle sprain 845.00

Foot – Fifth Metatarsal Fracture 825.25



102–ICD 9 CODES

Leg – Shin splints 844.9

Neurological

Alcohol Abuse 305.00

Cerebrovascular Accident (CVA) 434.91

Seizure 780.39

Emergent headache - Hemorrhage, Subarachnoid 430

Meningitis 322.9

REFERENCES

o Barkauskas, Baumann, Darling-Fisher , Health & Physical Assessment (Mosby’s current edition)

o Skedmore-Roth, L., Nursing Drug Reference (Mosby’s current edition)

B M H Th M k M l (M k R h L b t i t diti )



103–REFERENCES– Revised 1/18/08

o Beers, M.H., The Merck Manual (Merck Research Laboratories current edition)

o Dunn, S.A., Primary Care Consul tant (Mosby’s current edition)

o Snider, R.K., Essentials of Musculoskeletal Care (American Academy of Orthopaedic Surgeons current

edition)

o Skinner, H.B., Current Diagnosis and Treatment in Orthopedics (Lange Medical Books current edition)

Listed medications are found on the Standardized Health Services Technician Formulary, Health Services Al lowance List (Afloat), and the CG Nonprescription Medicat ion Program.

Documents

Family Medicine Excellent Differential Diagnosis Listing