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By C. Kafa. William Carey University.

Unlike the mitral valve discount imodium 2mg with mastercard, aortic valve stenosis is not noted as a complication of rheumatic fever buy discount imodium 2 mg on-line. Cardiac Catheterization Cardiac catheterization is seldom needed in the diagnosis of cases of rheumatic heart disease purchase 2mg imodium visa. Aspirin 100 mg/kg/day divided Q4 hours for 1 week, then reduce to 75 mg/kg/day for 4 weeks, then taper over 2 weeks. In significant carditis (significant valve pathology, congestive heart failure), use steroids (prednisone 2 mg/kg/day) instead of aspirin for 2 weeks, then taper steroids over 2 weeks. Treatment of Congestive Heart Failure: most cases of mild heart failure respond well to steroid therapy and bed rest. If the patient has moderate to severe congestive heart failure, digoxin Lasix and afterload reducing agents may be needed for treatment. Treatment of Sydenham Chorea: long-term antimicrobial prophylaxis and halo- peridol treatment. Length of prophylaxis may be one of the following: Ten years after the last episode of rheumatic fever or to adulthood, whichever is longer. Case Scenarios Case 1 History: A 16-year-old female presented to her primary care physician with history of sore throat for the past few days. The patient initially described diffuse joint pain, but after careful questioning, she states that there was severe bilateral knee pain and she was unable to stand. A grade 2/6 systolic murmur at the left upper sternal border was detected by auscultation with no radiation. Management: Rheumatic fever was suspected; therefore, penicillin was prescribed to eradicate acute infection and was advised to start long-term prophylaxis for rheumatic fever. Evaluation by the pediatric cardiologist revealed similar findings through history and physical examination. Echocardiography revealed normal cardiac structure and function with no evidence of mitral or aortic valve disease. Discussion: History and physical examination in this patient do not support rheu- matic fever. The heart murmur noted in this patient is consistent with an innocent heart murmur rather than a pathological murmur. The pediatric cardiologist may have chosen not to obtain an echocardiogram; however, echocardiogram may be worthwhile in cases where clinical presentation is not clear or when the cardiologist desires to document normality to avoid mislabeling a healthy child with a chronic illness. It is important to appreciate that a normal echocardiogram does not rule out rheumatic fever without cardiac involvement. Case 2 History: A 16-year-old female was referred to the cardiology clinic by her primary care physician. Over the past few days, she has had joint pain and swelling and has felt progressively tired. She first noted joint pain, swelling, and redness in her right knee that resolved just as she began experiencing similar symptoms in the left knee. Cardiac examination revealed distant S1 and S2 with a 3/6 holosystolic murmur heard best over the apical region; in addition, a 1 2/4 diastolic murmur was heard over the apical region. Transthoracic echocardiography revealed dilated left ventricle with mildly decreased systolic function. The mitral valve leaflets were thickened with moderate to severe 27 Rheumatic Fever and Rheumatic Heart Disease 323 regurgitation. Diagnosis and Discussion: This patient manifested two major Jones criteria: pol- yarthritis and carditis, thus satisfying criteria for the diagnosis of rheumatic fever and rheumatic heart disease. The time lapse between sore throat and the onset of the symptoms is consistent with the diagnosis of rheumatic fever. The migratory nature of polyarthritis in this patient is consistent with rheumatic fever. Carditis in this patient involves a valve lesion (mitral regurgitation), myocardial affliction (poor myocardial function), and pericardial disease (pericardial effusion). This young lady should be admitted to the hospital for bed rest and monitoring and for the management of pancarditis. She should receive penicillin to eradicate the streptococcal infection and be started on anti-inflammatory therapy with aspirin to reduce arthritis and carditis. Anti-inflammatory therapy may also include steroids in this case due to the severity of carditis. Prophylaxis should continue for a minimum of 10 years or longer if there is evidence of permanent cardiac disease. Long-term therapy includes low dose (antiplatelet) aspirin and in some cases warfarin to prevent clot formation within dilated coronary arteries. The higher rate among people of Japanese ethnicity and within siblings and twins suggests both genetic and environmental factors in the pathophysiology of this disease. The epidemiologic features of the disease suggest an infectious agent(s), which is supported by temporal (winter and early spring) and spatial clustering of cases as well as sharing some clinical features with inflamma- tory diseases that have well established underlying infectious causes (e.

The outcomes are also influenced by the lower percentage measured in the older age groups order discount imodium line. One of the risk factors that has even a higher weight in diabetes compared to non diabetes is the level of blood pressure purchase imodium 2mg online. Crude percentage of diabetic population > 25 with blood pressure measured in the last 12 months 100 100 99 97 99 96 95 92 91 80 82 60 40 45 32 20 0 Admin proven imodium 2 mg. Since this list is too long to show in this report we show the Total Cholesterol as an example. Crude percentage of diabetic population aged >25 with cholesterol tested in last 12 months 100 99 95 94 95 91 80 88 83 81 73 72 60 50 40 45 20 0 Admin. We will show the indicator of incidence and prevalence of dialysis/kidney transplantation as an example. All of these databases can split the total population by cause of renal failure and provide data for diabetes patients. The incidence and prevalence of dialysis/kidney transplantation in the year 2005 is shown for different European countries in figures 14 and 15. Death through acute complications of diabetes like hyperosmolar coma and ketoacidotic coma are reliable and can be retrieved from national death registers. Since most diabetic patients die however from a macrovascular complications, diabetes will normally not be the primary cause of death but a secondary cause. In only a few countries are regional (Scotland) or national (Denmark) databases of people with diabetes available that can look for the combination of death and diabetes while being alive. Doctors who fill in the death certificate will be very reliable on the primary cause of death, but unreliable for second causes and even less for concomitant diseases. It is obvious that a national database with the individuals with diabetes can solve this problem. Some differences can be explained by medical causes, but many have no obvious reason. For this reason it is important that politicians involved in health policy increasingly have access and regularly use targeted indicators to optimise the organisation of health care for people with diabetes. Paradoxically, key indicators that are crucially needed to plan diabetes care, like prevalence of impaired fasting glucose and death with diabetes as primary or secondary cause are still inconsistently available at the moment. In recent years, the discover of innovative molecular targeted treaments - such as imatinib for subtypes of myeloid chronic leukaemia likely will modify the natural history of these diseases, and improve prognosis in the near future. Population based survival and prevalence are important indicators of outcome and are crucial to plan the resources necessary for public health provision. The diffusion of innovative molecular targeted therapies are likely to improve the prognosis in the near future. However, the high cost of these new treatments may generate inequalities in availability and access to treatments, which should be carefully monitored. Better standardization and uniform classification will help explaining the reasons of differences in survival across the European countries. In 2002, its age standardised incidence rate in men was double in the Western European countries (11/100,000) compared to the East European countries (4,5/10000). The regional variation in incidence of all Leukaemias considered together was lower (ranging from 10/100,000 in Western Europe to 8/100,000 in Eastern Europe). In the Eastern European countries women aged up to 55 had the highest incidence pattern compared to the other regions. Many of the etiological studies carried out to date suggest etiological hypotheses, however a large part of these studies are not conclusive. The relevant knowledge can be briefly summarised as follows: Congenital conditions. An occupational risk for hematologic cancers in hairdressers and cosmetologists has been reported, but there are also studies that were unable to confirm this hypothesis. Working with certain chemicals (benzene) in the chemical industry increases risk for leukaemia, too. The role of formaldehyde has recently been reviewed, but there is not conclusive evidence of its causal association to leukaemia or lymphoma. Radiation used for diagnosis, however, exposes people to much lower levels of radiation and is not linked to leukaemia. Results from recent studies show that the association between electromagnetic fields and leukaemia is weak. These values are more than the double of those in men from the East European countries. Higher differential between incidence and mortality rates suggests better survival. Eastern European countries have poor survival comparatively to the countries in the other European Regions. Although the predicted evolution of the mortality rate in the Western and Northern European countries reflects the incidence trend, the differential value between is lower. Conversely, in the Eastern European countries the predicted increase of the incidence and mortality rates is lower than in the other European regions.

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Killing most of the be avoided or reduced in patients with signicant normal ora in the pharynx and gastrointestinal cirrhosis buy imodium 2 mg with amex. Patients who have could otherwise be used by pathogenic bacteria discount 2 mg imodium amex, just arrived in the hospital tend to be colonized with and produce agents that inhibit the growth of community-acquired pathogens; patients who have competitors order cheap imodium online. Loss of the normal ora allows resis- been in the hospital for prolonged periods and have tant pathogens to overgrow. The severely ill Within 3 Days patient who is toxic and hypotensive requires broad- (Table 1. Within 3 days following the spectrum antibiotics; the patient who simply has a administration of antibiotics, sequential cultures of new fever without other serious systemic complaints mouth ora reveal that the numbers and types of bac- can usually be observed off antibiotics. Use the Fewest Drugs Possible die, and resistant gram-negative rods, gram-positive cocci, and fungi begin to predominate. Multiple drugs may lead to antagonism rather quickly the selective pressures of broad-spectrum than synergy. Some regimens, such as penicillin antibiotic coverage can be discontinued, the lower the and an aminoglycoside for Enterococcus, have been risk of selecting for highly resistant pathogens. Classication of Antibiotics by Spectrum of Activity Narrow Moderately Broad Broad Very Broad Penicillin Ampicillin Ampicillin sulbactam Ticarcillin clavulinate Oxacillin/Nafcillin Ticarcillin Amoxicillin clavulanate Piperacillin tazobactam Cefazolin Piperacillin Ceftriaxone, Cefepime Cephalexin/Cephradine Cefoxitin Cefotaxime Imipenem Aztreonam Cefotetan Ceftizoxime Meropenem Aminoglycosides Cefuroxime axetil Ceftazidime Ertapenem Vancomycin Cefaclor Cexime Gatioxacin Macrolides Ciprooxacin Cefpodoxime proxetil Moxioxacin Clindamycin Azithromycin Tetracycline Tigecycline Linezolid Clarithromycin Doxycycline Quinupristin/dalfopristin Talithromycin Chloramphenicol Daptomycin Trimethoprim Levooxacin sulfamethoxazole Metronidazole regimen can be initiated. Continuing broad-spectrum About the Steps Required to Design antibiotics beyond 3 days drastically alters the host s an Antibiotic Regimen resident ora and selects for resistant organisms. All Else Being Equal, Choose The Least responsible for infection at each anatomic site. Use the minimum number and narrowest spec- antibiotics that are equally effective. Switch to a narrower-spectrum antibiotic regi- antibiotic s cost range to assist the clinician in making men based on culture results. Take into account acquisition cost and the costs However, in assessing cost, factoring in toxicity is of toxicity. However, because the sputum culture was extended hospital stay because of nephrotoxicity are positive for a resistant E. Continuing broad-spectrum One of the most difcult and confusing issues for antibiotics beyond 3 days drastically alters the host s nor- many physicians is the interpretation of culture results. After Wound cultures and sputum cultures are often misin- 3 days streamline the antibiotics. Once a patient has been started on an antibi- antibiotics to treat the specic pathogens identied by otic, the bacterial ora on the skin and in the mouth culture and Gram stain. Often these new organisms do not invade the host, but simply represent new ora that have colonized these anatomic sites. No definitive method exists for differentiating Following a motor vehicle accident, a 40-year-old between colonization and true infection. However, man was admitted to the intensive care unit with several clinical findings are helpful in guiding the 4 fractured ribs and a severe lung contusion on the physician. He defervesced, and secretions from from Infection his endotracheal tube decreased over the next 3 days. Evidence for a new superinfection includes a) new fever or a worsening fever pattern, b) increased peripheral leukocyte count with left shift, c) increased inammatory exudate at the origi- Case 1. The initial therapy for a prob- d) increased polymorphonuclear leukocytes on able early S. Anti-infective agents are often considered to be safe; however, the mul- How does the antibiotic kill or inhibit bacterial growth? Does the dosing schedule need to -Lactam Antibiotics be modied in patients with renal dysfunction? The -Lactam antibiotics have a common central How broad is the antibiotic s antimicrobial spectrum? The side antibiotics, their mechanisms of action, and their major chain attached to the -lactam ring (R1) determines toxicities. The differences between the specic antibiotics many of the antibacterial characteristics of the specic in each class can be subtle, often requiring the expertise of antibiotic, and the structure of the side chain attached an infectious disease specialist to design the optimal to the dihydrothiazine ring (R2) determines the phar- anti-infective regimen. The specic indications for each wall transpeptidase and transglycolase causes rapid anti-infective are briey covered here. Inhibition of this transpeptidase discussion of specic regimens is included in the later prevents the cross-linking of the cell wall peptido- chapters that cover infections of specic anatomic sites. About -Lactam Antibiotics The activity of all -lactam antibiotics requires active bacterial growth and active cell wall synthesis. Penicillins, cephalosporins, and carbapenems killed, but those in an active log phase of growth are are all b-lactam antibiotics: quickly lysed. Hypersensitivity reactions are the most common side effects associated with the -lactam antibiotics. Penicillins are the agents that most commonly cause allergic reactions, at rates ranging from 0. Ceftriaxone is excreted in high con- allergies also prove to be allergic to cephalosporins and centrations in the bile and can crystallize, causing biliary carbapenems. Cefepime has been associated with antigens increase the probability of a host immune encephalopathy and myoclonus in elderly individuals.

A person with a magnesium deficiency tends to be uncooperative buy imodium with a mastercard, withdraw buy 2 mg imodium, apathetic discount imodium generic, or belligerent. It is vital to obtain enough oxygen, if you want a clear mind which functions properly. Vitamin E helps the brain obtain enough oxygen from the amount supplied to the lungs. A lack of thyroxine, the hormone from the thyroid, results in a slowing of physical and mental functions. Hyperthyroidism is related to emotional disturbance, forgetfulness, slow thought processes, and irritability. When the adrenals do not function properly, depression and other forms of mental illness may result. Exercise, especially out-of-doors in the fresh air, combined with relaxation helps rejuvenate the body and mind. Ginkgo biloba improves brain function and cerebral circulation, and enhances memory. Now Christ invites you to come and accept the salvation which He alone can work out in your life. The winter months have shorter hours of daylight and more overcast skies during the daytime, resulting in less light entering the eyes. This light deficiency sends signals to the pineal, pituitary, and hypothalamus glands; and they do not function as fully as usual. Purchase a hand gripper at a sporting goods store, and slowly increase your usage of it until you are using it 5-10 minutes, 4 times a day. Over a period of 4-6 weeks of doing this every day, you may be able to move up to 8-10 pounds lifted without pain. Medical Tribune (January 12, 1977) reported that 14 of 18 patients, on a four-week program with this exercise, obtained complete pain relief. He presents us with bribes, as he bribed Christ; pretending that he will give us the world if we will obey him. This nerve controls the thumb muscles and sensation in the thumb, palm, and first three fingers. The median nerve passes through a very small opening, about a quarter inch below the top of the wrist. Either compression or injury to this nerve can cause problems: Pressure from the bone spurs inflammatory arthritis or tendonitis, swelling due to pregnancy or water retention. Other causes include repeated stressful motions, such as writing, typing, or hammering. The tendons swell and compress the median nerve that runs to your hand, causing great pain. A common pattern is rapid and continuous use of the fingers, producing a repetitive wrist motion injury. This exercises all the muscles of the wrist, restores circulation, and gets your wrist out of the position that usually causes the trouble. If possible, stop all such movements for several days and see if improvement occurs. If possible, rotate your duties, so you do not do those repetitive tasks every day. For example, if you let your hand drop over the side of the bed while you are sleeping, the pressure on the median nerve is increased. Here are several suggestions for avoiding its occurrence: Use a tool instead of flexing your wrists forcibly. Your hand should be in approximately the same position as if it were holding a pen. They may have trials in this life, but their life is secure and they will live with their Maker in heaven. If gums are hot and swollen, give cold water and rub gums with a cloth that has been held on ice. Fast on fruit juices, water, or nervine herb teas (listed below) until all symptoms subside. He puts them on a cleansing and building program, discarding all meat eating, and requiring that they never return to it (so they will not again become infested with worms). After the convulsion is past, begin testing with pulse tests for food allergies (see "Pulse Test"). Complex partial (temporal lobe): A blank stare, random activity, and a chewing motion.

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The skin and stroma are sutured as a single layer using interrupted vertical mattress su- tures or alternatively closed with individual layers cheap imodium 2mg free shipping. Diagnosis Diagnosis of supernumerary teats buy 2 mg imodium otc, Siamese teats order generic imodium online, and ke- ratinized corns simply requires inspection. Supernumer- ary teats cojoined to a major teat require more careful consideration and treatment, but if identied in calf- hood, the treatment is the same. Most veterinarians perform this ex- numerary teat (left) and outline of a resultant incision amination when vaccinating 4- to 8-month-old calves (right). When surgery is done at this early age, it does not matter whether the ancillary teat has a separate gland. If, however, surgery is delayed until after the rst lacta- tion, surgical repairs may become considerably more complicated because of the need to connect separate gland cisterns to the major teat. Keratin corns or keratomas may be surgically dis- sected from the teat ends, but simpler means of therapy exist. A light teat bandage held on the teat by adhesive tape may be used to moisten the keratinized material, and the keratinized material may be gently separated from the teat itself after several days of soaking. Saline, lanolin and aloe mixtures, and ichthammol ointment have all been used successfully to soften keratin corns and allow subsequent removal. A focal occlu- stroyed in these animals; nonetheless a guarded prog- sion at the distal aspect of the teat cistern is identied as nosis is justied. The rosette of Furstenberg and the streak canal (thin hyperechoic line at the tip of the teat) are normal. Injuries to the teat end with dried exudate and scabs make milkout very dif- are caused by the digit or medial dewclaw of the ipsilat- cult and predispose to mastitis. Many causes, including eral limb of the affected cow or by injury from neigh- irritation from teat dips, excessive vacuum pressure, and boring cows stepping on the teat. Teat-end injuries are mechanical abrasions have been suggested, but the ex- more common in cows with pendulous udders or in act cause of the lesion often is difcult to ascertain. Acute injuries cause inammation, hemorrhage, and edema within the distal Signs teat stroma and sphincter muscle. Subsequent soft tissue Painful soft tissue swelling of the distal teat is the cardi- swelling in the teat end mechanically interferes with nal sign of acute teat-end injury. Mastitis is the feared and frequent sequela to laceration of the distal teat skin may be present but incomplete milkout in cows with teat-end injuries. When present, lacerations tend to be cow is further predisposed to mastitis if the physical de- at the teat end. Degloving injuries to the teat end are fense mechanism of the streak canal is compromised. Repeated or chronic teat-end injury leads Palpation of the teat end allows detection of brosis in to brosis of the affected tissues, granulation tissue at the sphincter muscle or granulation tissue dorsal to the the site of any mucosal or streak canal injury, and contin- streak canal and sphincter muscle at the ventral-most ued problems with milkout. Pain is not as apparent with has been associated with defective milking machine chronic teat-end injuries as in acute cases. Teat dilators impregnated with dyes are not favored because they seem to induce chemical damage to the steak canal. Wax and silicone teat inserts that may retain patency with less iatrogenic mastitis are commercially available. The wax insert is recommended for initial use, but it disintegrates after several days. In- sertion of silicone rubber inserts after the wax has disin- tegrated is recommended. Nursing care is helpful but unfortunately is often not available on modern dairy farms. Soaking the injured Treatment teat with concentrated Epsom salts in a cup of warm Treatment of acute teat-end injuries should address both the injury and any management factors that might lead to further injury, such as overcrowding, lack of bed- ding, and milking machine problems. Treatment considerations must be acceptable and logical to the milkers because the milkers are responsi- ble for any ongoing treatment. Milkers also are subject to the end results of the cow s pain caused by manipula- tion of the acutely injured teat. Unless one has milked cows, it may not be apparent exactly how difcult it is to remain patient when being kicked at by cattle that object to having injured teats handled. Client compli- ance necessitates empathy for the patient, as well as the people responsible for milking the cow. The best treatments for acute teat-end injury include symptomatic antiinammatory therapy and reducing further trauma to the teat end. If milkout is simply reduced but not prevented, milkers sometimes use dilators of various types between milkings to stretch the sphincter muscles, thus allowing machine milkout. If milkout is difcult, it is best to avoid further machine milking and to utilize a teat cannula to effect milking twice daily when the other quarters are machine milked. If cannulas are used, the milker must exert extreme care to avoid exogenous in- oculation of the teat cistern with microbes. Therefore the teat end must be cleaned gently, and alcohol must be applied before introducing the sterile cannula.

There are lots of experts out there: Chiropractors adjust the back by pushing and thrusting purchase imodium with paypal. Agency for Health Care Policy and Research issued a report buy imodium amex, that chiropractors generally provided the most effective treatments for acute back pain order imodium 2mg online. They cost far less, do the job quicker, and do not give medicinal drugs (most of which are usually poisonous). The British Medical Journal reported that chiropractic treatments proved more successful than hospital treatments in nearly every way. X rays are generally considered a routine part of back pain diagnosis; yet only a few back conditions show up on x rays! If the pain is caused by muscle strain or a herniated disk, an x ray will not reveal anything because muscles, disks, and ligaments are all soft tissues. These are medical doctors who also do back surgery, they are very likely to recommend it and that is something you want to avoid, if at all possible. Osteopaths can prescribe drugs and do surgery also, but they are less likely to do so. They have a good record of helping to solve serious back problems (such as disk problems) without resorting to surgery (which they are not licensed to do). Preventive measures that will help you, either before or after experiencing back problems: Be very careful when lifting something. Take several deep breaths, to increase muscle strength and then slowly lift with the legs, not the back, and hold the object close to your body. Do not lift from a bending forward position (closing windows, lifting things from deep in the car trunk). When the muscles are chilled or you are exhausted, it is easier to injure joints because the muscles are not able to do the work needed. Exercises, to build the muscles are very important, if you would avoid back trouble. This is due to the fact that the trunk, being heavier, sinks farther into the bed, causing the back to arch. Women should wear low-heeled shoes if they want to protect their pelvic organs and spine. Keep your pelvis flat on the floor and push up with your hands, arching your back as you lift your shoulders off the floor. Raise your head and shoulders off the floor as high as you can while keeping your lower back on the floor. Not only are they expensive, but frequently do not solve your movement and pain problems. And there is always the possibility that the operation will only result in greater pain, more serious damage, and even less mobility. The primary cause is that one set of the spinal muscles (right side or left side) is stronger than the other. These changes are the result of degeneration of muscles on one side; and, in some instances, they may be the early stage of muscular dystrophy. Cling to Jesus and, in spite of the disappointments of earth, you will have peace of heart. Hot Leg Bath with Fomentation to the spine; prolonged Neutral Bath, 1-4 hours daily. This is tubercular in origin, and shows little pain or fever and few symptoms other than great emaciation, loss of strength, and fluid in the abdominal cavity. Your only danger is in leaving His side, to follow after the luring temptations Satan offers you. Copious water drinking; prolonged Neutral bath; cold Compress or Ice Bag over heart for 15 minutes, 2-3 times a day, for cardiac weakness. Hot Enema followed by Fomentation to abdomen for 20 minutes, 3 times daily; well-protected Heating Compress during the interval between. Copious water drinking; graduated cold applications (Tonic Frictions), twice daily. Cervical catarrh and erosions often require the use of the curette [a spoon- shaped scraping instrument for scraping foreign matter from a cavity]. If caused by neuralgia: Give hot Hip and Leg Pack or very hot Revulsive Sitz, 3 times a day; hot water bottle over seat of pain and heat to feet and legs. If due to chronic congestion in a pelvic organ: Hot Hip and Leg Pack every 2-4 hours, with abdominal Heating Compress and heating leg packs during the interval between. If due to inflammation or acute congestion: Hot Hip and Leg Pack or Hot and Cold Pelvic Pack every 2- 4 hours, followed by continuous heat to legs with cooling compress to lower abdomen, external genitals and inner surfaces of thighs.

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Depressed mental status and stiff neck suggest guideline to possible causative agents; however buy discount imodium 2mg online, the use bacterial meningitis generic imodium 2 mg with amex. Pulmonary auscultation often underestimates decreased cell-mediated immunity buy 2mg imodium visa, and depressed the extent of pneumonia: macrophage function) can greatly alter the typical a) Bronchial breath sounds and egophony sug- radiologic appearance of specic pathogens. As it spreads, this form of infection respects the anatomic boundaries of the lung and does not cross the ssures. The bronchopneumonia form performed during the initial evaluation for possible of pulmonary infection originates in the small pneumonia. A respiratory rate of more than Inltrates tend to be patchy, to involve multiple areas 30 breaths per minute, a systolic blood pressure under of the lung, and to extend along bronchi. Inltrates 90 mm Hg, a pulse above 125 beats per minute, and a are not conned by the pulmonary ssures. Bron- temperature below 35 C (95 F) or above 40 C (104 F) chopneumonia is commonly observed with S. Depressed mental status is gram-negative bacilli, Mycoplasma, Chlamydia, and also associated with a poor prognosis. Miliary extent of infection, and when pneumonia is being con- tuberculosis commonly presents with micronodular sidered, the physical exam should be followed by a interstitial inltrates. Asymmetry of chest movements may be observed, movement being diminished on the side with the pneu- 4. When infection has progressed to consolidation, often cause extensive tissue necrosis, resulting in loss as in case 4. Histoplasmosis, coccidiomycosis, patient is asked to say E, an A is heard on ausculta- and cryptococcosis can present as nodular lung tion (egophony). Deoxygenated blood passes from the right side of the heart to the left side, creating a physiologic About Chest X-Ray in Pneumonia right-to-left shunt. Positive blood cultures denitively identify the cus aureus, gram-negative organisms, Myco- cause of the disease. Inuenza and cytome- Sputum requires careful analysis and frequently pro- galovirus, Pneumocystis, miliary tuberculosis. Fungal (histoplasmosis, cells from the nasopharynx, making interpretation of coccidiomycosis, cryptococcosis) and right- the cultures difficult. Patterns on chest radiographs are only rough patient coughs deeply and brings up the sample from guides. Considerable overlap between the vari- the tracheobronchial tree and does not simply expecto- ous pathogens has been observed. The adequacy of the sample should be determined by low-power microscopic analy- sis of the sputum Gram stain. Sputum Gram stain and culture are optional in these patients, as are any additional tests. With the exception of patients under the age of ered for hospitalization, additional tests to assess the 50 years, without underlying disease, and with severity of the illness need to be ordered. Arterial blood O2 below 60 mm Hg and pH saturation should be determined, and if it is at all below 7. Ideally the sputum collection should be super- tum samples usually become contaminated with some vised by a physician. Gram stain can be helpful in differentiating normal power microscopic analysis: ora (mixed gram-positive and gram-negative rods and cocci) from the offending pathogen. When a single bac- a) More than 10 squamous epithelial cells indi- cates extensive contamination with mouth terial type predominates, that bacterium is likely to be ora. Sputum Gram stain should be performed in all In reviewing bacterial morphology, the observer seriously ill patients with pneumonia. In ideally a) Decolorization should be assessed for ade- stained regions, the nucleus and cytoplasm should be quacy. Sputum culture suggests a bacterial cause for the disease; a predomi- a) Should never be ordered without an accom- nance of mononuclear cells is more consistent with panying Gram stain. Rapid d) Is insensitive, because mouth ora can over- processing has been shown to increase the yield for grow the pathogen. Sputum cultures are falsely negative e) Is helpful for determining the antibiotic sen- approximately half the time. This method will be particularly helpful in Culture is most helpful in determining the antibiotic identifying organisms that are not normally part of the sensitivities of potential pathogens. In the intubated patient, specic discussion later in this chapter), urinary antigen sputum culture alone should never be the basis for ini- for L. This test is always be positive, a result that often simply represents moderately sensitive and highly specic.