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Dav id L. Reich, MD

• Horace W. Goldsmith Professor and Chair
• Department of Anesthesiology
• Mount Sinai School of Medicine
• New York, New York

Concentrated povidone-iodine gastritis healthy diet purchase discount motilium on-line, hydrogen peroxide dukan diet gastritis purchase 10mg motilium mastercard, and detergents can cause significant tissue toxicity and are not recommended for internal wound irrigation (7) gastritis ibs diet buy genuine motilium. Thus eosinophilic gastritis elimination diet discount 10 mg motilium free shipping, povidone-iodine can be used to sterilize the skin as a skin prep for suture closure, but the wound should be irrigated with saline and not with povidone-iodine. However, one must consider the requirement of local anesthesia and sometimes sedation, cost issues (sutures are inexpensive, but they require a set of instruments and often, suture removal at a follow up visit), and more time and skill to apply. Non-absorbable sutures made of nylon or polypropylene are commonly used for closing the skin layer of a laceration. Advantages include their ability to retain tensile strength for more than 60 days, and their relatively low tissue reactivity. In contrast, absorbable sutures such as chromic gut and polyglactin do not need to be removed. Deep sutures are beneficial in reducing the skin tension required for the skin sutures and the prevention of hematomas, dead space, and scarring. Some physicians prefer to use special fast absorbing sutures in the outer skin layers to avoid the pain and anxiety associated with suture removal (5) (popular products include fast absorbing gut and Vicryl Rapide). Otherwise, sutures should be removed after about 3-14 days depending on their location: face (3-5 days), scalp (5-7 days), trunk (7-10 days), extremities (10-14 days). Facial sutures should be removed earlier to prevent the formation of sinus tracts. After suture removal, wound closure tape is usually applied to reinforce the wound and prevent dehiscence. The advantages of wound closure tape are that there is almost no tissue reactivity and they can be applied very rapidly. Tape should not be used alone in areas of high tension since they have low tensile strength and a high rate of dehiscence. Wound closure tape would be acceptable for smaller lacerations which are under little or no tension. Tissue adhesives, which are cyanoacrylates, have been found to have negligible tissue toxicity, bacteriostatic properties, and good tensile strength (7). After holding the two edges together, it is applied to the surface of the skin, requiring about 30 seconds for polymerization, forming a strong bond to the uppermost layer of the skin (10). This polymer holds the edges of the laceration together, allowing for good wound approximation and healing. The adhesive should never be placed inside the wound, since this results in a foreign body effect and impedes the wound edges from approximating. For deeper lacerations to the epidermis, absorbable sutures can be used in the deep tissues in conjunction with tissue adhesive applied to the surface edges of the wound. Tissue adhesives have been found to have comparable cosmetic results when compared with sutures (3,4,12). Some disadvantages include less tensile strength compared to sutures, and increased wound dehiscence over joints and high-tension areas. Tissue adhesives are seemingly simple, but they should be used by experienced personnel since they have many adverse effects described which are preventable if used in the correct manner, and if their use is avoided in wound conditions which are unsuitable for tissue adhesives. What is the purpose of using epinephrine in local infiltration and topical anesthesia What has the best cosmetic result in the repair of lacerations: sutures or tissue adhesives What is the major clinical reason for preferring healing by secondary or tertiary intention (as opposed to primary closure) True/False: Antibiotics have only a modest effect on reducing the rate of wound infections in contaminated wounds. Comparison of plain, warmed, and buffered lidocaine for anesthesia of traumatic wounds. A randomized trial comparing octylcyanoacrylate tissue adhesive and sutures in the management of lacerations. Since epinephrine is a vasoconstrictor, it slows the rate of local anesthetic release into the general circulation permitting a higher total dose of local anesthetic that can be given (useful if the wound is large), it extends the duration of action, and decreases bleeding. The research done on the comparisons between sutures and tissue adhesives have shown that they have comparable cosmetic results. Cocaine component: arrhythmia, urticaria, drowsiness, excitation, seizure, vomiting, flushing, and death. Significantly contaminated wounds, are at greater risk of infection if closed by primary intention. On review of birth records, a moderate-sized scrotal mass had been appreciated on newborn examination with no other abnormalities noted. According to his parents, the bulge has not changed in size since birth and there has been no noticeable discomfort. His parents are reassured and counseled on the possibility of a communicating hydrocele/complete inguinal hernia and to proceed to an emergency room if signs or symptoms of incarceration and strangulation occur. On subsequent well child visits, the right scrotal mass is noted to minimally decrease in size. His parents continue to report no fluctuation in size during activity, crying or defecation. At his 12 month well child visit, the right scrotal mass is noted to be unchanged since his last visit 3 months prior. The estimated incidence of inguinal hernias in children is 5-50/1,000 live births. It is seen more frequently in males than females with a ratio of about 5:1 with a definite familial tendency. About 50% of cases present before 12 months of age with most occurring in the first 6 months of life. Approximately 99% of all inguinal hernias in children are indirect inguinal hernias. Most inguinal hernias are unilateral with about 60% occurring on the right side and 30% on the left side. Of note, inguinal hernias are more common in premature infants with an incidence of 5-30%. Most cases are bilateral, occurring in about 62% of affected premature infants (2-5). Normally, in the male fetus, the testes descend to the vicinity of the internal ring of the inguinal canal by approximately 28 weeks gestational age. With testicular descent, the lining of the peritoneal cavity extends into the inguinal canal and scrotum. Each testis descends through the inguinal canal external to the processus vaginalis. In the female fetus, a similar mechanism with descent of the ovaries into the pelvis occurs. The processus vaginalis in females extends through the inguinal canal into the labia majoris and is referred to as the canal of Nuck (2). In males, a hydrocele is formed when there is patency of the processus vaginalis between the scrotum and the peritoneal cavity resulting in an accumulation of fluid between the layers of the tunica vaginalis surrounding the testis. In the weeks prior to birth or shortly after, the processus vaginalis closes spontaneously in the area of the internal ring, obliterating the entrance to the inguinal canal. The scrotal fluid collection that remains within the tunica vaginalis is referred to as a scrotal hydrocele, or a non communicating hydrocele. If the processus vaginalis fuses proximally and distally but remains open in between, the isolated fluid collection is referred to as a hydrocele of the cord. This type of hydrocele, although not in communication with the peritoneal cavity or the scrotum, is often associated with a hernia and/or a scrotal hydrocele (6). In some older boys, a scrotal hydrocele may result from inflammation within the scrotum caused by various conditions including testicular torsion, torsion of the appendages, epididymitis, and testicular cancer (1,4). When the processus vaginalis fuses distally but remains patent proximally, abdominal contents can enter the inguinal canal resulting in an inguinal hernia. However, if the processus vaginalis fails to fuse completely, there will be communication between the scrotum and the peritoneal cavity through the patent processus vaginalis resulting in an inguinal-scrotal hydrocele, or communicating hydrocele. Of note, there is a rare but important type of communicating hydrocele called an abdominal-scrotal hydrocele. With this type of hydrocele, the communication is between the scrotum and a cystic loculation of fluid within the lower abdomen. This may result in recurrent communicating hydroceles or unusually large hydroceles. If a communicating hydrocele is large enough, abdominal contents may extend through the patent processus vaginalis to the scrotum resulting in an inguinal-scrotal hernia (complete inguinal hernia).

If the diagnosis of acute appendicitis is equivocal gastritis diet mayo clinic 10mg motilium with mastercard, laboratory studies gastritis diet ñêà÷àòü order motilium 10 mg visa, including a complete blood cell count with differential gastritis diet íäåêñ buy motilium 10 mg low price, may be useful in supporting the diagnosis; however chronic gastritis flare up cheap motilium online visa, laboratory studies cannot be relied upon to definitively confirm or rule out this condition. Children with lower lobe pneumonia may present with referred abdominal pain, along with fever and vomiting. The girl in the vignette, however, has had no cough or other respiratory symptoms (which would typically be seen in patients with pneumonia), and has no pertinent findings on her lung examination. Although pneumonia can cause referred abdominal pain, patients with this diagnosis would not be expected to have focal abdominal tenderness or clinical signs of peritonitis. Malrotation of the bowel with volvulus is an emergency that requires immediate surgical intervention to avoid significant morbidity (such as bowel ischemia and short bowel syndrome) and mortality. Patients with volvulus most commonly present during the first year after birth, though the condition can present at any age. Classic symptoms include severe abdominal pain (which can be a challenge to identify in infants), along with bilious emesis and signs of abdominal obstruction. The girl in this vignette has no history of bilious vomiting, and her presentation is not consistent with that of volvulus. Patients with mesenteric adenitis would not be expected to present with pain migration, peritoneal signs, or a toxic clinical appearance. He was in his usual state of health until he developed a runny nose and cough the day before presentation. On the day of presentation, he has felt warm to the touch, had decreased oral intake, and became progressively lethargic and listless. Throughout the day, the rash progressed, significantly covering his trunk, arms, and legs. His physical examination reveals a well-nourished but toxic-appearing, lethargic child. He has a nonblanching, purpuric rash evenly distributed over his face, trunk, and upper and lower extremities. He is in moderate respiratory distress, with clear lung fields and good bilateral air exchange. The nurse places 2 large-bore intravenous catheters, and fluid resuscitation is rapidly initiated. Because of its capacity to cause rapidly progressive septic shock and meningitis in healthy children, Neisseria meningitidis is one of the most feared bacterial pathogens. Rates of carriage range from less than 2% in children younger than 2 years of age to as high as 40% in adolescents and young adults. Individuals in crowded living conditions, such as military barracks and college dormitories, are at higher risk of infection. Younger children are more likely to become ill with meningococcal disease because of less developed innate immune defense mechanisms. Children with acquired or congenital immune defects, such as complement deficiency or functional asplenia, are predisposed to invasive meningococcal disease. Meningococcemia can initially masquerade as a viral syndrome, with presenting signs and symptoms including high fever, rash, chills, and body aches. Within hours, the rash, which can initially be confused with a viral exanthem, will become purpuric (purplish, blotchy, and nonblanching). Endotoxin from the bacterial capsule causes a severe host inflammatory response that can lead to cardiovascular collapse because of myocardial depression and vasodilation, disseminated intravascular coagulation, lethargy, respiratory failure, and death. Pediatricians should be on the alert for signs or symptoms that indicate severe illness. Tachycardia out of proportion to the degree of fever should raise suspicion for shock. A rule of thumb is that the heart rate may increase by 10 beats/min for every degree Celsius above 37 without causing additional concern. A rash that does not blanch (ie, petechiae or purpura) is less likely to be a viral exanthem, rather, it raises concern for thrombocytopenia, sepsis, or disseminated intravascular coagulation. Lastly, signs of meningitis such as vomiting without diarrhea, lethargy, or a stiff neck help differentiate meningococcemia from a viral illness. Artificial ventilation should be provided to any child with oxygenation, ventilation, or airway protective reflexes, and should be considered in children who are obtunded or in shock. Intravenous or intraosseous access should be established within the first 2 minutes and aggressive fluid resuscitation should be initiated. Inotropes, vasopressors, and steroids should be considered if the shock is refractory to fluids. Although a blood culture and lumbar puncture are important to make the diagnosis, antibiotics should not be delayed. While N meningitidis is sensitive to penicillin, ceftriaxone is the appropriate initial therapy when the diagnosis may be uncertain, because it also covers resistant streptococcal disease. Chloramphenicol is an excellent bactericidal agent for meningococcemia and penetrates the blood-brain barrier, but it has an unfavorable side effect profile. Amphotericin B is an effective antifungal agent for use in immunocompromised patients, but would not be appropriate treatment for the boy in this vignette. A rule of thumb is to expect an increase of up to 10 beats/min for every degree Celsius above 37 without additional concern. Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine. Where scale has been removed, there are areas of hemorrhage (ie, Auspitz sign) (Item C71A). The lesions of nummular eczema may be round or oval but are not elevated and exhibit crust (dried fluid) rather than scale (Item C71B). Unlike in psoriasis, the plaques of pityriasis rosea are thin and have fine scale that is located at the trailing edges of lesions (ie, the scale does not cover the entire lesion) (Item C71C). The lesions of tinea corporis are annular with fine scale on the elevated borders and central clearing. Psoriasis is a papulosquamous (ie, elevated lesions with scale) disorder likely caused by a genetic predisposition and an environmental trigger (like infection or trauma). It is believed to be an immune-mediated inflammatory process characterized by epidermal hyperplasia. Recently, psoriasis has been linked to comorbidities, including metabolic syndrome and cardiovascular disease. Lesions typically affect the extensor surfaces of the extremities, but may also occur on the scalp, face, umbilicus, and gluteal cleft. Lesions appear in areas of trauma (the Koebner phenomenon), thus explaining the commonly observed involvement of the extensor surfaces of the elbows and knees. The most common manifestation is pitting (Item C71E), but individuals may develop thickening, yellowing, or roughness of the nails. It begins as a generalized eruption composed of erythematous macules and papules that may mimic a viral exanthem. Psoriasis involving the diaper area may mimic irritant contact dermatitis, seborrheic dermatitis, or candidiasis. Treatment is designed to reduce inflammation and normalize epidermal proliferation. First-line therapy for the scalp, trunk, or extremities is a mid-potency topical corticosteroid (eg, triamcinolone 0. For the face, flexures, or groin, a low-potency preparation (eg, hydrocortisone 1% or 2. If the disease is not controlled with a topical corticosteroid alone, a topical calcipotriene, an agent that normalizes epidermal proliferation, may be added. Other topical agents that may be beneficial are calcineurin inhibitors, retinoids, keratolytics, tars, and anthralin. Phototherapy or systemic agents (eg, methotrexate, cyclosporine A, acitretin, or biologics) are reserved for patients with severe disease that does not adequately respond to topical treatment. The mother has a 4-year-old son at home, and requests that her newborn be discharged 24 hours after birth. He should be observed for 48 hours because of premature gestation and inadequate intrapartum antibiotic prophylaxis during labor (<4 hours before delivery). Neonates are exposed to microorganisms from the maternal genital and anorectal tract during labor or via ascending spread after rupture of membranes. Inadequate intrapartum antibiotic prophylaxis in a high-risk group may result in partial treatment and delayed onset of symptoms.

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As used in this section gastritis diet potatoes generic motilium 10 mg without prescription, "psychosis" refers to a mental disorder in which: (i) the individual has manifested delusions gastritis back pain buy motilium with a mastercard, hallucinations gastritis ibs diet order genuine motilium on line, grossly bizarre or disorganized behavior gastritis muscle pain buy motilium online from canada, or other commonly accepted symptoms of this condition; or (ii) the individual may reasonably be expected to manifest delusions, hallucinations, grossly bizarre or disorganized behavior, or other commonly accepted symptoms of this condition. However, the Examiner should form a general impression of the emotional stability and mental state of the applicant. Examiners must be sensitive to this need while, at the same time, collect what is necessary for a certification decision. If any psychotropic drugs are or have been used, followup questions are appropriate. Affirmative answers related to rejection by military service or a military medical discharge require elaboration. Reporting symptoms such as headaches or dizziness, or even heart or stomach trouble, may reflect a history of anxiety rather than a primary medical problem in these areas. If there was a hospital admission for any emotionally related problem, it will be necessary to obtain the entire record. Valuable information can be derived from the casual conversation that occurs during the physical examination. Information about the flow of associations, mood, and memory, is generally available from the usual interactions during the examination. Communication (abnormal if incomprehensible, does not answer questions directly); 5. Cognition (abnormal if unable to engage in abstract thought, or if delusional or hallucinating). Aerospace Medical Disposition Drug and alcohol conditions are found in Substances of Dependence/Abuse. It is, therefore, incumbent upon the Examiner to be aware of any indications of these conditions currently or in the past, and to deny or defer issuance of the medical certificate to an applicant who has a history of these conditions. Describe your current status: current medication dose, how long you have been on it, and how you function both on and off the medication. When was the most recent change in medication (discontinuation, dose, or change in medication type) Review the overall symptom and treatment history, with a timeline of evaluations and treatments medication is (including start and stop dates). Specify if using your own clinic notes and/or notes from other providers or hospitals. Review the overall symptom and treatment history, with a timeline of evaluations and treatments board certified (including start and stop dates). List name, dosage, dates of use, and presence or absence of any side effects and outcomes. Discuss any prior diagnostic questions or issues and explain why/how these are no longer under consideration or have been ruled-out. History: Items from the clinical, educational, training, social, family, legal, medical, or other history pertinent to the context of the neuropsychological testing and interpretation. Recommendations: additional testing, follow-up testing, referral for medical evaluation. Submit the CogScreen computerized summary report (approximately 13 pages) and summary score sheet for any additional testing (if performed). If each item is not addressed by the corresponding provider there may be a delay in the processing of your medical certification until that information is submitted. If you do not agree with the supporting documents, or if you have additional concerns not noted in the Special documentation, please discuss your observations or concerns. Interval treatment records such as clinic or hospital notes should also be submitted. Guide for Aviation Medical Examiners the following is a table that lists the most common conditions of aeromedical significance, and course of action that should be taken by the examiner as defined by the protocol and disposition in the table. Bereavement; All Submit all pertinent If stable, resolved, no medical information associated disturbance Dysthymic; or and clinical status of thought, no recurrent report. Certain personality disorders and other mental disorders that include conditions of limited duration and/or widely varying severity may be disqualifying. If these episodes have been severe enough to cause some disruption of vocational or educational activity, or if they have required medication or involved suicidal ideation, the application should be deferred or denied issuance. Psychotic Disorders are characterized by a loss of reality testing in the form of delusions, hallucinations, or disorganized thoughts. They may also occur as accompanying symptoms in other psychiatric conditions including but not limited to bipolar disorder. Generally, only one episode of manic or hypomanic behavior is necessary to make the diagnosis. Organic mental disorders that cause a cognitive defect, even if the applicant is not psychotic, are considered disqualifying whether they are due to trauma, toxic exposure, or arteriosclerotic or other degenerative changes. Example: Thrombocytopenia due to chemotherapy, malignancy, autoimmune disorders, or alcohol use. Applicants for first or second class must provide this information annually; applicants for third-class must provide the information with each required exam. No other treatment is needed (do not include support group or support group counseling). Any evidence of cognitive dysfunction or is a formal neuropsychological [] None [] Yes-explain evaluation indicated The airman is back to full, unrestricted activities and no new treatment is recommended at this time. The Examiner may wish to counsel applicants concerning piloting aircraft during the third trimester. Hearing Record Audiometric Speech Discrimination Score Below Conversational Voice Test at 6 Feet Pass Fail I. The applicant must demonstrate an ability to hear an average conversational voice in a quiet room, using both ears, at a distance of 6 feet from the Examiner, with the back turned to the Examiner. If an applicant fails the conversational voice test, the Examiner may administer pure tone audiometric testing of unaided hearing acuity according to the following table of worst acceptable thresholds, using the calibration standards of the American National Standards Institute, 1969: 1 2 3 5 0 0 0 0 0 0 0 Frequency (Hz) 0 0 0 0 H H H H z z z z 3 3 3 4 Better ear (Db) 5 0 0 0 3 5 5 6 Poorer ear (Db) 5 0 0 0 If the applicant fails an audiometric test and the conversational voice test had not been administered, the conversational voice test should be performed to determine if the standard applicable to that test can be met. If an applicant is unable to pass either the conversational voice test or the pure tone audiometric test, then an audiometric speech discrimination test should be administered. A passing score is at least 70 percent obtained in one ear at an intensity of no greater than 65 Db. For all classes of certification, the applicant must demonstrate hearing of an average conversational voice in a quiet room, using both ears, at 6 feet, with the back turned to the Examiner. For all classes of certification, the applicant may be examined by pure tone audiometry as an alternative to conversational voice testing or upon failing the conversational voice test. Upon failing both conversational voice and pure tone audiometric test, an audiometric speech discrimination test should be administered (usually by an otologist or audiologist). Newer audiometers are calibrated so that the zero hearing threshold level is now based on laboratory measurements rather than on the survey. Pilot activities will be restricted to areas in which radio communication is not required. The Snellen chart should be illuminated by a 100-watt incandescent lamp placed 4 feet in front of and slightly above the chart. If the applicant wears corrective lenses, only the corrected acuity needs to be checked and recorded. There are specific approved substitute testers for color vision, which may not include some commercially available vision testing machines. Guide for Aviation Medical Examiners D. Intermediate Vision Visual Acuity Standards: As listed below or better; Each eye separately; Snellen equivalent; and With or without correction. If age 50 or older, near vision of 20/40 or better, Snellen equivalent, at both 16 inches and 32 inches in each eye separately, with or without corrective lenses. Equipment and Examination Techniques Note: If correction is required to meet standards, only corrected visual acuity needs to be tested and recorded.

Possible reasons for treatment failure include compliance issues chronic gastritis diet mayo clinic discount motilium 10 mg, re-exposure gastritis leaky gut motilium 10mg on-line, co-pathogens and carrier status (6) gastritis diet 4 you order motilium 10mg on-line. Different types of streptococci including serogroups C and G may also cause pharyngitis via food and waterborne routes of infection diet while having gastritis purchase motilium 10 mg overnight delivery. Although these types may cause glomerulonephritis, they are not associated with acute rheumatic fever. Treatment, however, is recommended when these organisms are identified in symptomatic patients although the proven benefits are unknown. The same antibiotics that are used for group A streptococci are effective for types C and G (3). Arcanobacterium haemolyticum is a rare cause of pharyngitis that usually occurs in adolescents or young adults. The illness may mimic group A streptococcal infection including a scarlatiniform rash. Neisseria gonorrhoeae may cause a pharyngitis if inoculated into the pharynx by oral contact with infectious material. Usually, the infection is asymptomatic but clinical pharyngitis and tonsillitis may develop. The characteristic finding is the grayish brown diphtheric pseudomembrane which may involve the tonsils unilaterally or bilaterally and can extend to involve the soft palate, nares, pharynx, larynx or even the tracheobronchial tree (3). Case fatality rates range from 3% to 23%, the usual mechanisms of morbidity and mortality being upper airway obstruction from extensive membrane formation and myocarditis. Edema of the soft tissues in the neck and prominent cervical and submental adenopathy may give the patient a "bull-neck" appearance (3). The disease is best prevented by Page 189 immunization, but if necessary, is treated with equine antitoxin and antibiotics, erythromycin or penicillin G intravenously. Mycoplasma pneumoniae may cause pharyngitis, but since it is also commonly isolated from controls, the significance of such infections remains unknown. Chlamydia pneumoniae has also been reported to cause pharyngitis either by itself or preceding a pneumonia. Since routine testing does not diagnose either of these organisms, treatment is not likely to be offered. The incidence of these organisms is likely seen in only a small percentage of infections and since serious complications are not commonly observed, it is likely that these infections resolve without treatment in most instances. Acute tonsillopharyngitis precedes the formation of abscess, usually with an afebrile period noted or unresolving fever before the onset of severe throat pain. There may be trismus (pain on opening the mouth) and refusal to speak or swallow because the pain may be so intense. On exam, one of the tonsils is usually markedly swollen, with effacement of the anterior tonsillar pillar and deviation of the uvula to the opposite side. Treatment involves incision and drainage of the abscess and intravenous antibiotics. Penicillin may be used although some prefer clindamycin for better anaerobic coverage. Authorities vary on whether tonsillectomy should be performed after the initial episode (2,10). Retropharyngeal abscess can also manifest as a complication of bacterial pharyngitis or less commonly from extension of vertebral osteomyelitis or penetrating injury to the posterior pharynx. The potential space between the posterior pharyngeal wall and the prevertebral fascia contains lymphatic tissue that involutes around age 3 to 4 years, making infection less common after that age. A child with a preceding acute nasopharyngitis or pharyngitis who refuses to eat, has high fever, severe distress, hyperextension of the neck or noisy gurgling respirations may have a retropharyngeal abscess. Imaging (lateral neck radiographs) is essential to confirm the diagnosis, although in an uncooperative child, a bulge in the posterior pharynx may be seen. To obtain a proper soft tissue lateral neck x-ray, the neck should be in full extension (lordotic) and the x-ray should be taken in end-inspiration. False positive x-rays (false widening of the prevertebral soft tissue) may occur with poor positioning. Untreated retropharyngeal abscesses may rupture into the airway or spread down the fascial planes to the mediastinum. Treatment includes incision and drainage under general anesthesia and empiric intravenous antibiotics with coverage for Staphylococcus aureus until culture and sensitivity information is available (2,10). Mechanical problems such as tonsillar hypertrophy leading to obstructive sleep apnea and chronic mouth breathing may cause pharyngitis. Foreign body must always be included in the differential of sore throat that does not appear infectious. Asymmetric swelling of the tonsils without infection may be a clue to malignancy (2,11). Adult type epiglottitis should be considered in older children and teens complaining of a severe throat without much clinical findings. Diagnoses such as chronic fatigue syndrome contain sore throat as part of their criteria but continue to be controversial. The latter symptoms occur for 3 to 6 days with three weeks during which the patient is entirely well interspersed with clockwork periodicity. As one author puts it, is periodic fever an infectious disease or immune dysregulation Pharyngitis can have a myriad of causes, but for the most part, the causes are easily managed viral infections. The physician has to have a certain awareness of the more serious problems which can present as pharyngitis and the appropriate workup and management once the diagnosis is suspected. Certain clues can help the physician diagnose the more serious causes of sore throat and treat them appropriately. He has been afebrile, has rhinorrhea, cough and one day of diarrhea associated with his sore throat. The best course of action is (this may be a controversial question depending on your practice setting): a. Swab his throat and give a 10 day course of antibiotics, you will call him if the culture is negative for group A strep so that he can stop antibiotic treatment. A 14 year old boy who you know is homeless and possibly engaging in prostitution comes into clinic complaining of sore throat, rash and pronounced fatigue. On exam, shallow ulcers are noted on the soft palate and vesicles are noted on one palm and both soles of the feet. A 6 year old child recently adopted from somewhere in Russia complains of sore throat and is noted by the parents to have a lot of "grayish junk" in his mouth and nose. Exam shows an adherent grayish-white membrane over both tonsils and the soft palate that, when removed, leaves an edematous, bleeding area of tissue. In children, nonsuppurative sequelae of group A strep infection of the pharynx include (circle all that apply): a. Section 3-Summaries of Infectious Diseases-Diptheria, Enterovirus (Nonpolio) Infections, Epstein-Barr Virus Infections (Infectious Mononucleosis), Group A Streptococcal Infections. Antibiotic prescribing for children with colds, upper respiratory tract infections, and bronchitis. Her past medical history is significant for atopic dermatitis (uses topical hydrocortisone), as well as multiple visits for wheezing episodes which respond well to nebulized albuterol. A presumptive diagnosis of reactive airway disease is made, and he is discharged to home on oral albuterol and prednisone. She returns 2 days later with increased coughing and tachypnea with an oxygen saturation of 94% in room air. A presumptive diagnosis of pneumonia is made and she is admitted to a general hospital for further evaluation and management of pneumonia and asthma exacerbation. She returns to the office 3 days later with increasing coughing and hypoxia (oxygen saturation 92%). Based on her clinical presentation of hypoxia and repetitive coughing; a working diagnosis of pertussis is made. Household contacts are subsequently interviewed, and erythromycin prophylaxis is started in all contacts. After 7 days, she improves and is discharged to home to complete her course of erythromycin. Bordetella pertussis is a gram negative coccobacilli that is the cause of an acute respiratory illness initially characterized by protracted coughing. With respect to the differential diagnosis, protracted coughing can also be caused by Mycoplasma, parainfluenza or influenza viruses, enteroviruses, respiratory syncytial virus, or adenoviruses.