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By: Daniel James George, MD

  • Professor of Medicine
  • Professor in Surgery
  • Member of the Duke Cancer Institute

https://medicine.duke.edu/faculty/daniel-james-george-md

H & E Stain Case Report A 93 year old white male was referred to symptoms 0f high blood pressure buy 30mg remeron with mastercard the Department of Dermatology due to medicine recall purchase remeron with mastercard a left inguinal area “rash” medications epilepsy purchase remeron 30 mg free shipping. The patient stated that he first noticed itching and redness at the left inguinal area and scrotum approximately six months prior to symptoms meningitis cheap remeron on line his visit. His primary care physician prescribed topical antifungal medications, and there was no improvement. On exam there was diffuse erythema with some excoriation at the left inguinal and Figure 5 scrotal areas. The penis, rectum, and Figure 2 Post Imiquimod treatment right scrotal and right inguinal areas Mucicarmine stain showed no abnormalities. Urology and Gastroenwould require significant flaps or grafts to vacuolated pale cytoplasm, large nuclei, terology evaluations including cystoscopy close the defect (Fig 3). Mohs surgery in particuattempted, with surgical salvage reserved cells are large round cells with abundant lar has shown improvement in the high for treatment failure. Mohs surgery with day for five days a week, for a total of six throughout the epidermis. Iniits’ epithelial origin cytokeratin is found in Conclusion tially the patient developed mild burning Pagetoid cells. Often these weeping at the center of the treatment the presence of mucin in the Paget’s patients are elderly, and wide excision area. Subsequently, staining for mucin with flaps and/or grafts for closure of the course of imiquimod there was noted to with musicarmen, alcian blue, aldehyde defect can expose these patients to sigbe central clearing of the erythema and fuschsin, and colloidal iron will be posinificant perioperative morbidity and morthe patient denied pruritis or discomfort. Imiquimod is a biologic weeks a third six week course was combodies directed against low-molecular response modifier that stimulates both pleted. The second and third courses of weight keratins will yield positive results innate and acquired immunity. Lesions and causes interferon gamma production present on the vulva in 60%, perianal from T lymphocytes. Bcell activation has area in 33%, with the remainder occuralso been shown to stimulate higher Discussion ring at other sites; axillae, eyelids, umbiliimmunoglobulin production. Imiquimod Sir James Paget first described a lesion cus, external auditory canals, also increases Langerhan cell migration involving the nipple in 18741. This case mucocutaneous junctions, and most from skin to lymph nodes, therefore was associated with underlying breast recently the face. The Phase 1 clinical trial of oral imiquimod described a similar lesion with a “rawskin examination reveals a non-descript reveals possible systemic effects similar ness” of the glans penis. In-vitro studies sive lesions which he described became and oozing with excoriations. The non-specific clinical presentaand tolerance seen with injectable interremains controversial. Topical believe that it originates from malignant patients are treated for such entities as imiquimod has little (less than 1%) sysdegeneration and aberrant proliferation of tina cruris, pruritis vulva, lichen sclerosis temic absorption. If an underlying malignancy is ment of verruca, basal cells, squamous dence of this association with underlying found, up to 50% of patients will already cells, melanoma, colon cancer, sarcoma malignancy. Naohito H: Sentinel Lymph Node Biopsy in Patients with Extramammary Paget’s Disease. Dermatol Surg 30:10: imiquimod may have a significant role in October 20041329-1334 the dermatologist’s armamentarium. Shieh S: Photodynamic therapy of the treatment of ExtraReferences: mammary Paget’s Disease. Bartholomew’s Hosp Rep mary Paget’s Disease of the vulva with topical imiquimod 10:87-89,1874. Guerrieri M: Extramammary Paget’s Disease: Role of radiVolume 47, Number 4, October 2002, S229-S235. Dermatol Surg, 30:10:October 2004, 1361gical treatment with Mohs micrographic surgery. The cost for this advertising is: Black and White 1/4 page-$125, 1/2 page-$200, full page-$350 Full 4 color ad 1/4 page-$275, 1/2 page-$350, full page-$500 Resident members may run a 3" column black and white ad stating their desired professional position. Willing to talk to dermatology residents graduating in Please Inquire: the next 18 months. It typically presents in patients with rheumatoid arthritis and other connective tissue diseases. The lesions began on the matous dermatitis, bowel-associated derelbows several years prior and subsematosis-arthritis syndrome, pyoderma quently developed on the hips and distal gangrenosum, and Behcet’s disease. Topical antibiotics and oral steroids hip and digit lesions were believed to be a were used twice daily without relief. The the patient had a known history of diadifferential diagnosis of the hip included betes mellitus, hypertension, congestive Herpes simplex virus, pressure or friction heart failure, peripheral vascular disease, blisters secondary to the wheel chair, and and rheumatoid arthritis. Vasculitis, tory was significant for bilateral below the trauma and infection were considered for knee amputations, which left her wheel the digit lesions. The Etanercept, Furosemide, Nitroglycerin, Crusted erosions on left hip patient refused a digit biopsy. A dense perivascular and interstitial matous to violaceous plaques on bilateral neutrophilic infiltrate, collars of fibrin in elbows (Figure 1). Multiple grouped tense blood vessel walls and diffuse fibrosis was vesicles on the left hip and crusted eronoted (Figures 4 and 5). Subepidermal bullae with neutrophils and focal necrosis were found on the hip biopsy. The patient was also continued on the biologics and immunosuppressives by the rheumatologist. The Erythematous macules on right digits patient has since been lost to follow up. In fully described papular lesions in patients with developed lesions, neutrophils were rheumatoid arthritis with features of diminished in number. Palisaded granuloleukocytoclastic vasculitis and palisading mas surrounded fibrin and thick collagen granulomas. In old lesions, palisaded granudescribed three patients with rheumatoid lomas contained degenerated collagen arthritis with nodules and papules over and only scattered neutrophils. Histologic exam revealed was found in vessel walls, but the dermis a dense neutrophilic infiltrate resembling was fibrotic. Lesions varied from painful injury causes ischemia, altering collagen Figure 4 to asymptomatic and occurred on differand inducing a granulomatous reaction. H & E stain of 3 mm punch biopsy of ent body areas including fingers, butthese immune complexes may also trigright elbow at 100X showing palisaded tocks, shoulders, wrists, thighs, chest, ger a granulomatous reaction. The majority of these A histologic differential diagnosis must matitis with suppuration and neupatients had rheumatoid arthritis or also be examined for completeness. Fully Ackerman originally described rheumadeveloped lesions may resemble granutoid neutrophilic dermatitis in 1978. Erythema eletrunk, shoulders, neck and extremities vatum diutinum is a form of localized vasand occur most in association with high culitis that resolves with fibrosis, but no development of palisaded granulomas. Sweet’s presents histologic presentations that coincide with these include Churg-Strauss granuloma, as erythematous plaques with a “mounthe disease evolution. Early lesions cutaneous extravascular necrotizing grantain range” appearance on various body appear both clinically and histologically as uloma, rheumatoid papules, superficial sites. With progression, lesions ulcerating rheumatoid necrobiosis, linear of these diseases have similar clinical appear both clinically and histologically as subcutaneous bands, and interstitial granpresentations and may occur with cona granulomatous, dermal process and ulomatous dermatitis with cutaneous nective tissue diseases. Leukocygranuloma formation and the elbows are subcutaneous bands on the lateral trunk toclastic vasculitis was evident throughout the old lesions with fibrosis and collagen which histologically resembled rheumathe entire dermis. In 1995, Gottlieb and Ackertrophilic infiltrate and collagen degenerarheumatoid arthritis with a positive man reported ten patients with similar tion were noted. Rheumatoid papules: lesions showing features of vasculitoid arthritis or another connective tissue 1. Arch Dermatol that cutaneous manifestations of internal lomatous drug reaction:a distinctive clinical and pathologic 1994;130:1278-83. Linear subcutaneous is imperative that as Dermatologists we bands in rheumatoid arthritis:an unusual form of rheumawork in conjunction with the primary care toid granuloma. Interstitial granulomaproviders and/or rheumatologists in treattous dermatitis with cutaneous cords and arthritis: linear ing these patients.

The multiplanar format permits a complete assessment of size treatment solutions purchase generic remeron pills, location treatment head lice order 15mg remeron amex, extent and topoChapter 16 Tumors and Tumor-like Lesions of Blood Vessels 281 17 treatment table purchase remeron paypal. Diagnosis of vascular malformations is done prefphy in 12 histologically proven cases medicine knowledge cheap remeron 15 mg mastercard. J Dermatol 17:701–706 soft tissue hemangiomas: correlation with pathologic find27. Radiol Clin North Am 31:552–559 (1992) Maffucci’s syndrome [hemangiomatosis osteolytica]: a 30. J Vasc Surg 16: 544–551 sizing vascular tumor: spindle cell, epithelioid, or unclassified 7. Am J Clin Pathol 96:660–663 graphic appearances of hemangiomas of skeletal muscle. Levin D, Gordon D, McSweeney J (1976) Arteriography of M,Grignon A (1998) Soft tissue hemangiomas in children and peripheral hemangiomas. Ehara S, Sone M, Tamakowa Y, Nishida J, Abe M, Hachiya J Am J Roentgenol 155:545–549 (1994) Fluid-fiuid levels in cavernous hemangioma of soft tis35. Naka N, Ohsawa M, Tomita Y, Kanno H, Uchida A, Aozasa K raphy characterization of soft tissue vascular malformations. Ziyeh S, Spreer J, Rossler J, Strecker R, Hochmuth A, Schu557 macher M,Klisch J (2004) Parkes Weber or KlippelTrenaunay 47. Ramon F,Degryse H,De Schepper A (1992) Vascular soft tissue O (2004) Imagerie des anomalies vasculaires des parties tumors: medical imaging. Sauramps Medical,Montpellier,pp 417–427 benign angiomatous lesions of the extremities. Cancer 88:198– mangiomas of the extremities: correlation with lesion size and 204 proximity to bone. Pediatr Dermatol 54:811–854 Evaluation of hemangioma by positron emission tomography: 55. Yagmai I (1978) Angiographic features of soft tissue and malformations of infancy and childhood. Scientific Review P ropranolol for Infantile em angiom as: E arly xperience at a ertiary V ascular A nom alies enter Lisa M. Ten recently been introduced as a novel pharmacologic patients experienced minor but reportable side effects treatment for infantile hemangiomas. At theraStudy Design: Retrospective single institution peutic doses, propranolol is safe and effective in the review. Adjunctive therapies may still be Materials and Methods: We reviewed children required. Minor side effects, expected from betatreated with propranolol for problematic hemangiblocker therapy, are common but easily managed. Parental questionnaires were obtained to Laryngoscope, 120:676–681, 2010 evaluate perceived therapeutic response and complications to oral propranolol. Twenty-seven patients began vascular anomalies and are considered the predominant therapy during the proliferative phase of their lesions vascular tumor type. Ninety-seven percent of patients displayed natural phases of proliferation (growth) and involution (dissolution). Patients were determined giomas are frequently left untreated and allowed to to be excellent responders (n fi 16, 50%), partial resfollow their natural course. Common locations for problematic hemangiomas include the face, ear, orbit, and From the Department of Otolaryngology, Division of Pediatric Otolaryngology (L. Current treatment options for problematic hemangithe authors have no conflicts of interest or funding to disclose. Systematic After receiving consent, photographic documentation of all examination of the use of propranolol in a tertiary care setlesions is performed on all patients presenting to our vascular ting has not yet been described. Hemangiomas undergoing propranolol therprofile of propranolol in children is still not well docuapy were photographed in series before and during their mented. Interval exams with photographs were peron both proliferative and involuting hemangiomas at our formed to document treatment response. Using parental questionnaires photographs was performed by five blinded observers who were and blinded observers we document the perceived response physicians with variable levels of experience in the treatment of vascular anomalies. Patient charts were reviewed for those treated with propranolol for problematic hemangiomas from September 2008 Parent Questionnaire through June 2009. Problematic hemangiomas were defined as A questionnaire was developed by the vascular anomalies hemangiomas with imminent undesirable functional or cosmetic center to assess the impact of propranolol treatment from the outcomes if left untreated. Alternative interventions (steroid perspective of close observers (parents) of the patients over injections, laser, and surgery) would have been performed in their treatment course. Families were included if their child these patients despite the availability of oral propranolol. Conhad received propranolol for the treatment of a problematic hesent to treat with propranolol and document disease response mangioma for a period of 1 month or greater. The questionnaire was received from all parents with infants and children particiincluded the following questions designed to be in terms that pating in this study. As previously described by our vascular anomalies cen• Have you noticed a color change in the skinfi Patients in the both the proliferanight monitoring at the onset of propranolol treatment (n fi 2 in this study). Hemangioma locations included the interaction or clinic visits were performed monthly. In patients nasal tip (n fi 9), periorbital (n fi 8), cheek (n fi 5), trunk with proliferating lesions, treatment proceeded from the prolif(n fi 4), parotid gland (n fi 3), neck (n fi 3), subglottis erative phase to the theoretic conclusion of hemangioma growth (n fi 3), extremity (n fi 3), glabella (n fi 2), lip (n fi 2), and at 12 months of age. Several patients had overlapping response was weaned off propranolol at 5 months of age, only to hemangiomas involving more than one anatomic site. Thus, our protocol has Prior to propranolol therapy, 15 patients (47%) sufbeen to continue therapy until 12 months of age. Patients in the involutional phase remained on propranolol for at least 6 fered a complication related to hemangioma growth months and until resolution or observation of benefit ceases. In contrast, therapy and was termed a nonresponder requiring alterfour of the five patients with hemangiomas in the invonate therapy (Fig. Four patients had complete lutional stage had been treated with either oral or resolution with no residual evidence of disease (Fig. Four with frank or impending ulceration, and steroid injecpatients, at the writing of this paper, have been weaned tions were performed in patients with periorbital lesions off the propranolol at 11 to 12 months of age with no evicausing functional impairment. Patient who received propranolol and one intralesional steroid injection into a large orbital hemangioma. Response scores indicated that hemangiomas the two neutral responses included one child who had changed in size and appearance toward resolution continued growth while on propranolol (Fig. Similar to Reported Side Effects clinical findings, four patients were considered to have Propranolol was suspected to be the cause of side complete resolution by their response raters (mean foleffects reported by 10 of 22 families inquired (Table I). Minor side effects included increased somnolence (n fi 6), gastroesophageal reflux (n fi 2), allergic rash (n fi 1), and respiratory syncytial virus exacerbation (n fi 1). Parent Questionnaire There were no reports of serious side effects related to Twenty-two patients treated with propranolol for cardiac events, bronchospasm, or hypoglycemia. Nearly >1 month were provided parental questionnaires regardevery patient with reported side effects was managed ing the therapeutic response. The One patient required cessation of therapy due to psoritime for this to occur was on average <1 week from the atic-like rash. Although the majority have little impact deep components of the hemangioma; 17 (77%) noted on childhood health, various problematic head and neck improvement in the superficial portions of the hemangihemangiomas will develop rapidly and interfere with oma. Their overall opinion of propranolol treatment was normal function and appearance. These problematic ‘‘happy with the response, would recommend’’ in 20 of 22 hemangiomas require intervention to control growth Fig. Similarly, both parents and practitioners in this study recognized disease improvement near 2 to 4 weeks from the onset of therapy. Four patients have so far been weaned from propranolol with no evidence of rebound or recurrence.

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The needle seems to symptoms indigestion order remeron 30mg divide cells from each dle lengths medicine app order remeron australia, diameters and numbers medicine xarelto purchase remeron 15mg, which can make it very other rather than cutting through the cells so that many cells confusing for their users medications januvia purchase cheap remeron. Because the needles are set in a roller, every needle initially penetrates at an angle and then goes deeper as the roller turns. Finally, the needle is extracted at the converse angle; therefore, the tracts are curved, reflecting the path of the needle as it rolls into and then out of the skin, for about 1. The epidermis and particularly the stratum corneum remain “intact,” except for these tiny holes, which are about four cells in diameter. The treatment times can range from 10 to 60 minutes, depending on the size of the area being treated. The skin develops multiple microbruises in the dermis that initiate the complex cascade of growth factors that Figure 9. Post-treatMeNt care Postprocedure appearance (4) includes the following: day 1 and 2: Depending on how deeply the technician inserts the needle into the epidermis, the tissue may have slight to moderate swelling and may be tender, red, and bruised, with a slight lymph discharge from the treated areas. Minor itching may occur and the “needled” tissue may exhibit the appearance of “cat scratches. Immediately after the treatment, the skin looks bruised, but bleeding is minimal, and there is only a small ooze of serum that soon stops (Figure 9. Some practitioners recommend soaking the skin with saline swabs for an hour or two and then cleaning the skin thoroughly with a oil-based cleanser. A thin layer of Vaseline or equivalent may be applied to reduce skin humidity loss. The patient is encouraged to use topical vitamin A and vitamin C as a cream or an oil to promote better healing and greater production of collagen. No products have to be applied on the treatment areas for 36 hours after treatment. Makeup and sunblock can be applied on Day 2 posttreatment, if the treatment area is dry and unbroken. It is very important to continue using the topical vitamin cream for at least 6 months postprocedure to ensure the production of healthy collagen and elastin. The importance of a thorough but gentle of potential contamination from drains and plugs. Patients should washing of the skin, a few hours after the procedure, cannot be be reminded to use only tepid water because the skin will be more stressed enough. While the water is running over the face or body, and by Day 4 or 5, the skin has returned to a moderate pink flush, the patient should gently massage the treated skin until all serum, which can easily be concealed with makeup. As the skin has a memory and will seek to return to its previous state, it’s recommended to repeat skin-needling treatments over a period of 1 to 2 years. The outcome of collagen induction therapy combined with a prescribed posttreatment skin care routine can produce dramatic results that will last for years. So it’s recommended that patients continue home needling to ensure the longevity of their scar improvement. The home needling can be safely combined with the use of peptide serum and/or tretinoin to maximize improvements in depressed scarring. Clinical results vary between patients, with some achieving 90% improvement in scarring and others less than 50%. The number of treatments (5) required varies depending on the individual collagen response on the condition of the tissue and desired results and will be determined by the dermatologist: You may need 2 to 6 treatments. Our experience (6) has shown that, after only two sessions of treatment, the level of severity of rolling scars in all patients is largely reduced: the digital photographic comparison of lesions, before (Figure 9. The formation of scabs Besides, no patient showed visible signs of the procedure or should be discouraged because they may cause obstruchyperpigmentation. Milia are uncommon, though, but when they occur gen induction therapy a dramatic increase of new collagen they should be treated by pricking and draining. Although difficult to estimate, pustules are more common and usually found in patients there is at least 400% and 1000% more collagen and elastin treated for acne scars. The epidermis demonstrated 40% thickening the pustules are allowed to dry on the skin, they will form of stratum spinosum and normal rete ridges at 1 year postthin scabs that effectively prevent the penetration of the operatively. Patients are instructed to use a topical virocidal if they feel the tingling feeling that is typical of herpes. Higher doses of vitamin A may cause a retinoid reaction that will aggravate the pink flush of the skin and also cause dry, flaky skin. Moreover, it is absolutely recommended to not use badly tooled and copied version of the medical device: the material is too soft and the tips easily bend when touching a hard surface, for example, bones. This again results in cutting and ripping tissue, nerves, vessels, and the lymphatic system when rolled through the skin. Skin needling is a simple technique and can have an “immediate effect” on the improvement of rolling acne scars. The most important one is that the epidermis remains intact because it is not damaged, eliminating most of the risks and negative side effects of chemical peeling or laser resurfacing. There is scientific proof that the needling procedure also stimulates revascularization, repigments stretch marks, and fills cutaneFigure 9. From this point of view, skin needling is now well treatment: note how tips are bent like a fishhook. Furthermore, it offers results not International Institute of Permanent Cosmetics. Clin Exp (subcision) surgery for the correction of depressed scars Derm 2008; in press. Minimally invasive percutaneous collagen collagen induction therapy: an alternative treatment for induction. This combination of • Several fractional laser devices are available and each varsequelae were responsible for the decline in popularity of the ies as to the type of laser source, treatment settings, spot procedure. Traditional erbium dependent on the type and depth of the scarring as well lasers had lower rates of complications but were largely ineffecas the patient’s skin type and tolerance for risk. When these lasers became fractionated, the ability of complications compared with traditional laser resurfacing. Both target water and both vaporize the For the treatment oF acne scars skin efficiently. These differences in depth of penetration have new, the history of the use of these devices for this indication significant import with respect to the treatment of acne scars. The depth and surface area of the scars being treated are the main determinants for system selection and energy settings. Superficial scarThere are many different devices that may be utilized to treat acne ring may be amenable to treatment with a fractional nonablascars. This less invasive device will improve the patient’s devices that are used throughout the world. Instead, a focus will appearance (and self-esteem) with less risk and minimal be placed on the systems that are most prevalent at the present downtime. Although the various manufacturers incorporate different available and the risks and benefits compared with fractional technologies and have differences in their treatment algorithms, photothermolysis should be discussed with each patient prior some general trends are valid across the various platforms. Chief among be useful to have an understanding of the present fractional laser the options for the treatment of acne scars are dermabrasion, devices as indicated for the treatment of acne scars. This device uses that clinical improvements in the range of 51% to 75% were an erbium source at a wavelength of 1550. Few complicathis required the use of a blue dye to enable the tracking system tions were noted. Whether additional treatments would have to scan the areas that had and had not been treated. This was improved scars to a greater extent or intrinsic collagen remodviewed by many as an inconvenience and subsequent devices eling helped diminish the appearance of the scars after the no longer use this dye. This cooling has several functions but the require the use of blue dyes to target the laser. This has also been two most relevant ones for the treatment of acne scars is that demonstrated to improve the appearance of acne scars. Fluences used portion of the hair follicle enabling the stem cells to repopulate in these patients were between 35–40 mJ/ microthermal zone the skin from a deeper (and thus more even) level. When treating acne, this ability allows the of patients had an improvement in the appearance of their acne user to increase the density when it is necessary to ablate more scars between 50% and 75%. Whereas other techniques such as dermabrasion Many different skin types have been treated with this device and chemical peeling do not enable the physician to match the in an effort to treat acne scars. As with other reports, adverse events were limited to transient In clinical experience, the Fraxel has been used to treat acne issues such as erythema and edema.

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In a combat situation medications prescribed for depression cheap 30 mg remeron fast delivery, body recovery should be attempted unless the attempt exposes the rescue team to treatment lead poisoning generic remeron 15mg overnight delivery undue danger medications made easy 15 mg remeron for sale. In non-combat situations symptoms you have cancer cheap remeron 30mg visa, attempt body recovery only if it can be accomplished with a minimum of risk to the rescue team. If there is any suspicion of death as a result of foul play or other forensic circumstances (suicide, homicide, neglect, accident, etc. In the event of a military aircraft crash, do not disturb the scene except to assess and resuscitate any casualties which are not dead (see above). If the casualties must be moved to perform medical treatment, every attempt should be made to record the exact location where the patient was found, and his/her exact position (photographs from multiple angles are helpful). Body recovery may be the responsibility of local law enforcement or military authority, depending on the circumstances and location of the mishap. In most circumstances, it is best to leave the body or bodies in position until investigating authorities arrive and survey the site. See Decompression sickness symptoms of, 3–16—3–17 Benign paroxysmal vertigo Bird breeder’s lung, 4–18 differential diagnosis of, 3–20—3–21 Birth control pills. See Oral contraceptives dizziness in, 3–20 Bisacodyl suppositories, 3–13 Benign positional vertigo, 3–20—3–21 Bithionol Benzathine penicillin for fascioliasis, 5–39 for acute rheumatic fever, 5–99 side effects of, 5–39 for syphilis, 5–30 Black flies, 4–53 Benzidazole, 5–53 Black widow spider bite, 4–60 Benzocaine, 5–16 Blackheads, 4–38 Benzocaine/menthol, 4–58 Bladder Benzodiazepam, 5–145 antispasmodics for, 3–82 Benzodiazepines catheterization of abuse of, 5–150 equipment for, 8–34 for anxiety, 3–5 indications for, 8–33—8–34 for elbow dislocation, 3–67 precautions for, 8–35 intoxication of, 5–150t procedure for, 8–34—8–35 for mania, 3–17 infections of, 4–93 for pain control, 8–38, 8–39 lacerations of in cesarean section, 3–102 for psychosis and delirium, 5–152 sudden emptying of, 8–36 withdrawal from, 5–151t suprapubic aspiration of, 8–35—8–36 Benzoin, tincture of, 5–8 Bladder tap. See Hemorrhage Body heat, preserving, 7–13 Bleeding disorder, snakebite-induced, Body lice, 4–62—4–63 5–145—5–146 in relapsing fever, 5–89 Bleeding ulcer, 4–85 Body surface area, 7–20f Blepharitis Body temperature differential diagnosis of, 3–25 rapid reduction of, 6–50 red eye with, 3–24 regulation of, 6–47 treatment of, 3–25 Boiling, water treatment, 5–119—5–120 Blister agents, 6–53—6–54 Boils, 4–52 Blisters Bolivian hemorrhagic fever, 6–61 friction, 5–7—5–8 Bone marrow genitourinary, 4–89 failure of, 4–8 Blood suppression of, 4–8—4–9 components of, 4–8 Borborygmi, 4–86 Giemsa stain for parasites of, 8–47—8–48 Borrelia glucose level of. See American trypanosomiasis Chlamydia Chagoma, 5–53 cultures of, 3–37, 3–38 Chancroid pneumoniae, 4–14 in genital ulcers, 5–28 psittaci, 5–31 treatment of, 5–29 trachomatis, urethral discharges of, 5–26 Charcoal, activated. See Cardiopulmonary resuscitation D vitamin deficiency, 5–138t Crab lice, 4–62—4–63 Da Nang lung. See Acute respiratory distress synCranberry juice, 4–94 drome Creeps, 6–36 Dacryocystitis, 3–26 Cricothyroidotomy, 7–1 differential diagnosis of, 3–26 in airway management, 8–3 treatment of, 3–27 for airway obstruction, 3–117 Dairy products, boiling of, 5–109 equipment for, 8–5—8–6 Dandruff, 4–49—4–51 indications for, 8–5 Dapsone needle technique, 8–6 for brown recluse spider bite, 4–61 precautions in, 8–7 for leprosy, 4–45 surgical technique, 8–6—8–7 Darkfield microscopy, 4–64 Crimean-Congo hemorrhagic fever, 6–61 Darling’s disease. See Vaginal delivery skin lesions in, 4–38—4–39 Delusions, symptoms of, 5–152 symptoms of, 4–38 Demerol treatment of, 4–40 after cesarean section, 3–102 Dermatomes, of cutaneous innervation of hand, 5–168f for urolithiasis, 4–92 Dermatophyte infections Demodex folliculorum, 5–32 assessment of, 4–50 Demulcents, 6–53 causes of, 4–49—4–50 Dengue fever follow-up for, 4–50 assessment of, 5–65—5–66 patient education for, 4–50 diagnostic algorithm for, 3–30—3–34f signs of, 4–50 differential diagnosis of, 5–84, 5–87, 5–89 symptoms of, 4–50 follow-up for, 5–66 treatment for, 4–50 patient education for, 5–66 zoonotic disease considerations in, risk factors for, 5–65 4–50—4–51 signs of, 5–65 Dermatophytosis, 4–50—4–51 symptoms of, 5–65 Dermatosis, pediatric, 4–42—4–43 transmission of, 5–65 Dermoplast, 4–58 treatment for, 5–66 Desert rheumatism. See also Preeclampsia volume-restricting, 8–31 signs of, 3–105, 3–108 wet-to-dry, 8–28 treatment of, 3–109 Driving restrictions, seizure disorder, 4–35 Ecthyma contagiosum Drug eruptions, 3–114 assessment of, 4–46 Drug hypersensitivity, 3–113t cause of, 4–45—4–46 Drug reactions follow-up for, 4–46 differential diagnosis of, 4–65, 6–31 patient education for, 4–46 fever with, 3–31 signs of, 4–46 Drug-related fatigue, 3–29 symptoms of, 4–46 Drug-related pruritus, 3–114 treatment for, 4–46 Drug-related syncope, 3–118 Ectopic pregnancy Dry eye acute pelvic pain with, 3–41, 3–42 differential diagnosis of, 3–25 ruptured, 3–3t red eye with, 3–24 treatment of, 3–43 treatment of, 3–25 Eczema, 3–113 Dry socket. See Electrocardiography Dysmenorrhea Elapidae snakes, 5–143, 5–144 diagnosis of, 3–45 Elastoplast, 5–8 differential diagnosis of, 3–44t Elavil, 3–82 primary, 3–45 Elbow joint symptoms of, 3–45 aspiration at, 8–29 treatment of, 3–45 dislocation of Dyspareunia, 3–51 anterior, 3–65 Dyspepsia assessment of, 3–67 alleviating or aggravating factors in, 3–11 diagnostic tests for, 3–67 treatment for, 3–12 differential diagnosis of, 3–67 Dyspnea, 3–115 follow-up, 3–68 assessment of, 3–116 patient education for, 3–68 on exertion, with congestive heart failure, post treatment care for, 3–67—3–68 4–3 posterior, 3–65 exposure history in, 3–115 procedure for, 3–67 follow-up, 3–117 Electrical injuries, 7–26 medical history in, 3–115 assessment of, 7–27 neurological exam for, 3–116 follow-up for, 7–28 patient education for, 3–117 patient education for, 7–28 signs of, 3–115—3–116 signs of, 7–27 symptoms of, 3–115 symptoms of, 7–26—7–27 treatment of, 3–117 treatment for, 7–27—7–28 Dysrrhythmias, 8–10 Electrocardiogram rhythm, 3–118 Electrocardiography in congestive heart failure, 4–4 E vitamin deficiency, 5–138t for myocardial infarction, 4–1, 4–2f Ears normal with chest pain, 4–8 barotrauma to, 6–1—6–2 in pericarditis, 4–6 dizziness in trauma to, 3–20 for pulmonary embolus, 4–23 middle, 6–34 three-lead, 8–10—8–12 Eastern equine encephalitis, 5–66 applying chest electrodes in, 8–11 Ebola virus, 6–61 equipment for, 8–10 Echinococcosis, 5–32 interpreting, 8–11—8–12 Echovirus, 3–112t patient preparation for, 8–11 preparation for, 8–10—8–11 patient education for, 5–37—5–38 Electrocution, 7–26 symptoms and signs of, 5–37 Electroencephalography transmission of, 5–37 for memory loss, 3–87 treatment for, 5–37 for seizures, 4–35 Enterobius vermicularis nematode, 5–37 Elephantiasis. See Underwater blast Erythromycin injury for acute rheumatic fever, 5–99 Exposure management, M5 item list for, 1–18 for chancroid, 5–29 External auditory canal, blocking of, 6–34 for chemical burns, 7–18 Extraocular muscle in dentistry, 5–19 derangement of, 3–27 for erysipelas, 4–42 examination of for red eye, 3–24 for granuloma inguinale, 5–29 Extremities, secondary trauma survey of, 7–4 for impetigo contagiosa, 4–43 Eye globe, ruptured, 3–27 for ingrown toenail, 5–3 differential diagnosis of, 3–28 for lymphogranuloma venereum, 5–29 treatment of, 3–28 for mastitis, 3–8 Eye patch, 3–25 for pelvic inflammatory disease, 3–51 Eyelid laceration, 3–28 for pinta, 4–64 Eyes for pneumonia, 4–13 drainage of, 3–27 for preterm labor infection, 3–94 injuries of for prostatitis, 3–82 assessment of, 3–27—3–28 for relapsing fever, 5–90 from blister agents, 6–53 for urethral discharges, 5–27 follow-up, 3–29 for yaws, 4–63 with hymenoptera sting, 4–58 Eschar, 7–17 laser, 7–28—7–29 Escharotomy patient education for, 3–29 chest, 7–19, 7–21f signs of, 3–27 symptoms of, 3–27 Feldene, 4–84 treatment for, 3–28 Femoral neck stress fracture, 3–73 pain in with red eye, 3–24 Femoral shaft stress fracture, 3–74 problems of Femur fractures, hemorrhage control in, 7–13 acute red eye without trauma, 3–24—3–26 Fentanyl acute vision loss without trauma, for chemical burns, 7–18 3–22—3–24 continuous infusion of in field, 5–158t eye injury, 3–27—3–29 dosing guidelines for, 5–156t orbital or periorbital inflammation, for pain control, 8–39 3–26—3–27 Fetal complications, cesarean section for, 3–100 protection of in Bell’s palsy, 4–37—4–38 Fetal head crowning, 3–88, 3–90f, 3–91f Fetal heart tones, 3–87 Fever. See also Urolithiasis for hypothermia, 6–44 assessing, 4–87 Flumazenil, 8–40 hematuria with, 4–88 Flunixin meglumine (banamine) Flashlight examination for equine colic, 5–133 for orbital or periorbital inflammation, 3–26 for equine lameness, 5–135 for red eye, 3–24 Fluocinonide, 4–70 Flaviviruses, 5–66 Fluorescein strip staining Flavoxate for acute vision loss without trauma, 3–23 for prostatitis, 3–82 for eye injury, 3–27 for urinary incontinence, 4–90 for orbital or periorbital inflammation, 3–26 Flexeril (cyclobenzaprine) for red eye assessment, 3–24 for joint pain, 3–63 Fluoride deficiency, 5–139t side effects of, 3–64 Fluoroquinolones Flight operations, decompression sickness risk in, 6–37 for biological warfare agents, 6–56 Flomax (tamsulosin) for inhalational anthrax, 6–57 for prostatitis, 3–82 for pneumonia, 4–13 for urinary incontinence, 4–91 for urinary tract infections, 4–94 Flonase, 3–31 Fluoxetine (Prozac) Floricet, withdrawal from, 5–150 for apnea, 4–26 Florinal, withdrawal from, 5–150 for depression, 3–17 Floxin Fly eggs, myiasis transmission, 4–52 for epididymitis, 3–84, 3–85 Focal motor seizures, 4–34—4–35 for urinary tract infections, 4–94 Focal neurologic signs, 4–31 Flu. See also Common cold; Influenza Folate deficiency, 5–137t assessment of, 4–10—4–11 Foley catheterization causes of, 4–10 in cesarean section, 3–102 follow-up, 4–12 for prostatitis, 3–81 patient education for, 4–12 for venomous snake bite, 5–145 signs of, 4–10 Foley catheters symptoms of, 4–10 for bladder catheterization, 8–34 treatment of, 4–11—4–12 in episiotomy, 3–103 Flucinolone, 4–65 Folic acid deficiency, 5–137t Fluconazole in anemia, 4–8 for blastomycosis, 5–60 Folliculitis, 3–114 for candida vaginitis, 3–48t, 3–50 Food for candidal penile infection, 3–78 acquisition of, 5–108 for candidiasis, 5–58 contamination of for coccidioidomycosis, 5–61 categories of, 5–108 for paracoccidioidomycosis, 5–63 in cyclosporiasis transmission, 5–36 for pityriasis versicolor, 4–51 in leptospirosis, 5–86 for urinary tract infections, 4–93 potentially hazardous, 5–108 Fluid overload, 4–3 preparing and serving of, 5–110 procurement of, 5–108—5–109 in compartment syndrome, 8–31 storage and preservation of, 5–109—5–110 compartment syndrome management in, of meat and animal products, 5–126—5–128 8–30 Food-borne disease femoral shaft, 3–74 factors in, 5–108 hip, 3–73 prevention of, 5–126 assessment of, 3–73 Food poisoning treatment of, 3–74 acute bacterial in hip dislocation, 3–68 assessment of, 4–80 in hypovolemic shock, 7–12 causes of, 4–79 in joint pain, 3–59, 3–60 follow-up for, 4–80 with low back pain, 3–6, 3–7 patient education for, 4–80 shoulder, 3–71 signs of, 4–80 splinting for, 8–32 symptoms of, 4–79—4–80 stress, foot, 5–6—5–7 treatment for, 4–80 of tooth or crown, 5–12—5–13 diarrhea with, 3–19 traction for, 8–33 differential diagnosis for, 4–71 with underwater blast injury, 6–19 Foot Francisella tularensis, 5–102, 6–60 cutaneous innervation of, 5–173f Frank breech, 3–96 disorders of. See Podiatry; specific disorders Freckles, 4–38 friction blisters of, 5–7 Freezing injury. See Acquired immune deficiency syndrome; for adrenal insufficiency, 4–28 Human immunodeficiency virus for decompression sickness, 6–5 Hives, 4–39 for heat stroke, 6–51 in anaphylactic shock, 7–10 for mastitis, 3–8 Hoof testers, 5–134 for pulmonary over inflation syndrome, 6–8 Hookworm. See also Cutaneous larva migrans for syncope, 3–118 assessment of, 5–42 for urolithiasis, 4–92 differential diagnosis of, 5–48 Hydrocele, above testis, 3–80 follow-up for, 5–42 Hydrocortisone incidence of, 5–41 for adrenal insufficiency, 4–28 patient education for, 5–42 for bed bug bites, 4–55 signs of, 5–42 for contact dermatitis of penis, 3–78 species of, 5–41 for millipede exposure, 4–57 symptoms of, 5–41—5–42 Hydrofluoric acid burn, 7–19 treatment for, 5–42 Hydrogen peroxide, 6–15 zoonotic considerations in, 5–42 Hydromorphine, 3–102 Hornet sting, 4–57—4–59 Hydropel, 5–8 Horses Hydrophidae snakes, 5–143, 5–144 colic in, 5–132—5–133 Hydrophobia. See Diarrhea; Flu; Influenza differential diagnosis of, 3–44t Intestinal flukes, giant, 5–38 physical examination for, 3–46 Intestinal ischemia/infarction, 3–3t symptoms of, 3–46 Intestinal obstruction. See also Urolithiasis symptoms of, 3–59—3–60 Killer whales, 6–17 treatment of, 3–62—3–63 Killip classification, myocardial infarction, 4–3 Joint fluid analysis, 8–28 Kinyon’s carbol-fuchsin stain, 8–47 Jugular venous distention Kissing bug bite, 5–53 in congestive heart failure, 4–4 Kissing disease. See Loiasis differential diagnosis of, 3–114, 4–65 Local infiltration, anesthesia, 5–159 Lichenification, 4–39 Lodine, 4–33 Lichenoid keratosis, benign, 4–66 Loiasis, 4–52 Lidex gel, 5–17 Loperamide Lidocaine for acute diarrhea, 3–19 in appendectomy, 4–77 for fever, 3–34f in axillary blockade, 5–174t Lorazepam in Bartholin’s gland abscess drainage, 3–53 for anxiety, 3–5 for bladder catheterization, 8–34 for mania, 3–17 for cesarean section, 3–100, 3–101 for pain control, 8–39 for chest pain, 3–12 for psychosis and delirium, 5–152 for digital block of finger or toe, 5–163t for tetanus, 5–101 in dorsal slit procedure, 3–79 Lotrimin for elbow dislocation, 3–67 for balanitis, 3–78 with epinephrine, 5–20 for candidal penile infection, 3–78 for breast abscess drainage, 3–9 Low back pain, 3–6 in episiotomy, 3–103 assessment of, 3–6 for eye injury, 3–28 follow-up, 3–7 local infiltration of, 5–159 mechanical, 3–6 for pain control, 8–39 in joint pain, 3–62 for patellar dislocation, 3–69 treatment of, 3–6—3–7 for suprapubic bladder aspiration, 8–35 patient education for, 3–7 in suturing, 8–22 prevention of, 3–7 in testis torsion treatment, 3–83 referred, 5–1 in thoracentesis, 4–16 signs of, 3–6 in thoracostomy, 8–7 symptoms of, 3–6 for trochanteric bursitis, 3–73 treatment plan for, 3–6—3–7 in tube thoracostomy, 8–8 Loxosceles spider, 4–60 for venomous fish bites, 6–15 Lumbar mobility assessment, 3–61 Ligament tear, knee, 3–59 Lumbar puncture, 3–87 Lightning injuries, 7–26 Lung fluke, 5–45 assessment of, 7–27 Lungs follow-up for, 7–28 cancer of patient education for, 7–28 cough with, 3–15 signs of, 7–27 differential diagnosis of, 5–54 symptoms of, 7–26—7–27 pleural effusion with, 4–15 treatment for, 7–27—7–28 disease of, 3–14 Lindane granulomas of in histoplasmosis, 5–62 for scabies, 4–61 intubation of for airway compromise, 7–25f shampoo, for pediculosis, 4–63 Lupus Lingual nerve blockade, 5–23f erythematosus, 4–39 Lipoma, removal of, 8–26 fatigue with, 3–30t Liposomal amphotericin B, 5–43 joint pain with, 3–60 Liquid waste disposal, 5–118 treatment of, 3–63 Lisinopril, 4–5 vulgaris, in cutaneous tuberculosis, 4–44 Listeria, food poisoning, 4–79 Lyme disease, 5–32 Lithotomy table, 3–38 assessment of, 5–88 Liver differential diagnosis of, 3–113t, 4–37, 5–89, amebic abscess of, 5–104 5–98 disease of, 3–113 fatigue with, 3–30t enlargement of follow-up for, 5–88 patient education for, 5–88 5–84, 5–86, 5–87, 5–89, 5–104, signs of, 5–88 6–50 symptoms of, 5–88 fever with, 3–32 transmission of, 5–88 follow-up for, 5–45 treatment for, 5–88 Giemsa stain for, 8–47—8–48 zoonotic disease considerations in, patient education for, 5–45 5–88—5–89 prevention and control of, 5–120 Lymph nodes, tender or draining, 3–34f prophylaxis for, 5–45 Lymphadenitis signs of, 5–44 differential diagnosis of, 5–57 symptoms of, 5–44 in nontuberculous mycobacterial infections, transmission and incidence of, 5–44 5–56 treatment for, 5–44—5–45 treatment of, 5–57 Malarone, 5–45 Lymphadenopathy Malayan filariasis, 5–39 in American trypansomiasis, 5–53 Male genital problems. See under Sexually transmitted Pelvic masses, 3–43—3–44 disease Pelvic pain, 3–1 inflammation of foreskin of, 3–77—3–79 acute Penlac, 4–50 assessment of, 3–42—3–43 Penrose drain, 3–10 follow-up, 3–43 Pentamidine, 4–82 gynecologic causes of, 3–41—3–42 Pentavalent antimony, 5–43 patient education for, 3–43 Pentostam (sodium stibogluconate), 5–43 signs of, 3–42 Pepcid symptoms of, 3–42 for acute abdominal pain, 3–2 treatment for, 3–43 for gastritis, 4–81 chronic Peptic ulcer disease assessment of, 3–44t assessment of, 4–85 with dysmenorrhea, 3–45 causes of, 4–84 with endometriosis, 3–45 chest pain with, 3–11 gynecologic causes of, 3–43—3–44 complications of, 4–84 diagnosis and treatment of, 3–46—3–47 differential diagnosis of, 4–78 follow-up, 3–47 follow-up for, 4–85—4–86 patient education for, 3–47 patient education for, 4–85 with irritable bowel syndrome, 3–46 signs of, 4–85 with mittelschmerz, 3–46 symptoms of, 4–84—4–85 treatment for, 4–85 Pharyngitis Peptobismol, 3–34f differential diagnosis of, 4–11, 5–64, 5–79 Peracute, 5–135 streptococcal, 5–98, 5–99 Periapical abscess, 5–9, 5–13 Phenergan differential diagnosis of, 6–32, 6–33 for acute organic intestinal obstruction, 4–86 untreated, 5–13—5–14 after cesarean section, 3–102 Pericardial fluid, removal of, 8–13 for chemical burns, 7–18 Pericardial friction rub, 4–6 for peritonitis, 4–84 Pericardial tamponade Phenobarbital, 4–35 chest pain with, 3–10 Phenothiazine toxicity, 5–101 in pericarditis, 4–6 Phenoxybenzamine hydrochloride (Dibenzyline), treatment for, 3–12 6–43 Pericardiocentesis, 8–12—8–13 Phenylbutazone, 5–134—5–135 equipment for, 8–12 Phimosis, 3–77, 4–89 indications for, 8–12 consultation criteria for, 3–79 for pericarditis, 4–6 patient education for, 3–79 preparation for, 8–12 signs of, 3–78 for tamponade, 4–7 treatment of, 3–78, 4–89—4–90 Pericarditis Phlebotomy assessment of, 4–6 for congestive heart failure, 4–4 causes of, 4–6 for hypertensive emergency, 4–5 differential diagnosis of, 5–99 Phobias, 3–5 follow-up, 4–7 Phosgene, 6–53—6–54 patient education for, 4–6—4–7 Phosphorus deficiency, 5–139t referred pain to shoulder in, 3–70 Photophobia, 3–27 signs of, 4–6 Physical examination symptoms of, 4–6 animal restraint for, 5–128—5–130 treatment for, 3–12, 4–6 of animals, 5–130 viral, 8–12 of breasts (chest), 2–4 vital signs suggesting, 3–11, 3–12 cardiovascular, 2–3—2–4 Pericoronitis, 5–17 constitutional, 2–3 Peridex (chlorhexidine), 5–16 ear, nose, mouth, and throat, 2–3 Perineum, incision of. See Episiotomy gastrointestinal, 2–4 Periodontal abscess, 5–15 genitourinary, 2–4 Periorbital inflammation. See Onchocerciasis for pericarditis, 4–7 Rizatriptan (Maxalt), 3–56 Sandfly bite, 5–42 Rocephin (ceftriaxone) Sanitation, in field. See also Anaphylactic shock Sinus barotrauma, 6–3—6–4 anaphylactic, 7–10—7–11 Sinus squeeze, 6–33 differential diagnosis of, 6–9, 7–24 prevention of, 6–34 fluid resuscitation for, 7–14—7–17 Sinusitis with hemorrhage, 7–3 cough with, 3–15 hypovolemic, 7–11—7–14 differential diagnosis of, 4–11 treatment of, 7–24 infectious, 6–32, 6–34 Shock waves, underwater, 6–18 treatment of, 3–56 Shortness of breath. See Oroya fever Sleep Specimen transport, preparation for, 8–40—8–41 altered patterns of, 3–30—3–31 Spectinomycin disturbances of for disseminated gonococcal infection, 4–40 in depression, 3–16 for epididymitis, 3–85 fatigue and, 3–29 Speech, slurred, 4–37 memory loss with deprivation of, 3–86 Spermatocele, 3–80 Sleep apnea, 4–25 Spider angiomata, 3–87 fatigue with, 3–29 Spider bites, 4–60 treatment of, 3–31 assessment of, 4–60 Sleep wedge, 3–31 differential diagnosis of, 5–91 Sleeping sickness. See Anesthesia, total treatment for, 5–50 intravenous zoonotic disease considerations in, 5–51 Tourniquet test, 5–65 Trichinella spiralis, 5–32, 5–50 Tourniquets, 7–2 Trichinosis, 5–32. See Genital ulcers treatment for, 5–55 herpetic, 5–16 zoonotic disease considerations in, 5–56 perforated Tuberculous meningitis, 5–80 acute abdominal pain in, 3–3t Tularemia chest pain with, 3–10 assessment of, 5–103 skin, 4–39 in biological warfare, 6–60 urinary tract, 4–89 cause of, 5–102 Ulnar nerve block differential diagnosis of, 3–112t contraindications to, 5–165 follow-up for, 5–103 medial approach in, 5–165f patient education for, 5–103 ventral approach in, 5–164f signs of, 5–102—5–103 at wrist, 5–164—5–165 symptoms of, 5–102 Ultraviolet exposure, 4–65 treatment for, 5–103 Ultraviolet keratitis zoonotic disease considerations in, 5–103 differential diagnosis of, 3–25 Tumors treatment of, 3–25 low back pain with, 3–6 Ultraviolet light exam, for vision loss, 3–23 of testis and scrotum, 3–79—3–80 Ultraviolet sunlight, 3–115 Tuning fork, 6–1 Unconsciousness. See White blood cells Vitreoretinal injury, laser, 7–29 Weapon injuries, non-lethal, 7–28—7–29 Vitreous hemorrhage Weapons of mass destruction in acute vision loss, 3–22 chemical, 6–51—6–54 differential diagnosis of, 3–23 symptoms of, 6–51 treatment of, 3–23 Web space digital block Voiding of finger, 5–160f bladder catheterization for problems with, of toe, 5–162f 8–33—8–34 Weight normal, 4–88 control of for hypertensive emergency, 4–5 Volvulus, 4–86 loss of, 3–29 Weil’s disease, 5–86 follow-up for, 5–71 West Nile encephalitis, 5–66 patient education for, 5–70—5–71 Western equine encephalitis, 5–66 prevention and treatment of, 5–74t Wet lung syndrome. See Acute respiratory disrequired vaccination for, 5–106t tress syndrome signs of, 5–70 Wet mount symptoms of, 5–70 for candida vaginitis, 3–50 treatment for, 5–70 procedures in, 8–43—8–44 Yellowjacket sting, 4–57—4–59 Wet-to-dry dressings, 8–28 Yersinia Wheals, 4–39 enterocolitica, 5–32 Wheezing, 4–19, 4–20 in food poisoning, 4–79 Whipworm. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. Exempted from this legal reservation are brief excerpts in connection with reviews or scholarly analysis or material supplied specifically for the purpose of being entered and executed on a computer system, for exclusive use by the purchaser of the work. Duplication of this publication or parts thereof is permitted only under the provisions of the Copyright Law of the Publisher’s location, in its current version, and permission for use must always be obtained from Springer. Permissions for use may be obtained through RightsLink at the Copyright Clearance Center. The use of general descriptive names, registered names, trademarks, service marks, etc. While the advice and information in this book are believed to be true and accurate at the date of publication, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Printed on acid-free paper Springer is part of Springer Science+Business Media ( An important step is the training of nephrologists and physicians treating patients with renal diseases. Unacceptable delays in the recognition and treatment of (severe) renal disease due to lack of access to basic and comprehensive care often leads to preventable, acute and chronic adverse effects caused by malfunctioning kidneys. Kidney disease during infancy to adolescence due to (intrauterine) malnutrition, genetic inheritance, nephrotoxic agents or poorly treated primary diseases has devastating, often irreversible, effects on bone health, growth and intellectual development. Disparities in preventive and curative or supportive care arise from the lack of knowledgeable health care professionals, lack of (public) health care resources and lack of individual financial means to initiate and support therapies that are taken for granted in more affiuent countries. This Manual is the collaborative product of one of the few and successful pediatric sister center pairs, the Children’s Kidney Care Center at the St. John’s Medical College Hospital in Bangalore, India, and the Nephrology Division at the Montreal Children’s Hospital in Montreal, Canada. May it serve health care professionals, trainees, and physicians to improve the diagnosis and treatment of children with renal diseases worldwide. In developing countries, millions of people – most of them children – die each year from diseases that are preventable and treatable. For many of these children, kidney problems represent a serious threat to their survival. This Manual of Pediatric Nephrology is designed to give pediatrician and general physicians as well as trainees and other health care professionals a quick and practical approach to the diagnosis and treatment of children with different types of kidney diseases. The well-structured text is easy to read and covers all important areas in the field. Its appeal lies in the combined perspective provided by experienced nephrologists from different continents that takes into account the realities in emerging countries. Rather, it offers a first, quick and practical approach for the care of children with kidney disease. It is meant to serve practitioners, trainees, pediatricians, general physicians, and other health care professionals. The authors approached each chapter with the practical reality in emerging and resource-poor countries in mind. We hope that this concept renders the manual useful and versatile in a variety of settings and diverse medical practices. To this end, we are proud of the manual’s endorsement by the International Society of Nephrology Global Outreach initiative and the support by the International Pediatric Nephrology Association. It is unavoidable in a practically oriented, abbreviated book like ours that topics are missing or only mentioned cursorily.