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By I. Sanford. University of Wisconsin-Whitewater. 2018.

The weight taken when a child is dehydrated should • Moderate dehydration (7–10% loss of body not be recorded on a growth chart naproxen 500 mg fast delivery, as it will be weight) causes children to be restless discount 250 mg naproxen mastercard, “fussy”, or lower than normal owing to dehydration. The eyes are somewhat sunken and the the child should be weighed again after rehydration mouth and tongue are dry. There is increased thirst: has been completed and that weight should be older patients ask for water and young children recorded on the chart. If possible, children with drink eagerly when offered fluid from a cup or no signs of dehydration should also be weighed spoon. The is detectable, but rapid, and the fontanelle in infants assessment of hydration status is difficult in children is somewhat sunken. This is especially true for signs Module 3 Page 65 Assessing the child for other problems related to the child’s general condition or behaviour After the child has been evaluated for dehydration, such as sunken eyes, absence of tears and other problems – such as dysentery, persistent diminished skin turgor. If Using a patient record form possible, a fresh stool specimen should also be Information on the history, examination, and observed for visible blood. If bloody diarrhoea is treatment of each patient should be summarized present, the patient should be considered to have on a “Patient Record Form”. If dehydration is present it should also of this form may be used, but they should include be treated immediately. Episodes that have lasted at least • the child’s pre-illness feeding pattern; 14 days are considered to be cases of persistent • the child’s immunization history, especially as diarrhoea. Persistent diarrhoea patients with bloody regards measles; stool or a stool culture positive for Shigella should • important findings during examination of the receive antibiotics. If stool culture yields another child, especially signs of dehydration or bacterial pathogen, for example, enteropathogenic undernutrition, and the child’s weight; E. If Giardia cysts, or findings following rehydration therapy at the health trophozoites of either Giardia or E. Similarly, no “antidiarrhoeal” drug (including antimotility drugs, antisecretory drugs, When the form is completed it provides a valuable and adsorbents) has any proven value in patients record of the child’s progress during treatment. It also with persistent diarrhoea, therefore such drugs helps remind the healthcare worker of all of the steps should not be given. Completed forms should be kept at Sometimes it is difficult to determine whether a the health facility and reviewed regularly to identify child has persistent diarrhoea or is having sequential areas where management practices could be improved. Patients with persistent Page 66 Module 3 diarrhoea usually have loose stools every day, history and an examination to determine whether although the number per day may vary the child is adequately nourished or considerably. Additionally, in areas where have normal stools for one or two days after which vitamin A deficiency is a public health problem, diarrhoea resumes. If the period of normal evidence of such deficiency should be sought and (formed) stools does not exceed two days, the illness treated. However, if the period of normal stools is longer Feeding history than two days, any subsequent diarrhoea should The feeding history should consider both the child’s be considered to be a new episode. The child’s If no longer breastfeeding, when was breast- nutritional status declines and any preexisting feeding stopped? In turn, malnutrition contributes to diarrhoea, which is more severe, Animal milk or infant formula prolonged, and possibly more frequent. When these steps are followed, malnutrition can be either prevented or corrected and the risk of Weaning foods (for children aged 6 months or older): death from a future episode of diarrhoea is much At what age were soft foods started? Do these contain A brief nutritional assessment should be carried out vegetables, pulses, oil, fruit, eggs, or meat? Page 67 problems and to obtain the information needed How much food is given and how to make dietary recommendations. Module 3 Page 67 Feeding during diarrhoea • Very thin extremities, distended abdomen Breastfeeding: • Absence of subcutaneous fat; the skin is Is breast-milk given more often, as usual, or very thin less often? Signs of kwashiorkor Animal milk or infant formula • Essential features – oedema; miserable, Has this been continued? The following examinations may be performed: Weaning foods Have these been continued? Weight-for-age: this is the simplest measure of How frequently has food been offered? Weight-for-age is most What does the mother believe about giving valuable when recorded on a growth chart and used breast milk, animal milk, formula, or other to monitor growth over time; a series of points fluids or foods during diarrhoea? This may have the Mid-upper arm circumference: this test involves features of marasmus, kwashiorkor, or both. It is simple to perform (a weighing Signs of marasmus scale is not required) and valuable as a screening • “Old man’s face” test for undernutrition. However, it is not useful • Extreme thinness, “skin and bones” for monitoring growth over time. If height ratio is valuable because it detects children rectal thermometers are available and can be with recent weight loss (wasting); however, two disinfected after use, they are preferred. Any child with a history of recent fever length are more difficult to measure accurately than or with a temperature of 38° C or greater should weight.

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Skin lesions occur less frequently today than they once did but aid in the diagnosis if present (45) generic naproxen 500mg free shipping. They are often found on the heels purchase naproxen 500 mg mastercard, shoulders, legs, oral mucous membranes, and conjunctiva. They occur most commonly on the pads of the fingers and toes, are transient, and resolve without the development of necrosis. Janeway lesions are small, painless, erythematous macules that are found on the palms and soles. Figure 4 Cutaneous lesions on the left ankle and calf of a patient with disseminated Neisseria gonorrheae infection. Most patients will present with fever, rash, polyarthritis, and tenosynovitis (47). The rash usually begins on the first day of symptoms and becomes more prominent with the onset of each new febrile episode (50). The lesions begin as tiny red papules or petechiae (1–5 mm in diameter) that evolve to a vesicular and then pustular form (Fig. The pustular lesions develop a gray, necrotic center with a hemorrhagic base (47,50). Early in the infection, blood cultures may be positive; later, synovial joint fluid from associated effusions may yield positive cultures. Capnocytophaga Infection Capnocytophaga canimorsus is a fastidious gram-negative bacillus that is part of the normal gingival flora of dogs and cats (51,52). Human infections are associated with dog or cat bites, cat scratches, and contact with wild animals (51,52). Predisposing factors include trauma, alcohol abuse, steroid therapy, chronic lung disease, and asplenia (51,52). Skin lesions occur in 50% of infected patients, often progressing from petechiae to purpura to cutaneous gangrene (53). Other dermatologic lesions include macules, papules, painful erythema, or eschars. Clinical clues include a compatible clinical syndrome and a history of a dog- or cat- inflicted wound. Diagnosis depends on the culture of the bacteria from blood, tissues, or other body fluids. Unfortunately, the diagnosis is missed in greater than 70% of cases because of lack Fever and Rash in Critical Care 29 of familiarity with the bacteria and its microbiological growth characteristics (54). Dengue viruses are transmitted from person to person through infected female Aedes mosquitoes. The mosquito acquires the virus by taking a blood meal from an infected human or monkey. The virus incubates in the mosquito for 7 to 10 days before it can transmit the infection. The year 2007 was the worst on record since 1985 with almost 1 million cases of dengue fever and dengue hemorrhagic fever reported in the United States (58). The resurgence of dengue has been attributed to multiple factors including global population growth, urbanization, deforestation, poor housing and waste management systems, deteriorating mosquito control, virus evolution, and climate change (56). Dengue fever (also known as “breakbone fever” or “dandy fever”) is a short-duration, nonfatal disease characterized by the sudden onset of headache, retro-orbital pain, high fever, joint pain, and rash (57,59). The initial rash of dengue occurs within the first 24 to 48 hours of symptom onset and involves flushing of the face, neck, and chest (60). A subsequent rash, three to five days later, manifests as a generalized morbilliform eruption, palpable pinpoint petechiae, and islands of sparing that begin centrally and spread peripherally (1,60). Recovery from infection provides lifelong immunity to that serotype, but does not preclude patients from being infected with the other serotypes of dengue virus, i. Dengue hemorrhagic fever is characterized by hemorrhage, thrombocytopenia, and plasma leakage. Dengue shock syndrome includes the additional complications of circulatory failure and hypotension (57,59). If a patient presents greater than two weeks after visiting an endemic area, dengue is much less likely (61). Laboratory abnormalities include neutropenia followed by lymphocytosis, hemoconcentration, thrombocytopenia, and an elevated aspartate aminotransferase in the serum (62). Lyme disease is caused by the spirochete Borrelia burgdorferi, a microbe that is transmitted by the tick Ixodes. Lyme disease is endemic in the northeastern, mid-Atlantic, north, central, and far western regions of the United States. The disease has a bimodal age distribution, with peaks in patients younger than 15 and older than 29 years of age (67). Lyme disease has three stages: early localized, early disseminated, and late disease.

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Awad and Ra-id Abdulla Excessive pulmonary blood flow will bring back large volume of pulmonary venous return which will dilute the systemic venous return cheap naproxen 500mg with amex, thus making the oxygen satura- tion of blood in the single ventricle and consequently in the aorta high cheap naproxen 250 mg online, in this case in the low 90s. The single S2 in this child is due to transposition of the great arteries with the pulmonary valve posterior, making its closure sound inaudible. After initial management using diuretics and inotropic support to control conges- tive heart failure, the child was taken to the operating room where a band was placed over the main pulmonary artery to restrict pulmonary blood flow. This will be fol- lowed at about 3–6 months of age with a cardiac catheterization procedure to study pulmonary vascular resistance to ensure that they are within normal limits, followed by a Glenn shunt and ligation of the main pulmonary artery at about 3–6 months of age. Fontan procedure is completed by connecting inferior vena cava to the pulmo- nary arterial circulation through an intra-atrial baffle or extracardiac conduit. Chapter 22 Complex Cyanotic Congenital Heart Disease: The Heterotaxy Syndromes Shannon M. Hoffman Key Facts • The hallmark feature of heterotaxy is abnormal positioning of internal organs, including liver, spleen, intestines, venae cavae, atria, ventricles, and great arteries. Definition Heterotaxy syndromes are characterized by abnormal left–right positioning with consequent malformations of the usually asymmetric organs: heart, liver, intestines and spleen. Incidence Heterotaxy syndromes are rare, comprising only 1% of congenital heart disease in newborns. Right isomerism is more common in males while left isomerism tends to affect females. Pathology During the second and third weeks of embryonic development, normal left–right positioning is established. Disruptions to this process result in a variety of patterns of abnormal positioning and organ malformation: • Levocardia with abdominal situs inversus: Normal cardiac position (left-sided) and structure with abdominal organs in a mirror-image arrangement. Though considerable overlap exists between the two categories, right and left isomerism are often broadly described in this way: Right isomerism or bilateral right-sidedness or Asplenia syndrome: • Bilateral right atrial appendages • Bilateral three-lobed right lungs with bilateral right-bronchial anatomy • Midline liver with gallbladder • Intestinal malrotation • Absent spleen Left Isomerism or Bilateral Left-Sidedness or Polysplenia Syndrome: • Bilateral left atrial appendages • Bilateral two-lobed left lungs with bilateral left-bronchial anatomy • Midline liver with occasional absent gallbladder (extrahepatic biliary atresia) • Intestinal malrotation • Multiple spleens, often appearing as a cluster of grapes attached to the greater curvature of the stomach 22 Complex Cyanotic Congenital Heart Disease 259 Fig. The single ventricle is of left ventricular morphology and the outlet chamber is small with no inlet (atrioventricular valve). In addition, this patient has pulmonary stenosis With few exceptions, complex cardiac malformations accompany the heterotaxy syndromes. Cardiac Defects Associated with Right Isomerism More than left isomerism, right isomerism is often associated with severe abnor- malities of intracardiac anatomy, great artery connections, and systemic and pulmo- nary venous drainage. Both the aorta and the pulmonary artery often arise from the dominant ventricle (usually the right-sided ventricle) creating a double-outlet right ventricle. The aorta is often to the right of the pulmonary artery instead of its usual position on the left. This relationship is often called malposition or transposition of the great arteries. Pulmonary artery outflow obstruction is also common due to stenosis or even atre- sia of the subpulmonary area and pulmonary artery. In both lungs, the branching pattern of the pulmonary arteries is consistent with the branching pattern usually found in the normal right lung. Multiple anomalies of the systemic and pulmonary venous connections are also common. Bilateral superior vena cavae are often present, each connecting directly to its respective atrium. However, since the liver is midline, hepatic venous drainage is usually bilateral, connecting directly to the respective atrium under which each hepatic lobe lies. Pulmonary veins often connect to a systemic vein, either the bilateral superior venae cavae, the inferior vena cava, or another abnormal systemic vein, instead of draining directly into the heart. Additionally, two sinus nodes are often present, each sitting near the connection of the bilateral superior venae cavae to their respective atrium. Cardiac Defects Associated with Left Isomerism Left isomerism is associated with less severe abnormalities of intracardiac anatomy, great artery connections, and systemic and pulmonary venous drainage. In fact, a normal heart or only minimal malformation may be present in some cases. Cardiac features of left atrial isomerism are less consistent and more widely variable than the cardiac features of right isomerism. Abnormalities of the atrial septum are frequent, with a common atrium present in about 35% of patients. Two good-sized ventricles are frequently present, but may be malpositioned, often with some type of ventricular septal defect. Double-outlet right ventricle, transposed great arteries, pulmonary stenosis, and pulmo- nary atresia do occur, but with less frequency than in right atrial isomerism. Conversely, the anomalies of systemic and pulmonary venous connections are more consistent in left isomerism than in right. A dilated azygous vein drains venous return from systemic veins below the diaphragm to the superior vena cava, which may be left-sided.

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Clinical Features Treatment of Oesophageal Stricture There is long-standing history of epigastric Bougies of increasing size are passed down discomfort which progresses to dysphagia generic naproxen 250 mg mastercard, the lumen to dilate it cheap 500mg naproxen overnight delivery. The procedure needs more for liquids than solids as the solid food frequent repetition. If bouginage fails, external can pass down the sphincter because of its operation is required wherein the stenosed weight. Swallowed foods and liquids In this operation, the obstruction at the lower associated with mucous usually foul smelling, end is relieved by cutting through the are regurgitated. Through the left-sided thoracotomy, the lower part of Diagnosis oesophagus is exposed. An anterior longitu- Barium X-ray shows a spindle-shaped narrow- dinal incision is made in the muscular wall of ing of the cardiac end through which little or the oesophagus at the cardio-oesophageal no barium passes down. However, the nar- junction down to the mucosa but not through rowing is smooth and regular unlike in the mucous membrane. The mucosa is object which is retained in the pharynx or hyperaemic and at places ulcerated. Complications Foreign Bodies in Pharynx These include nutritional deficiencies and Small fish or meat bones are the commonly pulmonary complications because of frequent encountered foreign bodies in the pharynx. The chances of developing oeso- These may get lodged in the tonsils, valecullae, phageal malignancy are around 20 per cent. Treatment Diagnosis Conservative management includes adminis- The history is suggestive. Diagnosis is confirmed Proper examination of the throat should be using oesophageal manometry. Laparoscopic done and a detailed mirror examination cardiomyotomy has shown results comparable usually reveals the site of lodgement of the to open cardiomyotomy minus the attendant foreign body. Performing a fundoplication simul- X-ray of the soft tissues of the neck may taneously also takes care of the attendant sometimes be required to detect an otherwise reflux. Foreign Bodies in the Oesophagus These include an incision at least 6 cm long A variety of objects may be retained in the with 1 cm extending onto the cardia. Aetiology Children are usually in the habit of swallow- ing anything they can get hold of. Similarly, foreign body lodgement is common in the elderly because of improper mastication and week propulsive movements of the gullet. Certain oesophageal conditions like benign strictures or malignancy and sites of anato- mical narrowing of the oesophagus may arrest Fig. If the foreign body is arrested in the upper part of the oesophagus, the patient is very often able to localise the pain and site of the lodgement of the foreign body. Dysphagia is another important symptom of foreign body in the oesophagus and should raise the suspicion, particularly in children. A detailed examination of the pharyngeal wall, tonsils, valecullae and pyriform fossae should be carried out. Ideally both the anterioposterior and lateral views are taken to know the exact location and disposition of the foreign body (Figs 71. Foreign bodies in the oesophagus, parti- cularly flat objects like coins lie in the coronal plane in contrast to laryngeal or tracheal Fig. It is not good to wait and allow the foreign body to pass down as it may get arrested leading to fatal complications. Though foreign body removal is an emergency, the surgeon must have a know- ledge of the location and disposition of the foreign body so that he selects the proper endoscopic instruments and orients himself to the situation. If the size of the foreign ing of the chest and abdomen is done to note body is bigger than the diameter of the whether it has passed down. In case of pins and cotton soaked in barium paste or a gelatin needles, their point must be searched for. However, if the clinician is still violent method of its removal and no harm in doubt, oesophagoscopy should be done to should be done, if one cannot remove the be sure regarding the presence or absence of foreign body. They often have sharp edges and Complications associated metallic hooks which cause their Complications of foreign body in oesophagus impaction. Hence, such cases should be include the following: properly studied before attempting hapha- 1. In the cervical oesophagus, foreign bodies can be removed by left lateral oesophagotomy Spread of the Tumour while lower down, thoracotomy is needed to expose the oesophagus and remove the The tumour, usually of the ulcerative type, may infiltrate the oesophageal wall and foreign body. These include leiomyomas, fibromas, Spread beyond the oesophagus involves papillomas and haemangiomas. Lymphatic spread involves the Malignant Tumours of the mediastinal lymph nodes in the root of neck Oesophagus or nodes in abdomen (coeliac group). Blood- The malignant lesions of the oesophagus occur borne metastasis occurs commonly to the more frequently in males than in females. Bad oral hygiene, The patient commonly presents with rapidly smoking, spicy and hot foods and large progressing dysphagia. The dysphagia which quantities of hot salt tea have been found as is initially for solids occurs later for liquids the usual irritating factors.

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