Emergency Preparation in Dental Practice PDF

Emergency Preparation How can you be prepared for emergencies? Medical Be certified in basic life support (BLS) Know the location and proper use of em...

Emergency Preparation How can you be prepared for emergencies? Medical Be certified in basic life support (BLS) Know the location and proper use of emergency equipment Emergencies in the Know your patient Use good patient management techniques Dental Practice React to possible emergencies promptly Team approach and training is vital Documented office emergency plan Dr. Muhammad Reihan, MD Emergency call list Associate professor Internal Medicine Department Respiratory Distress Respiratory Distress Asthma: Manifestations: Shortness of breath Wheezing When airways narrow and Cough swell and may produce extra mucus which makes Chest tightness breathing difficult. Anxiety Cyanosis Respiratory Distress Chest Pain Management of asthma attack Acute Myocardial Infarction (MI) Terminate the procedure Occlusion of a coronary artery causing cessation of blood flow and death Position the patient upright (necrosis) of heart muscle Use a beta-2 agonist inhaler (albuterol, etc.) Give one puff at a time, if needed, give another puff every 60 seconds (maximum of ten puffs) Administer O2 Summon assistance Call 997 Chest Pain Chest Pain Manifestations: Sudden onset of severe pain Management: Crushing chest pain, may radiate to the jaw Call 997 and/or left arm Chew 1 regular aspirin (325 mg) or 4 baby aspirin (4 x 81 mg) Sweating, weakness, restlessness Monitor vitals Sense/look of impending doom Relieve pain (morphine, nitrous oxide) Dyspnea O2 (As needed for SpO2 > 92%) Some classic signs are not observed BLS if needed “silent MI”, particularly in o women o diabetics  Syncope Syncope Definition: Management: An abrupt transient loss of Stop the procedure consciousness with rapid and Place in Trendelenburg position spontaneous recovery, which is Cold washcloth on forehead for thought to be caused by comfort cerebral hypoperfusion Ammonia ampule for Causes: complete loss of consciousness Cardiac Check vital sign Neurological Call 997 Vasovagal Seizure Seizure Definition: Seizure triggers: (stimuli that can precipitate seizures) Excessive physical exertion Alcohol consumption An excessive and/or Fever (febrile seizures) hypersynchronous activity of Sleep deprivation cortical neurons that results Flashing lights (e.g., strobe lights, video games) in transient neurological Music symptoms Hormonal changes (e.g., at different phases of the menstrual cycle) Medication-related issues in patients with known epilepsy: e.g., o Poor adherence, o Recent changes in drug doses or formulation, o New medication interactions Seizure Seizure Causes of acute symptomatic seizures Management: Traumatic brain injury Try to stay calm Stroke Look around (remove dangerous items) Anoxic encephalopathy Note the time the seizure starts Intracranial surgery Cushion their head with something soft if they have Acute CNS infections (e.g., meningitis, encephalitis) collapsed to the ground Electrolyte imbalance (e.g., hypoglycemia, hypocalcemia) Don't hold them down Acute metabolic disturbances (e.g., uremia) Don't put anything in their mouth Alcohol withdrawal Try to stop other people crowding around Recreational drug use After the seizure stops put them in recovery position Prescription drug toxicity Call 997 Seizure Stroke Postictal status Manifestations: Refers to a specific condition that occurs after a seizure, characterized by a period of: Muscle weakness/paralysis o Altered consciousness o Confusion Speech/vision problems o Various neurological symptoms Loss of balance as the brain recovers from the seizure activity. Confusion The duration and intensity of postictal status can vary widely depending on factors such Headache as the type of seizure and the individual's overall health. In some cases, it may last only a few minutes, while in others, it can persist for hours. Loss of consciousness Management It’s important for caregivers to provide support and ensure safety during this recovery period. Call 997 Reassure the patient  Allergy-Related Emergencies Allergy-Related Emergencies Mild allergic reaction: The most common allergen dental clinic is latex Can be managed by oral antihistamine Mild allergic reaction: Itching, hives, rash Severe allergic reaction (anaphylaxis): Use EpiPen if available (inject in the thigh) Severe allergic reaction (anaphylaxis): Or administer epinephrine Respiratory distress as soon as possible (0.3-0.5 mg IM) Cardiac compromise Call 997 Could lead to coma and death CPR if needed Hypoglycemia Hypoglycemia Manifestations: Management of the conscious patient: Hunger Assess vitals and blood glucose Nausea Give oral carbohydrates Sweating (orange juice, candy, dextrose gel) Tachycardia Anxiety Unresponsive/unconscious patient: Diaphoresis Assess vitals and blood glucose Decreased ventilation CPR as necessary May progress to loss of consciousness, If IV access, administer 25-50 mL of 50% dextrose seizures, and/or coma If no IV access, administer 1 mg of glucagon IM Call 997 To Summarize Practice questions Have emergency equipment readily available A 16-year-old patient presents to clinic for routine dental check-up. After starting dental examination, the patient develops diffuse hives on his body. He states that All office personnel should know where emergency equipment is located and he feels his throat closing, and he is having difficulty breathing. What is the best how to use it treatment for this patient’s condition? Consider practice scenarios for emergency situations BLS Certification can save lives A. Administer epinephrine Always call 997 B. Administer norepinephrine C. Administer antihistamine D. Administer Oxygen via nasal cannula Practice questions A 45-year-old diabetic man in the dental office develops nausea, sweating, tachycardia and blurry vision. His wife tells you he took his insulin but skipped lunch because he wanted his teeth clean for the dental appointment. What is the best agent to be administered for this patient’s condition? A. Oral glucose B. Intramuscular glucagon C. Intramuscular epinephrine D. Sublingual nitroglycerin  Seizure Disorders Cerebrovascular Diseases Parkinson Disease Neurological Diseases Myasthenia Gravis Multiple Sclerosis Alzheimer’s Disease Intro Diseases affecting the neuromuscular system have a collective lifetime prevalence rate of 3% Epidemiology & Etiology to 5% Seizure Clinical Manifestations Thus, every oral health-care provider will encounter a patient who has had, or presently has, a neuromuscular disease diagnosis Disorders Diagnosis & Treatment The signs and symptoms as well as the complications and implications of these disorders or Oral Health Considerations their treatment can have significant impact on oral health as well as dental management decisions Seizures Disorder – Epidemiology & Etiology Seizures Disorder – Clinical Features Epilepsy is a brain disorder characterized by excessive neuronal discharge that can produce seizures, unusual body movements, and loss or changes in consciousness. Transient episodes of motor, sensory, or psychic dysfunction, with or without unconsciousness or convulsive Can be classified into two major categories: movements may be present Partial seizures Prevalence is around 1% in the general population Generalized seizures 75% no known etiology Higher frequency in males Seizures Disorder – Clinical Features Seizures Disorder – Generalized Seizures Generalized seizures – affects entire cortex: Partial seizures affects only part of Absence – impaired consciousness, staring, the brain: and eye blinking Simple – may be subtle, with Atonic – abrupt loss of muscle tone, loss of awareness intact consciousness, and sudden collapse Complex – involves impairment of Myoclonic – sudden jerking of arms and/or awareness, variable presentation: legs and impaired consciousness may have autonomic symptoms, Tonic-clonic – loss of consciousness, abnormal sensation, hallucinations repetitive jerking, sustained stiffening, post- seizure amnesia, and possibly cyanosis  Seizures Disorder – Diagnosis Seizures Disorder – Management Needs to see a neurologist Pharmacologic therapy is considered the Detailed neurological history and examination mainstay of epilepsy treatment MRI The goal is to choose an antiepileptic drug (AED) that is most appropriate for the CT specific type of seizure activity Electroencephalogram (EEG) Which can achieve control of seizure activity with minimal side effects Seizures Disorder – Oral Health Considerations Seizures Disorder – Oral Health Considerations Patients with Epilepsy are at an increased risk for: Obtain thorough medical history-including seizure Dental caries triggers and seizure frequency/level of control. Oral trauma Ask patient (or caregiver) for medication updates at each appointment. Medication changes can affect the Laceration, including bite injuries to tongue appropriate care of the patient from a medical and/or Ulcerations and glossitis as a result of medication-induced B-12 deficiency appointment management standpoint. Trauma-induced TMJ disc dislocation requiring reduction Monitor patient for anti-epileptic medication-induced Trauma-induced tooth avulsion – if tooth cannot be located, chest imaging indicated to rule out gingival hyperplasia. aspiration to lungs Meticulous oral hygiene is the best prevention. In severe Medication-induced gingival hyperplasia, bleeding gums, and delayed healing cases, surgical reduction may be needed. Seizures Disorder – Oral Health Considerations Seizures Disorder – Oral Health Considerations Powered toothbrushes may be too stimulating for some adults and should be recommended only after determining if the adult will tolerate one Some individuals with epilepsy are tube fed, therefore they If prosthetic restorations are considered, insure they are typically have low caries, rapid accumulation of calculus, GERD appropriate for the rate, level, and frequency of seizures, (Gastro-esophageal Reflux Disease), oral hypersensitivity, and are and they are resistant to damage or displacement during at high risk for aspiration in the dental chair an epileptic seizure to reduce choking hazards Position the patient in as upright a position as possible and utilize Fixed prosthetics are preferable to removable prosthetics low amounts of water and high-volume suction to minimize because choking and aspiration of appliances are of aspiration concern Determine if mouth guard could provide potential benefit Seizures Disorder – Oral Health Considerations As needed for patients with xerostomia: Epidemiology & Etiology Educate on proper oral hygiene (brushing, flossing) and nutrition Cerebrovascular Clinical Manifestations Recommend brushing teeth with a fluoride containing dentifrice before bedtime Disease Diagnosis & Treatment After brushing, apply neutral 1.1% fluoride gel Oral Health Considerations Instruct patient to spit out excess gel and NOT to rinse with water, eat or drink before going to bed Recommend xylitol mints, lozenges, and/or gum to stimulate saliva production and caries resistance  Cerebrovascular Disease – Epidemiology & Etiology Cerebrovascular Disease – Epidemiology & Etiology Cerebrovascular disease refers to disorders that result in damage to the cerebral blood vessels leading to impaired cerebral circulation Stroke is considered the second leading cause of death and the third leading A cerebrovascular accident (CVA), or complete stroke, is a sudden impairment in cerebral cause of disability in the world circulation resulting in death or a focal neurologic deficit lasting more than 24 hours The incidence of stroke in Saudi Arabia is 43.8 per 100,000 Transient ischemic attack (TIA), defined as a reversible, acute, short-duration, focal neurologic deficit (“mini stroke”) resulting from transient (reversible within 24 hours) Bakraa R, Aldhaheri R, Barashid M, Benafeef S, Alzahrani M, Bajaba R, Alshehri S, Alshibani M. Stroke Risk Factor Awareness Among Populations in Saudi Arabia. Int J Gen Med. 2021;14:4177-4182 https://doi.org/10.2147/IJGM.S325568 Cerebrovascular Disease – Clinical Features Cerebrovascular Disease – Diagnosis & Management Sensory and motor deficits Weakness Visual defects Brain Imaging (CT scan followed by MRI) Sudden headache Risk factor stratification (Check for diabetes, and hyperlipidemia) Altered mental status Acute treatment may contain thrombolysis with intravenous tissue plasminogen activator (t- Dizziness PA) Nausea Chronic treatment may contain daily aspirin and other antiplatelet medications Seizures impaired speech or hearing neurocognitive deficits such as impaired memory, reasoning, and concentration Cerebrovascular Disease – Oral Health Cerebrovascular Disease – Oral Health Considerations Considerations When providing care to patients who have had a stroke, dental providers should assess the patient’s risk for complications before providing any dental care Items to consider include the timing of the stroke and type and magnitude of dental procedure Effective pain control during the procedure and post-operative will reduce stress and the risk Patients who are taking Warfarin should report their international normalized ratio (INR) a for complications theraputic range is between 2-3 Metronidazole and tetracycline interact with warfarin which can increase the INR. Local anesthesia should have a limited amount of vasoconstrictor (epinephrine) Patients can be safely given local anesthesia with epinephrine 1:100,000 or 1:200,000 The amount of vasoconstrictor should be ≤ 0.04 mg. Little JW, Miller CS, Rhodus NL. Dental Management of the Medically Compromised Patient, 9th Ed. St. Louis, MO. Elsevier. 2018. Cerebrovascular Disease – Oral Health Considerations Oral manifestations associated with a stroke include unilateral paralysis of the face, loss of sensory stimuli or oral tissues, a flaccid tongue with multiple folds, and dysphagia Epidemiology & Etiology You may also notice that patients neglect oral self-care on Parkinson Clinical Manifestations one side of their mouth. This is associated with the brain damage that has occurred Disease Diagnosis & Treatment Oral Health Considerations Increased caries, periodontal disease, and halitosis is also common due to challenges with oral self-care Dental providers should recommend rigorous preventive measures such as 3-month recall appointments and application of topical fluoride  Parkinson Disease – Epidemiology & Etiology Parkinson Disease – Clinical Manifestations Resting tremor (in hands, arms, legs, jaw, and face) Rigidity or stiffness (limbs and trunk) Parkinson disease (PD) is a chronic, progressive, neurodegenerative disorder Bradykinesia (slowness of movement) PD results from degeneration of the dopaminergic cells in the substantia nigra, Postural instability or impaired balance and leading to depletion of the neurotransmitter dopamine in the basal ganglia coordination The prevalence of PD in Saudi Arabia has been estimated to be 27 per 100,000 Dementia population Behavioral/psychiatric symptoms (depression, anxiety, apathy, and irritability) Autonomic dysfunction (orthostatic hypotension, constipation, urinary frequency and urgency, and abnormal sweating) Alyamani AM, Alarifi J, Alfadhel A, et al. Public knowledge and awareness about Parkinson's disease in Saudi Arabia. J Family Med Prim Care. 2018;7(6):1216-1221. doi:10.4103/jfmpc.jfmpc_335_18 Parkinson Disease – Diagnosis & Management Parkinson Disease – Oral Health Considerations Patients with PD present several challenges to the dental health-care team Clinical diagnosis Patients with PD often must be treated in a relatively upright position Genetic testing in cases of hereditary patterns No cure for PD, only symptomatic treatment Dysphagia and impaired gag reflex increase the risk for aspiration of oral and Dopamine replacement therapy using levodopa (used by neurons to synthesize irrigation fluids, and high-speed evacuation of fluids is important in reducing the dopamine) combined with carbidopa (delays the conversion of levodopa into risk for aspiration pneumonia dopamine until it reaches the brain) remains the initial gold standard Levodopa and dopamine agonists can lead to both orthostatic hypertension and, Various medications are used in conjunction for different symptoms rarely, severe hypertension (Monitor BP in long visits and tell the patient to stand up from the chair slowly and over many stages) Myasthenia Gravis – Epidemiology & Etiology Myasthenia gravis (MG) is a chronic neuromuscular disease caused by autoimmune destruction of the Epidemiology & Etiology skeletal neuromuscular junction Myasthenia Clinical Manifestations MG is characterized by episodic weakness of the Gravis Diagnosis & Treatment skeletal muscles that increases during periods of activity and improves after periods of rest Oral Health Considerations The most common autoantibody is anti-acetylcholine receptor (AChR) The estimated prevalence rate for MG is 15 to 20 cases per 100,000 population in western countries Myasthenia Gravis – Clinical Features Myasthenia Gravis – Diagnosis & Management diplopia and/or ptosis Oropharyngeal, facial, and masticatory muscle weakness The clinical examination and history are highly suggestive of MG dysphagia, asymmetry, and dysarthria Tensilon (edrophonium) challenge (rapid resulting in immediate elevation of The clinical course of disease is variable but usually progressive available Ach) serum anti-AChR antibodies Treatment is with plasma exchange and high-dose intravenous immunoglobulin in addition to symptomatic treatment  Myasthenia Gravis – Oral Health Considerations Myasthenia Gravis – Oral Health Considerations Aspiration risks can be high and can be reduced by adequate suction, the use of a rubber dam, and avoiding bilateral mandibular anesthetic block Avoid prescribing drugs that may affect the neuromuscular junction, such as narcotics, Prolonged opening might be hard to maintain tranquilizers, and barbiturates MG patient may also be at risk for a respiratory crisis from the disease itself or Certain antibiotics, including tetracycline, streptomycin, sulfonamides, and clindamycin, can from overmedication affect neuromuscular activity and should be avoided or used with caution If this is a concern, dental procedure should happen in a hospital setting where Esther anesthetics which are metabolized by plasma cholinesterase should be avoided in MG intubation is available patients on anticholinesterase therapy Multiple Sclerosis – Epidemiology & Etiology Multuple sclerosis (MS) is characterized by multiple areas of central nervous system (CNS) white matter inflammation, demyelination, and gliosis (scarring) Epidemiology & Etiology Myelin is critical for propagation of nerve impulses Multiple Clinical Manifestations When myelin is destroyed in MS, slowing and/or complete block of impulse propagation is Sclerosis Diagnosis & Treatment manifested by abnormal muscular and neurologic signs and symptoms Oral Health Considerations Multiple Sclerosis – Epidemiology & Etiology Multiple Sclerosis – Clinical Features The age at onset is typically between 20 and 45 years The clinical manifestations of MS depend on More common in women than men (2:1) the areas of the CNS involved, and frequently affected areas include the optic chiasm, The cause of MS is unknown, genetic susceptibility to MS clearly exists brainstem, cerebellum, and spinal cord Substantial evidence suggests that autoimmune mechanisms are involved in the pathogenesis Visual Changes of MS Limb weakness Spasticity Ataxia Bladder and bowel dysfunction sensory impairment Multiple Sclerosis – Diagnosis Multiple Sclerosis – Management There is no definitive diagnostic test for detection of MS Therapy for MS can be divided into three categories: (1) treatment of acute attacks, (2) disease- modifying therapies, and (3) symptomatic therapy. Once MS is suspected, the clinician must evaluate for evidence of dissemination in space Steroids MRI Interferon CSF analysis Monoclonal antibodies Evoked potentials Symptomatic treatment (anticonvulsants, benzodiazepines, tricyclic antidepressants, smooth muscle relaxants, anticholinergic agents, and various pain medications)  Multiple Sclerosis – Oral Health Considerations Individuals may present to the oral health-care provider with signs and symptoms of MS Trigeminal neuralgia (TGN), which is characterized by Epidemiology & Etiology electric shock–like pain, may be an initial Alzheimer's Clinical Manifestations manifestation of MS (Refer to a medical care provider) Disease Diagnosis & Treatment Facial weakness and paralysis may also be evident Oral Health Considerations It is recommended to avoid elective dental treatment in MS patients during acute exacerbations of the disease due to limited mobility and possible airway compromise Alzheimer’s – Epidemiology & Etiology Alzheimer’s – Epidemiology & Etiology Alzheimer’s disease is the most common type of dementia It is a progressive disease beginning with mild memory loss and possibly leading to loss of the The global prevalence of dementia is estimated at 24 million and has ability to carry on a conversation and respond to the environment been predicted to quadruple by the year 2050 Alzheimer’s disease involves parts of the brain that control thought, memory, and language Alzheimer’s disease (AD) is the most common form of dementia in Western countries, accounting for up to 65% of new cases It can seriously affect a person’s ability to carry out daily activities In Saudi, Alzheimer’s disease is estimated to affect around 130,000 individuals https://www.moh.gov.sa/en/HealthAwareness/healthDay/2019/Pages/HealthDay-2019-09-21.aspx Alzheimer’s – Epidemiology & Etiology Alzheimer’s – Clinical Features Major pathological hallmarks of AD are amyloid plaques and neurofibrillary Memory loss that disrupts daily life, such as tangles that are absent in healthy brain tissue getting lost in a familiar place or repeating Massive apoptosis occurs in later stages of the development of AD in the human questions brain (brain slices) Trouble handling money and paying bills Difficulty completing familiar tasks at home, at work or at leisure Decreased or poor judgment Misplacing things and being unable to retrace steps to find them Changes in mood, personality, or behavior Alzheimer’s – Diagnosis Alzheimer’s – Management Mini-Mental State Examination may be used to assess global cognitive abilities PET scan There is no cure for AD, and therapy is aimed at slowing the progression of the disease MRI Cholinesterase inhibitors approved by the US Food and Drug Administration to treat mild to CSF analysis moderate cases of AD Common side effects of these medications include nausea, vomiting, diarrhea, weight loss, bradycardia, and syncope New monoclonal antibody drug recently approved the USFDA  Alzheimer’s – Oral Health Considerations Alzheimer’s – Oral Health Considerations Cholinesterase inhibitors may cause Patients with AD appear to be at higher risk for developing coronal and root caries, sialorrhea, whereas antidepressants and periodontal infections, temporomandibular joint abnormalities, and orofacial pain compared antipsychotics are often associated with to healthy subjects. xerostomia Patients with AD can become frustrated, irritable, and possibly combative when confronted Local anesthetics with adrenergic with unfamiliar circumstances or with questions, instructions, or information that they do vasoconstrictors should be used with caution not understand in AD patients taking tricyclic antidepressants The presence of a caregiver may be beneficial as they can verify patient information, due to potential risk of cardiovascular effects, interpret patient behavior, and alleviate anxiety such as hypertensive events or dysrhythmias  Defined as a significant loss of renal function in both kidneys to the point where less than 15% of normal GFR remains. A glomerular filtration rate (GFR) test is a blood test that checks how well your kidneys are working Renal diseases Renal failure Name: Muhammad Reihan Designation: Associate professor Department: Medicine Introduction for acute and chronic renal failure Stages of Chronic Renal Failure Renal failure may occur as; Chronic renal failure is often classified into four progressive stages Acute and rapidly progressing process based on the loss of GFR. Chronic form in which there is a progressive loss of renal function over a number of years. Stages of Chronic Renal Failure Diminished renal reserve Acute renal failure is potentially reversible. Renal insufficiency Renal failure Chronic failure can lead to permanent renal failure. End-Stage Renal Disease Chronic renal failure is the end result of progressive kidney damage and loss of function. Causes of chronic renal failure Symptoms of chronic renal failure Diabetes (the most common cause of chronic kidney disease in developed countries) Anemia Chronic infections Dry skin Renal obstruction (prolonged) Poor appetite Exposure to toxic chemicals, toxins Vomiting or Drugs (aminoglycoside antibiotics) Bone pain Hypertension Metallic taste in mouth Nephrosclerosis (atherosclerosis of the renal artery) Polycystic kidney disease Uremic Stomatitis - Soft tissue changes Oral manifestations of chronic renal failure - Uremic Stomatitis Soft tissue changes Urea secreted in saliva Painful plaques and crusts on;  Buccal mucosa  Dorsum of tongue Urease enzyme produced  Flor of mouth by oral microflora With gray pseudo membrane exudate and painful ulcers. Liberates free ammonia Damages oral mucosa Oral manifestations of chronic renal failure - Uremic Stomatitis Uremic Stomatitis - Soft tissue changes Soft tissue changes Bleeding diathesis; Ulcers secondary to Petechiae and ecchymosis  Anemia Irritation and chemical injury of mucosa  Viral infection (ammonium compounds) ( immunosuppressed) Xerostomia, unpleasant taste Burning mouth Uriniferous breath odour Gingival hyperplasia  Cyclosporine  Nifedepine (CCB) Uremic Stomatitis – Hard tissue changes Oral manifestation in hyperparathyroidism Hard tissue changes Tooth appear more radiopaque in background of Staining in teeth (iron supplements) osteoporotic bone Reduced caries (urea in saliva) Loss of trabeculaions of bone Delayed teeth eruption Ground glass appearance Enamel hypoplasia Tooth Mobility Total or partial loss of lamina dura The oral manifestations of oxalosis can include alveolar bone resorption and external root Loss of cortical outlines of inferior alveolar sinus , resorption, leading to: cortex of mandible  Increased tooth mobility  Pain Pulpal calcifications  Open bite Oral manifestation in hyperparathyroidism Treatment of chronic renal failure Multilocular radiolucency Careful management of fluids and electrolytes Restriction of dietary protein intake Arterial and oral calcification Treat anemia Renal dialysis Renal transplantation Etiology Cause : Group A beta hemolytic streptococci (GAHS)-serotype 12,4,1 Post-streptococcal Glomerulonephritis (PSGN) Impetigo Strep. throat  Pathogenesis Pathogenesis Throat/skin infection by GAHS Nephritic syndrome is an inflammatory process (serotype 12,4,1 ) Hematuria with Antibodies to streptococcus acanthocytes (anti-streptolysin O) are RBC casts in urine formed in the circulation. Proteinuria (< 3.5 g/24 h) Antigen- antibody circulating Hypertension immune complexes are Oliguria deposited at glomerular Azotemia basement membrane NephrItic syndrome indicates glomerular Inflammation Poststreptococcal glomerulonephritis Signs and symptoms Usually affects children 3–12 years of age and elderly patients Clinical features Occurs weeks after group A β-hemolytic streptococcal infections o Pharyngitis/tonsillitis (most common): 1–2 weeks after infection o Skin infections: 3–4 weeks after infection Periorbital and peripheral edema Hypertension Tea- or cola-colored urine Usually self-limiting in children May lead to rapidly progressive glomerulonephritis (RPGN) → renal insufficiency in adults Investigations Treatment Urine analysis Mainly supportive care, restriction of fluid and sodium Serology Diuresis within 7-10 days after onset of symptoms Throat swab 10 days of systemic antibiotic with penicillin V Renal functions  Haematology Blood Cells Disorders Dr. Mohamed Roshdi ,MD Ass Prof. Internal medicine  Aetiological Classification:  Bacterial:  Gram(+ve): streptococci, staphylococci  Gram(-ve): Klebsiella, pseudomonas, Haemophilus influenza  Anaerobic bacteria: bacteroids  Mycobacterial: TB, Leprosy  Spirochetal: syphilis, leptospirosis Infectious Diseases  Rickettsia: typhus  Chlamydia Dr. Mohamed Roshdi ,MD  Viral: Dengue, influenza, HSV, HZV, CMV, EBV, Measles, mumps, rubella Ass Prof. Internal medicine  Protozoal: malaria, ameobiasis, Bilharziasis, giardiasis  Fungal: candida albicans, Aspergillus Niger  Normal body core temperature is 36.5 – 37.2 °c Typhoid Fever - Oral: 35.2 - 38.2 °c Aetiology: - Rectal: 34.4 - 37.8 °c  Causative organism: Salmonella typhi & paratyphi A & B - Axillary: 35.5 - 37 °c  Mode of infection: Feco-oral transmission. Clinical picture:  Fever (pyrexia): increase body temperature more than the upper  Clinical manifestations : limit of normal  1st week: Fever (step-ladder), Headache, Relative bradycardia, Constipation, Rash ( rose spots ) Hyperpyrexia: increase body temperature > 40º c Types of Fever:  2nd week: fever (continuous), tachycardia, diarrhea, splenomegaly (No rash)  Sustained fever: daily fluctuations of fever is less than 1º c  3rd week: Convalescence begins  Remittent fever: daily fluctuations of fever is more than 1º c  Complications: intestinal bleeding , peritonitis, Meningitis , encephalitis,  Hectic fever: body temperature falls to normal level once or more convulsions, pyelonephritis during the day.  Investigations:  Relapsing fever: days of fever intercepted by days of normal  CBC: Leucopenia with relative lymphocytosis. temperature  Widal test: It is +ve from 2nd week (prognostic rather than diagnostic)  Culture: Blood culture is +ve in 1st week, Stool culture is +ve in 2nd week & Urine culture is +ve in 3rd week. (the best diagnostic investigation)  Treatment: - Ciprofloxacin , Co-trimoxazole ( septrin ), ceftriaxone BRUCELLOSIS Acquired immunodeficiency syndrome (AIDS) (Malta fever, undulant fever )  Aetiology: Infection with human immunodeficiency virus (HIV). Etiology:  Modes of infection: parenteral, Sexual & vertical  Causative organism: Brucella (melitenesis, abortus or suis)  Pathogenesis:  Mode of infection: contaminated milk or remnants of aborted animals The virus infects T-Lymphocytes mainly & may inhibit B- lymphocytes → Clinical picture : suppression of both cellular & humoral immunity.  Bone & muscle pain, vomiting, constipation When the T-Lymphocytes fall below 200 cells / dl, the patient develops  Relapsing fever: fever for 10 days then apyrexia for 10 days, then fever and so on. opportunistic diseases (infections & malignancy)  Hepatosplenomegaly & Lymph node enlargement.  Clinical picture: Complications :  Asymptomatic: may last up to 10 years  Relapse.  Acute HIV syndrome: fever, rigors, arthralgia & rash for 2 weeks  Infective endocarditis  Symptomatic syndromes:  Orchitis.  Generalized LN enlargement.  Paraplegia due to transverse myelitis.  Constitutional Disease: persistent fever, loss of weight, diarrhea.  Abortion.  Neurological Disease: Encephalitis, Neuropathy, Myopathy. Investigations :  Opportunistic Infections: CMV, HSV, TB & Pneumocystis carinii pneumonia.  CBC: Lymphocytosis  Secondary Neoplasms: Kaposi sarcoma, Non-Hodgkin's lymphoma  Blood Culture: +ve during fever spike. Investigations: Serological tests: Brucella agglutination test. (the best diagnostic test)  HIV- antibodies: for screening, appear within 2 weeks of infection. Treatment: doxycycline or rifampicin for 6 weeks  HIV-RNA by PCR : the best diagnostic test Treatment: Anti-Retroviral (HAART) Zidovudine 600 mg / day orally. FEVER OF UNKNOWN ORIGEN (FUO) Investigations : Definition:  Laboratory: Persistent elevation of body temperature over 38.5° C for 3 weeks without  ESR > 100: in TB , collagen, malignancy Specific diagnosis after at least one week of inpatient investigations.  CBC: leukemia, lymphoma, anemia Causes:  Liver , kidney function test.  Infections:  Serology: Widal test , ANA & Anti-Ds-DNA.  Bacterial: TB, infective endocarditis, Typhoid fever, Brucellosis, Lung abscess,  Culture: blood, urine, stool, sputum, CSF Pyelonephritis  Imaging:  Viral: EBV, CMV, HIV, Hepatitis  X-ray: chest , bone.  Protozoa: Malaria, Ameobiasis  U/S: Heart, Abdomen, Pelvis.  Malignancy:  Endoscopy: upper GIT & lower GIT.  Hematologic: Lymphoma, Leukemia  Biopsy: LN, Bone marrow  Non hematologic: Hypernephroma, Hepatoma, Bronchogenic carcinoma  Therapeutic tests: Metronidazole (amoeba), Chloroquine (malaria), Aspirin  Collagen disease: Rheumatic fever, PAN, SLE, RA (RF)  Others: inflammatory bowel disease, hemolysis, cerebral hemorrhage  Undiagnosed  Chronic infection of the lung caused by mycobacterium tuberculosis bacilli aerobic non motile bacillus - Immunocomprimised (by disease or drug): AIDS, DM, leukemia, steroids Apical cavities and fibrosis or fluffy cotton appearance Night fever, sweating, loss of weight & appetite Markedly elevated Of thick mucoid or mucopurulent coin shaped sputum Staining by hrs Used in combination for long period of time : only INH & rifampicin