Environmental Exposures Answers 475rupture. The rash is confined to clothed areasand may progress to a profunda
stage, in which the obstruction delves deeper into the skin and produces
larger vesicles that may become infected. These, however, are not pruritic and
may resemble a chronic dermatitis. The antibacterial treatment of choice is
Chlorhexadine,which is to be used in the acute phase. Salicylic acid may
also be used to assist in desquamation, but should not be used on large areas
because of possible salicylate intoxication.
(a and d)Although calamine and diphenhydramine (Benadryl) may
assist in symptomatic relief, they do not offer treatment. (b)Acyclovir is to
treat herpes infection. (e)Treatment is especially important in this patient
with insulin-dependent diabetes mellitus (IDDM) to prevent further infectious
complications that necessitate parenteral antibiotics.
422.The answer is e.(Rosen, pp 1997-2008.)The diagnosis of heat
exhaustionis initially made upon clinical presentation. Patients may have
general malaise, fatigue, frontal headache, impaired judgment, diaphoresis,
nausea, and show signs of dehydration with tachycardia and orthostatic
hypotension. Heat exhaustion may progress to heat stroke and lies along a
spectrum in which intermediate cases may often be difficult to delineate;
however, the treatment is essentially the same. It is important to bring the
patient to a cool location and start fluid replacement slowly as to prevent
cerebral edema, especially in younger patients. To help distinguish between
heat exhaustion and heat stroke, hepatic transaminases are helpful. Elevations
to several thousand units may be seen in heat exhaustion or healthy runners
after a marathon, whereas in heat stroke the levels are elevated to tens of
thousands.
(a)Heat syncope results from the dilatation of cutaneous vessels to
assist in the delivery of heat to the skin’s surface, thereby pooling the blood to
the periphery and causing syncope. Elderly patients and those who stand
for long periods are especially prone to this. (b)Heat edema occurs in patients
who are not acclimated to warmer temperatures and thereby develop swollen
feet and ankles. This is not a central process and altered mental states do
not occur. (c)Rhabdomyolysis may result in any case where there is muscle
breakdown caused by dehydration, stress, or exogenous factors. The patient
may have mild rhabdomyolysis; however, it alone does not explain this patient’s
symptoms.(d)Neurologic dysfunction, including seizures and coma, are a
hallmark of heat stroke, which result when treatment is not initiated and
thermoregulatory responses fail. These patients often have dry, hot skin with
core temperatures above 105°F.