HistoryA complete and thorough history is essential in the initial evaluation of a patient with acute diarrhea. The physician should elicit a detailed description of the diarrheal syndrome, including length of symptoms, quantity and quality of stool, presence of fever, and abdominal symptoms. The history should address recent travel to underdeveloped countries, potential exposures to raw or undercooked food, sick contacts, contact with children, and employment in health care facilities. A sexual history may elicit risk factors for herpes simplex, Chlamydia, Neisseria gonorrhoeae, or Treponema pallidum proctitits.Establishing the immune status of the host is essential. Patients with immune deficiencies due to organ transplant, HIV, and certain drugs (particularly steroids, chemotherapeutic agents, and immunosuppressants) can be more susceptible to less typical gastrointestinal pathogens. Such patients may also exhibit more severe symptoms and experience a more fulminant course, lowering the threshold for antimicrobial therapy and hospitalization.Recent hospitalization or antimicrobial therapy increases the likelihood of C. difficile infection or antibiotic-associated diarrhea. Other medications may cause diarrhea or other adverse gastrointestinal effects.Patients presenting with diarrhea after international travel often are infected with bacteria or parasites, most frequently enterotoxigenic E. coli. Recent camping, travel to mountainous areas, or a prolonged diarrheal illness lasting more than 14 days suggests Giardia infection.
Physical ExaminationPhysical examination should concentrate on assessment of volume status with particular attention to heart rate, blood pressure, and mental status, especially in the very young and elderly. A directed examination of the abdomen may qualify the illness, but sensitivity and specificity for agents of infectious diarrhea is extremely low. A rectal examination may reveal hemoccult or grossly positive blood or mucus and may elicit tenderness, indicating proctitis.*72/348/5*

The Centers for Disease Control and Prevention, a division of the U.S. Public Health Service, strongly recommends that certain people be vaccinated against influenza every year before the flu season begins. Children twelve years of age and younger should be given only the so-called split-virus vaccine. Children under nine years of age who have not been previously vaccinated should get two doses of split-virus vaccine, with a one-month gap between them and with the second dose given before December. Although the best time for vaccination is between October 15 and November 15, high-risk individuals who were not previously immunized may still benefit from vaccination even after a flu outbreak has begun in their communities.
Charges for a flu shot are now fully reimbursable for everyone covered by Medicare. The vaccine is also offered for a minimal fee at many public health clinics and health maintenance organizations (HMOs) and it is increasingly being offered free of charge to employees of large companies. Check with your local health department or your company’s medical department or benefits office. The vaccine is also available for a fee from many private physicians.
The current U.S. Public Health Service recommendations for flu vaccination are as follows:
Groups at High Risk for Serious Influenza Complications
Every person aged 65 and older.
Infants over 6 months of age and all children and adults with chronic heart or lung disease, cystic fibrosis, a chronic metabolic disorder like diabetes, kidney disease, anemia, or severe asthma.
People of any age with cancer or an immunological disorder (in-eluding HIV infection) or those on medications that suppress immunity and lower the body’s resistance to infection.
All residents of nursing homes and other chronic-care facilities, particularly those with long-term health problems.
Children and teenagers (aged 6 months to 18 years) who are on long-term aspirin therapy (they may be at risk of developing a life-threatening condition called Reye’s syndrome should they get the flu while taking aspirin).
Groups That Can Transmit Influenza to
High-Risk Persons
Physicians, nurses, and other personnel who work in a hospital, outpatient facility, nursing home, or chronic-care facility and have contact with high-risk patients in all age groups, including infants.
Health-care workers and volunteers who provide in-home care to high-risk persons.
Household members, including children, of anyone who is at high risk for serious flu complications.
Other Groups
While they are not covered by official public health recommendations, other people who might consider taking an annual flu shot include:
People like the police and firefighters who provide essential community services.
Students, teachers, day-care personnel, and others who work in institutional settings.
Pregnant women who have other medical conditions that might increase their risk of flu complications. If possible, the vaccine should be administered after the first 3 months of pregnancy. However, vaccination of high-risk women should not be delayed if they will still be in the first trimester when the flu season begins.
Foreign travelers who expect to be in tropics at any time of the year or in the southern hemisphere during April through September, when the flu season hits there. Pretravel vaccination with the previous season’s vaccine is especially important for those in high-risk categories.
Any person who wants to reduce his or her chances of getting the flu. Only cost and vaccine availability limit the ability of every young, healthy person to take an annual flu shot.
Who Should Not Be Vaccinated
People with extreme allergic reactions to eggs, since the virus used in the vaccine is grown in eggs and the vaccine can contain minute amounts of egg protein. • People with fever-causing illnesses, who should wait until they recover to take a flu shot.
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Fever
If an infection is localized, pus formation, redness, swelling, and irritation often occur. These symptoms indicate that the invading organisms are being fought systematically. Another indication is the development of a fever, or a rise in body temperature above the norm of 98.6°E Fever is frequently caused by toxins secreted by pathogens that interfere with the control of body temperature. Although this elevated temperature is often harmful to the body, it is also believed to act as a form of protection. Elevations of body temperature by even 1 or 2 degrees provide an environment that destroys some types of disease-causing organisms. Also, as body temperature rises, the body is stimulated to produce more white blood cells, which destroy more invaders.

Pain
Although pain is not usually thought of as a defense mechanism, it is a response to injury, and it plays a valuable role in the body’s response to invasion. Pain may be either direct, caused by the stimulation of nerve endings in an affected area, or referred, meaning it is present in one place although the source is elsewhere. An example of referred pain is the pain in the arm or jaw often experienced by someone having a heart attack. Regardless of the cause of pain, most pain responses are accompanied by inflammation. Pain tends to be the earliest sign that an injury has occurred and often causes the person to slow down or stop the activity that was aggravating the injury, thereby protecting against further damage. Because it is often one of the first warnings of disease, persistent pain should not be overlooked or masked with short-term pain relievers.
*20/277/5*

For people who cannot take flu vaccine or who failed to get vaccine protection in time and face a high risk of serious complications from the flu, there are two antiviral drugs—amantadine hydrochloride (Symmetrel) and rimantidine hydrochloride (Flumadine)— that can help to prevent infection by the type A flu virus, the most deadly one. These drugs are also helpful for people who took the vaccine but need extra protection, such as elderly people with heart or lung disease.
The drugs prevent type A flu viruses (but not type В viruses) from multiplying in the body. They are about 75 to 80 percent effective in preventing type A influenza, the type of flu that results in the most serious complications. However, to be effective, they must be taken daily before a flu outbreak begins and throughout the entire flu season since, unlike the vaccine, they have no lasting effect. In addition to their preventive value, the drugs may help shorten the course of an attack of type A influenza among people who should have been vaccinated but weren’t.
The drugs have some side effects that unfortunately are more frequent in people over sixty-five, the group most in need of protection. Typical side effects involve the central nervous system: difficulty sleeping, tremulousness, depression or confusion. However, these effects are usually mild and often go away while the medication is still being taken.
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The brucella germs are the cause of brucellosis or undulant fever. Undulant fever has been known also as Malta fever. The condition is far more widespread now than formerly, although methods of prevention have been developed based on our knowledge of the fact that the disease is spread through drinking milk from infected cattle and through contact with the meat of infected animals.
Aureomycin has been found to produce prompt improvement in the symptoms of undulant fever with a lowering of the fever, a reduction in the size of the spleen and the other general symptoms of this disease which are so unpleasant. Streptomycin and sulfadiazine employed together are especially effective in controlling the organisms of undulant fever. Aureomycin seems to be preferred, however, to this combination of drugs because later reports show more satisfactory results and less of the toxic reactions that accompany the use of the other antibiotics. The results with terramycin appear to be about as good as those with aureomycin.
Before the antibiotic drugs were discovered and found to be so useful in brucellosis, patients were usually put to bed and given proper diet. Under these circumstances they seemed to recover gradually, although relapses were exceedingly frequent. Brucellosis is a rather chronic disease which may last for several months – even years – and be quite weakening. After the infection is over, people are weak, fatigued, nervous and often depressed. Loss of ambition is one of the most prominent symptoms of people who have had undulant fever.
Because the emotional reaction to the weakness may be so great, doctors are warranted in assuring patients that with proper treatment, complete recovery may occur and they can eventually regain their strength. In order to enable the person who has been weakened by a chronic disease to regain strength, rest, sunshine and a good diet with plenty of protein and vitamins is of the utmost importance.
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