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1 Pupils Hypothalamic disease processes may lead to unilateral Horner s syndrome, while bilateral diencephalic involvement or destructive pontine lesions may lead to small but reactive pupils Ipsilateral pupillary dilation with no direct or consensual response to light occurs with compression of the third cranial nerve, eg, with uncal herniation The pupils are slightly smaller than normal but responsive to light in many metabolic encephalopathies; however, they may be fixed and dilated following overdosage with atropine, scopolamine, or glutethimide, and pinpoint (but responsive) with opiates Pupillary dilation for several hours following cardiopulmonary arrest implies a poor prognosis 2 Eye movements Conjugate deviation of the eyes to the side suggests the presence of an ipsilateral hemispheric lesion or a contralateral pontine lesion A mesencephalic lesion leads to downward conjugate deviation Dysconjugate ocular deviation in coma implies a structural brainstem lesion unless there was preexisting strabismus The oculomotor responses to passive head turning and to caloric stimulation relate to each other and provide complementary information In response to brisk rotation of the head from side to side and to flexion and extension of the head, normally conscious patients with open eyes do not exhibit contraversive conjugate eye deviation (doll s-head eye response) unless there is voluntary visual fixation or bilateral frontal pathology With cortical depression in lightly comatose patients, a brisk doll s-head eye response is seen With brainstem lesions, this oculocephalic reflex becomes impaired or lost, depending on the site of the lesion The oculovestibular reflex is tested by caloric stimulation using irrigation with ice water In normal subjects, jerk nystagmus is elicited for about 2 or 3 minutes, with the slow component toward the irrigated ear In unconscious patients with an intact brainstem, the fast component of the nystagmus disappears, so that the eyes tonically deviate toward the irrigated side for 2 3 minutes before returning to their original position With impairment of brainstem function, the response becomes perverted and finally disappears In metabolic coma, oculocephalic and oculovestibular reflex responses are preserved, at least initially.

Usually occurs after 7 10 days of antibiotics Can occur after a single dose or several weeks after completion of antibiotics 1 8 days

Enterohemorrhagic Escherichia coli, including E coli O157:H7 and other Shiga-toxin producing strains (STEC) Enterotoxigenic E coli (ETEC) Vibrio parahaemolyticus

Usually abrupt onset of diarrhea, often bloody; abdominal pain In adults, it is usually selflimited to 5 10 days In children, it is associated with hemolytic-uremic syndrome (HUS) Antibiotic therapy may increase risk of HUS Watery diarrhea and abdominal cramps, usually lasting 3 7 days In travelers, fluoroquinolones shorten disease Abrupt onset of watery diarrhea, abdominal cramps, nausea and vomiting Recovery is usually complete in 2 5 days

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In assignment of the organizational data you link the different modules in the system by defining how the structures relate to one another This is best shown by the association of sales organizations and plants A plant is always linked to one company code, and can be linked to several sales organizations This means that the plant is owned by the company code and can only take orders from and make deliveries to customers in its sales organization This is illustrated in Figure 1-22 In Figure 1-22 Plants 1, 2, and 3 belong to Company code 1 Sales organization 1 uses Plants 1 and 2 Sales organization 2 uses Plants 2 and 3 Sales organizations 1 and 2 can make cross-company sales for goods from Plants 4 or 5 After you have defined your data, and the other application components have defined theirs (such as the company codes having been defined by FI and the plants by MM), it is time to assign the SD organizational data The assignments are extremely easy settings to make once you understand how the structures should be built up (as explained previously) They are assigned in the following structure paths in the SAP Customizing Implementation Guide: SAP Customizing Implementation Guide | Enterprise Structure | Assignment | Sales and Distribution: Assign sales organization to company code Assign distribution channel to sales organization

Stool culture Special tests required to identify toxinproducing strains Stool culture on special medium

(continued )

Table 30 3 Acute bacterial diarrheas and food poisoning (continued )

Organism Vibrio cholerae Incubation Period 24 72 hours Vomiting + Diarrhea +++ Fever Associated Foods Contaminated water, fish, shellfish, street vendor food Diagnosis Stool culture on special medium Clinical Features and Treatment Abrupt onset of liquid diarrhea in endemic area Needs prompt intravenous or oral replacement of fluids and electrolytes Tetracyclines shorten excretion of vibrios

Fever, diarrhea that can be bloody, cramps Usually self-limited in 2 10 days Early treatment (erythromycin) shortens course May be associated with Guillain-Barr syndrome Abrupt onset of diarrhea, often with blood and pus in stools, cramps, tenesmus, and lethargy Stool cultures are positive Therapy depends on sensitivity testing, but the fluoroquinolones are most effective Do not give opioids Often mild and self-limited Gradual or abrupt onset of diarrhea and lowgrade fever No antimicrobials unless high risk (see text) or systemic dissemination is suspected, in which case give a fluoroquinolone Prolonged carriage can occur Severe abdominal pain, (appendicitis-like symptoms) diarrhea, fever Polyarthritis, erythema nodosum in children If severe, give tetracycline or fluoroquinolone Without treatment, self-limited in 1 3 weeks Acute onset, vomiting, watery diarrhea that lasts 4 8 days Supportive care Nausea, vomiting (more common in children) diarrhea (more common in adults), fever, myalgias, abdominal cramps Lasts 12 60 hours Supportive care

Shigella species (mild cases)

Fecally contaminated foods touched by infected food handlers Shell fish and fecally contaminated foods touched by infected food handlers

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