By H. Carlos. Lasell College.
Susceptibility—Susceptibility is widespread discount voveran sr 100 mg on-line, aggravated by friction and excessive perspiration in axillary and inguinal regions purchase 100 mg voveran sr with amex, and when environmental temperatures and humidity are high order voveran sr 100 mg without a prescription. Preventive measures: Launder towels and clothing with hot water and/or fungicidal agent; general cleanliness in public showers and dressing rooms (repeated washing of benches; frequent hosing and rapid draining of shower rooms). A fungi- cidal agent such as cresol should be used to disinfect benches and ﬂoors. Control of patient, contacts and the immediate environment: 1) Report to local health authority: Obligatory report of epidem- ics in some countries; no individual case report, Class 4 (see Reporting). Epidemic measures: Educate children and parents about the infection, its mode of spread and the need to maintain good personal hygiene. Identiﬁcation—This fungal disease presents with characteristic scaling or cracking of the skin, especially between the toes (interdigital), diffuse scaling over the sole of the foot (dry type) or blisters containing a thin watery ﬂuid; commonly called athlete foot. In severe cases, vesicular lesions appear on various parts of the body, especially the hands; these dermatophytids do not contain the fungus but are an allergic reaction to fungus products. Presumptive diagnosis is veriﬁed by microscopic examination of potas- sium hydroxide-or calcoﬂuor white-treated scrapings from lesions that reveal septate branching ﬁlaments. Note that bacteria, including Gram- negative organisms and coryneforms, as well as Candida and Scytalidium species, may produce similar lesions. They are also common in industrial workers, schoolchildren, athletes and military personnel who share shower or bathing facilities. Period of communicability—As long as lesions are present and viable spores persist on contaminated materials. Educate the public to maintain strict personal hygiene; take special care in drying between toes after bathing; regularly use a dusting powder or cream containing an effective antifungal on the feet and partic- ularly between the toes. Control of patient, contacts and the immediate environment: 1) Report to local health authority: Obligatory report of epidem- ics in some countries; no individual case report, Class 4 (see Reporting). Oral terbinaﬁne, or itraconazole may be indicated in severe, extensive or protracted disease; griseofulvin, although less active, is an alternative. Epidemic measures: Thoroughly clean and wash ﬂoors of showers and similar sources of infection; disinfect with a fungi- cidal agent such as cresol. Identiﬁcation—A chronic fungal disease involving one or more nails of the hands or feet. The nail gradually becomes detached from the nail bed, thickens, and becomes discolored and brittle, an accumulation of soft keratinous material forms beneath the nail or the nail becomes chalky and disintegrates. Diagnosis is made by microscopic examination of potassium hydroxide preparations of the nail and of detritus beneath the nail for hyaline fungal elements. Mode of transmission—Presumably through extension from skin infections acquired by direct contact with skin or nail lesions of infected people, or from indirect contact (contaminated ﬂoors and shower stalls) with a low rate of transmission, even to close family associates. Preventive measures: Cleanliness and use of a fungicidal agent such as cresol for disinfecting ﬂoors in common use; frequent hosing and rapid draining of shower rooms. Control of patient, contacts and the immediate environment: 1) Report to local health authority: Ofﬁcial report not ordinarily justiﬁable, Class 5 (see Reporting). Epidemic measures, Disaster implications and International measures: Not applicable. It is a symptom of infection by many different bacterial, viral and parasitic enteric agents. The speciﬁc diarrheal diseases—cholera, shigellosis, salmonellosis, Escherichia coli infections, yersiniosis, giardiasis, Campylobacter enteritis, cryptosporidiosis and viral gastroenteropa- thy—are each described in detail under individual listings elsewhere in this book. Diarrhea can also occur in association with other infectious diseases such as malaria and measles, as well as chemical agents. Change in the enteric ﬂora induced by antibiotics may produce acute diarrhea by overgrowth and toxin production by Clostridium difﬁcile. Approximately 70%–80% of the vast number of sporadic diarrheal episodes in people visiting treatment facilities in less industrialized countries could be diagnosed etiologically if the complete battery of newer laboratory tests were available and utilized. From a practical clinical standpoint, diarrheal illnesses can be divided into 3 clinical presentations: 1) Acute watery diarrhea (including cholera), lasting several hours or days; the main danger is dehydration; weight loss occurs if feeding is not continued. The details pertaining to the individual diseases are presented in separate chapters. Each has a different pathogenesis, possesses distinct virulence properties, and comprises a separate set of O:H serotypes. Transmission is usually through contaminated food, water or hands; an outbreak in 2003 in Ohio was attributed to respiratory transmission via contaminated sawdust. The diarrhea may range from mild and nonbloody to stools that are virtually all blood. Lack of fever in most patients can help to differentiate this infection from that due to other enteric pathogens. The other most common serogroups in the United States are O26, O111, O103, O45, and O121.
Also take note of any stridor voveran sr 100 mg line, especially with crying buy cheap voveran sr 100mg line, that may indicate a vascular ring trusted voveran sr 100 mg. The abdominal exam should include careful assess- ment of the liver position and distance of the edge relative to the costal margin. Cardiac auscultation begins with a general assessment of the chest, looking for signs of hyperdynamic precordium. Palpation of the chest may reveal the presence of a lift or heave of increased right ventricular pressure or thrill associated with a grade 4 or higher murmur. Use the appropriate stethoscope for the patient’s size and listen systemati- cally to each part of the cardiac cycle and at each area on the chest. S1 is best heard at the apex and marks the beginning of systole, whereas S2 is best heard at the mid to upper sternal border 6 W. This is the result of hypoxia in peripheral tissue, which causes the opening of normally collapsed capillaries to better perfuse the hypoxic tissue. Perfusion of these collapsed capillaries will result in expansion of the volume of these peripheral tissues (tips of digits) resulting in clubbing. This phenomenon is seen in other lesions causing hypoxia of peripheral tissue, such as with chronic lung disease and chronic anemia (causing hypoxia through reduction of level of hemoglobin and therefore reduction of oxygen carrying capacity) such as with ulcerative colitis, Crohn’s disease, and chronic liver disease Fig. By identifying S1 and S2, the systolic versus diastolic intervals can likewise then be distinguished, even though they may be of equal duration (at higher heart rates). In the case of mesocardia or dextrocardia, the apical impulse will be displaced rightward. S1 is usually single, though in reality is the result of multiple low frequency events, which can often have at least two detectable components (“split S1”). This normal finding is relatively common in older children or adolescents, and is Fig. Increased blood flow in the right heart such as seen in patients with atrial or ventricular septal defects will cause dilation and increase in right atrial pressure. This will eventually lead to congestion of organs draining blood into the right atrium such as the liver, leading to its enlargement Fig. This is sometimes mistaken for the presence of an early systolic ejection sound or “click,” though a click is usually somewhat higher in frequency and intensity, slightly later in timing, and is well heard at the apex, where the split S1 is usually not heard. These changes are due to the alteration in the time period blood can flow from the atria to the ventricles. S2 is an important event to characterize in children, as it may be the only abnormal finding indicating serious pathology. The interval should close with expiration, at least in the sitting position, though may occasionally remain slightly split when supine, sometimes reflecting an incomplete right bundle branch block (normal variant). Wide, fixed splitting of S2 is a sign of right heart volume overload from an atrial septal defect or anomalous pulmonary return. A narrowly split (or single) S2, with increased intensity of P2 component is an important sign of pulmonary hypertension. Paradoxical splitting of S2 (widening of the interval with expiration, and closing with inspiration) is due to delayed closure of the aortic valve (A2) and is often found in aortic stenosis or left bundle branch block. The first heart sound is typically single, reflecting closure of the tricuspid and mitral valves and occurs at the onset of systole. S2 is normally split, consisting of closure of the aortic valve, followed by the pulmonary valve. The aortic valve closes first due to the shorter left bundle branch of the His conduction system. This will allow the left ventricle to contract a few milliseconds before the right ventricle and therefore complete systole a few milliseconds before the right ventricle, hence aortic valve closes before pulmonary valve. This phenomenon is exaggerated during inspiration due to the increase in blood return to the right heart secondary to the sump effect of a negative intrathoracic pressure, thus leading to wider splitting of the second heart sound. The opposite is true in expiration, leading to approximation of the aortic and pulmonary components of the second heart sound, thus sounding as a single heart sound 1 Cardiac History and Physical Examination 9 An intermittent S3 is a common, nonpathologic finding in older children and adolescents, while S4 and/or S3–4 gallop is a sign of left ventricular dysfunction. Clicks are additional, brief sounds in systole that are usually due to valve abnor- malities, but may also be caused by increased flow in a dilated ascending aorta or main pulmonary artery. A constant, early systolic ejection click, occurring immedi- ately after S1 and well heard at the apex, is a sign of bicuspid aortic valve. This click (or “ejection sound”) is heard better in the sitting or standing position, but does not vary from beat to beat or shift in timing relative to S1. An early systolic ejection sound that is better heard in expiration than inspiration and best heard at the left upper sternal border is most consistent with an abnormal pulmonary valve. In diastole, an opening snap is an early diastolic sound made by a stenotic mitral valve. Murmurs are sounds of longer duration caused by either the passage of blood through the heart and vessels with resulting vibrations of the normal cardiac struc- tures (innocent murmurs) or turbulent flow across abnormal structures such as valves or septal defects (Fig.
S1 first heart sound discount voveran sr 100 mg without prescription, S2 second heart sound voveran sr 100 mg line, A aortic valve closure discount voveran sr 100mg free shipping, P pulmonary valve closure. On the other hand, if oxygen saturation drops significantly with closure of the ductus arteriosus, it becomes necessary to keep the ductus arteriosus patent with a prostaglandin infusion. This is followed by surgical interposition of a systemic to pulmonary arterial shunt to secure adequate pulmo- nary blood flow until complete surgical repair can be performed. The surge in catecholamines brought on by stress or anxiety can further constrict this narrowing. On auscultation, the murmur is diminished or eliminated due to significant reduc- tion in pulmonary blood flow. Hypercyanotic spells are true emergencies and are often cause for patients to undergo palliative or complete repair soon after the episode. Older children often instinctively assume a squatting position in an effort to relieve cyanosis. This is effective because squatting increases the systemic vascular resistance above that of the pulmonary vascular resistance via kinking of the femoral vessels with resultant increase in pulmonary blood flow. In infants and younger children, bringing their knees up to their chests can break a tet spell. In the hospital setting, treatment of hypercyanotic spells should start with attempts to reduce any cause of anxiety to the child. Allow the child’s mother to hold him or her in a knee-to-chest position to increase systemic vascular resis- tance, preferably in a dark quiet room to assist in calming the child. Observation from a distance with minimal intervention is best if the child appears to be responding to this measure. In the event these measures are not fruitful, the child will require hospitalization with placement of an intravenous line and the use of an intravenous beta blocking agent such as esmolol which reduces muscle contractility through its negative inotropic effect. On occasion, vasopressive drugs such as phenylephrine are used to increase systemic vascular resistance, thus forcing blood to flow through the pul- monary valve. In unstable children, it is best to avoid complete repair and therefore, augmentation of pulmo- nary blood flow through systemic to pulmonary arterial shunt can be placed. On the other hand, complete surgical repair can be considered if children can be somewhat stabilized prior to surgical repair. Unrepaired children are at significant risk for developing brain embolization and possible brain abscess due to right to left shunting although these complications do not typically occur in the first year of life. Over time, the resulting pulmonary regurgitation causes the right ventricle to dilate and become fibrotic and the child becomes prone to ventricular arrhythmias. There has been a tendency lately to be aggressive in managing this potentially damaging pulmonary regurgitation through implantation of compe- tent pulmonary valves before adulthood. Although these valves are currently implanted surgically, implantation via interventional cardiac catheterization (currently an experi- mental approach) has been successful and may become the method of choice in the near future. Chest X-Ray In general, the cardiac silhouette is normal in size and the mediastinum is narrow due to the small pulmonary arteries. Electrical conduction abnormalities as well as right ventricular fibrosis due to chronic pulmonary regurgitation may cause ventricular arrhythmias such as prema- ture ventricular contractions and ventricular tachycardia. Echocardiography Echocardiography is the mainstay of diagnosis in the modern era of pediatric cardiology. The ductus arteriosus is also seen early on in neonates and patients are frequently followed in the hospital until the ductus is closed to ensure that there is adequate pulmonary blood flow across the narrowed pulmonary valve (Fig. Cardiac Catheterization While no longer necessary for diagnosis in most cases, there remains a role for cardiac catheterization. Treatment In the modern era of congenital heart surgery, with patients being successfully oper- ated on at smaller weights and younger ages with excellent results, it is now often possible for patients to undergo complete anatomic repair as their initial operation. Parents are instructed to look for signs of inadequate pulmonary blood flow such as hyper- pnea, cyanosis, or general failure to thrive. In addition, patients with hypercyanotic spells are admitted for treatment of the episode and invariably scheduled for 174 D. Torchen complete repair during that admission so as to avoid the chance of another spell. Patients remaining asymptomatic at home are surgically repaired at around 4–6 months of age. A systemic to pulmonary arterial shunt is a synthetic vascular tube connecting the aorta, or one of its branches, to the pulmonary arteries thus augmenting pulmo- nary blood flow. Patients requiring a systemic to pulmonary arterial shunt are followed closely and are brought back to the operating room for complete repair. Long-Term Management During the initial repair, it is important to relieve obstruction to pulmonary blood flow. Depending on the degree of pulmonary stenosis and the location of the obstruction (subvalvar, valvar, or supravalvar), surgeons may find it necessary to cut across the pulmonary valve to enlarge the outflow tract (transannular patch) rendering the valve ineffective, resulting in significant pulmonary regurgitation. This is typically well tolerated initially, however, after many years of free pulmonary insufficiency; the right ventricle becomes dilated and less compliant, eventually becoming a possible source of potentially lethal ventricular arrhythmias.
Contrast material filling a cardiovascular structure may show: • Anatomical details of structure purchase 100mg voveran sr fast delivery. Complications of Cardiac Catheterization Vascular Vascular injury is more likely in small children 100mg voveran sr amex, when using large sheaths or cath- eters 100mg voveran sr fast delivery, when patient is using anticoagulants, after interventional procedures, and in arterial access sites. Significant hematomas may occur and if large, may be painful and result in hemodynamic compromise. This is suspected when there is severe back pain, unexplained drop in hematocrit or hemodynamic compromise. Vascular injury as a result of cardiac catheterization includes: • Arterial occlusion: Patency of arteries should always be carefully monitored after cardiac catheterization. Signs of limb ischemia such as pallor, coldness, paresthesia, and decrease or absent peripheral pulses and delayed capillary refill should be monitored and if present treated promptly. Management includes prolonged compression or thrombin injection in selected patients. Arrhythmias: • Atrial and ventricular premature beats are usually caused by catheter manipulation but are insignificant and transient. If it persists, over- drive pacing or electrical cardioversion is performed for termination. It occurs mainly in sick infants and responds to medical or electrical cardioversion. Most common sites of perforations are: atrial appendage and right ventricular outflow tract in small infants. Hemopericardium should be suspected if the patient developed hypoten- sion, enlarged cardiac silhouette, and decreased movement of the silhouette nor- mally generated by contractility. Hypoventilation and Apnea Depressed breathing may result from sedation used to perform cardiac catheteriza- tion. High-risk patients for respiratory depression include: Down syndrome patients, airway abnormality, borderline cardiac function, patients with gastroe- sophageal reflux, increased pulmonary vascular resistance, and the use of prosta- glandin infusion. It is customary in many centers to have experienced anesthesiologists to be supervising anesthesia/sedation, airway patency, and effec- tive respiration during cardiac catheterization, particularly if patients or procedure are deemed high risk. Embolism This may be systemic or pulmonary and include: • Air embolism: this can be prevented by using appropriate size sheath and fre- quent catheter flushing. Allergy It may be precipitated by local anesthetics, iodinated contrast agents, or latex expo- sure. Treatment includes: Diphenhydramine, H2 blockers, fluid resuscitation, and epinephrine. Complications Related to Intervention This includes balloon or device damages to nearby cardiac structures, heart perfora- tions and embolization. Capture and removal of the device is attempted first, if not successful, surgical intervention is necessary to remove embolized device. Death Death rates have declined steeply over the past two decades reaching less than 0. Interventional Catheterization The role of interventional cardiac catheterization in managing children with heart disease continues to expand and include lesions which were, till recently, amenable only to surgical repair. Improvement in tools available for interventional catheterization such as catheters, stents, and devices and the improvement in imaging techniques during procedures 5 Cardiac Catheterization in Children: Diagnosis and Therapy 75 such as transesophageal echocardiography and intracardiac echocardiography in addition to fluoroscopy are allowing safe and effective therapeutic procedures in children with heart diseases. Balloon Atrial Septostomy (Rashkind Procedure) Catheters with inflatable balloons are used to enlarge atrial communications and allow better shunting across the atrial septum. Once the catheter tip is inside the atrium, the stiff balloon is inflated and the catheter is then yanked back. This will cause the inflated balloon to be pulled through the atrial septum and into the right atrium, thus tearing the atrial septum and enlarging the atrial communication. Indications: lesions requiring better mixing of systemic and pulmonary blood at the atrial level, such as in: • Transposition of the great arteries with restrictive atrial septal defect. Larger atrial communication will allow better mixing of blood and higher level of oxy- gen saturation till surgical repair is possible. If Rashkind atrial septostomy did not produce an effective atrial communication, then special catheters with blades embedded within an inflatable balloon can be used. The blades are exposed once the balloon is inflated, thus creating cuts in the atrial septal wall to allow for more effective enlarging of the atrial septal defect. Balloon Valvuloplasty Balloon dilation of stenotic valves is a well established technique to eliminate stenosis. Aortic stenosis may be relieved with balloon valvuloplasty as long as aortic regur- gitation is not significant since this may worsen with balloon valvuloplasty. Pulmonary Valve Stenosis Valvar pulmonary stenosis can respond to balloon dilation if the pulmonary annulus size is normal with no significant additional stenosis below or above the valve since supra and subvalvar stenosis do not respond well to balloon dilation. Dilating a stenotic valve results in rupture of the abnormally fused valve cusps, this will result 76 A. Pulmonary valve stenosis is performed when the pressure gradient across the valve is 50 mmHg or more.
Initial signs and symptoms may be nonspeciﬁc with fever generic 100 mg voveran sr with amex, chills discount voveran sr 100 mg without a prescription, malaise order voveran sr 100mg with visa, myalgia, nausea, prostration, sore throat and headache. Lymph- adenitis often develops in those lymph nodes that drain the site of the bite, where there may be an initial lesion. This is bubonic plague, and it occurs more often (90%) in lymph nodes in the inguinal area and less commonly in those in the axillary and cervical areas. All forms, including instances in which lymphadenopathy is not apparent, may progress to septicemic plague with bloodstream dissemination to diverse parts of the body that include the meninges. Secondary involvement of the lungs results in pneumo- nia; mediastinitis or pleural effusion may develop. Secondary pneumonic plague is of special signiﬁcance, since respiratory droplets may serve as the source of person-to-person transfer with resultant primary pneumonic or pharyngeal plague; this can lead to localized outbreaks or devastating epidemics. Though naturally acquired plague usually presents as bubonic plague, purposeful aerosol dissemination as a result of deliberate use would be manifest primarily as pneumonic plague. Plague organisms have been recovered from throat cultures of asymptom- atic contacts of pneumonic plague patients. Modern therapy mark- edly reduces fatality from bubonic plague; pneumonic and septicemic plague also respond if recognized and treated early. However, one report stated that patients who had not received adequate therapy for primary pneumonic plague within 18 hours after onset of respiratory symptoms were less likely to survive. Slow growth of the organism at normal incubation temperatures may lead to misiden- tiﬁcation by automated systems. Occurrence—Plague continues to be a threat because of vast areas of persistent wild rodent infection; contact of wild rodents with domestic rats occurs frequently in some enzootic areas. While urban plague has been controlled in most of the world, human plague has occurred in the 1990s in several African countries that include Botswana, the Demo- cratic Republic of the Congo, Kenya, Madagascar, Malawi, Mozambique, the United Republic of Tanzania, Uganda, Zambia and Zimbabwe. Plague is endemic in China, India, Lao People’s Democratic Republic, Mongolia, Myanmar and Viet Nam. In the Americas, foci in northeastern Brazil and the Andean region (Brazil, Ecuador and Peru) continue to produce sporadic cases and occasional outbreaks including an outbreak of pneu- monic plague in Ecuador in 1998. Reservoir—Wild rodents (especially ground squirrels) are the nat- ural vertebrate reservoir of plague. Lagomorphs (rabbits and hares), wild carnivores and domestic cats may also be a source of infection to people. Mode of transmission—Naturally acquired plague in people oc- curs as a result of human intrusion into the zoonotic (also termed sylvatic or rural) cycle during or following an epizootic, or by the entry of sylvatic rodents or their infected ﬂeas into human habitat; infection in commensal rodents and their ﬂeas may result in a domestic rat epizootic and ﬂea-borne epidemics of bubonic plague. Domestic pets, particularly house cats and dogs, may carry plague infected wild rodent ﬂeas into homes, and cats may occasionally transmit infection through bites, scratches or respiratory droplets; cats develop plague abscesses that have been a source of infection to veterinary personnel. The most frequent source of exposure that results in human disease worldwide has been the bite of infected ﬂeas (especially Xenopsylla cheopis, the oriental rat ﬂea). Person-to- person transmission by Pulex irritans ﬂeas (“human” ﬂea), is presumed to be important in the Andean region of South America and in other places where plague occurs and this ﬂea is abundant in homes or on domestic animals. Certain occupations and lifestyles (including hunting, trapping, cat ownership and rural residence) carry an increased risk of exposure. In the case of deliberate use plague bacilli would possibly be transmitted as an aerosol. Incubation period—From 1 to 7 days; may be a few days longer in those immunized who develop illness. Period of communicability—Fleas may remain infective for months under suitable conditions of temperature and humidity. Bubonic plague is not usually transmitted directly unless there is contact with pus from suppurating buboes. Pneumonic plague may be highly communica- ble under appropriate climatic conditions; overcrowding facilitates trans- mission. Preventive measures: The basic objective is to reduce the likelihood of people being bitten by infected ﬂeas, having direct contact with infective tissues and exudates, or of being exposed to patients with pneumonic plague. In sylvatic or rural plague areas, the public should be advised to use insect repellents and warned not to camp near rodent burrows and to avoid handling of rodents, but to report dead or sick animals to health authorities or park rangers. Dogs and cats in such areas should be protected periodically with appropriate insecticides. Rat suppression by poisoning (see 9B6) may be necessary to augment basic environmental sanitation measures; rat control should always be preceded by measures to control ﬂeas. Collection and testing of ﬂeas from wild rodents and their nests or burrows may also be appropriate. After the third booster dose, the intervals can be extended to every 1 to 2 years. Immunization of visitors to epidemic localities and of laboratory and ﬁeldworkers han- dling plague bacilli or infected animals is justiﬁable but should not be relied upon as the sole preventive measure; routine immunization is not indicated for most persons resident in enzootic areas.
The overall picture is often one of emotional dullness buy voveran sr 100mg low cost, lack of drive and slowness; but discount 100 mg voveran sr otc, particularly in persons previously with energetic order voveran sr 100 mg otc, restless or aggressive characteristics, there may be a change towards impulsiveness, boastfulness, temper outbursts, silly fatuous humour, and the development of unrealistic ambitions; the direction of change usually depends upon the previous personality. A considerable degree of recovery is possible and continue over the course of several years. These states are often associated with old age, and may precede more severe states due to brain damage classifiable under dementia of any type (290. Mood may fluctuate, and quite ordinary stress may produce exaggerated fear and apprehension. There may be marked intolerance of mental and physical exertion, undue sensitivity to noise, and hypochondriacal preoccupation. The symptoms are more common in persons who have previously suffered from neurotic or personality disorders or when there is a possibility of compensation. This syndrome is particularly associated with the closed type of head injury when signs of localized brain damage are slight or absent, but it may also occur in other conditions. Postcontusional syndrome (encephalopathy) Post-traumatic brain syndrome, nonpsychotic Status postcommotio cerebri Excludes: frontal lobe syndrome (310. It should be used for abnormal behavior, in individuals of any age, which gives rise to social disapproval but which is not part of any other psychiatric condition. To be included, the behavior--as judged by its frequency, severity and type of associations with other symptoms--must be abnormal in its context. Disturbances of conduct are distinguished from an adjustment reaction by a longer duration and by a lack of close relationship in time and content to some stress. They differ from a personality disorder by the absence of deeply ingrained maladaptive patterns of behavior present from adolescence or earlier. Where the emotional disorder takes the form of a neurotic disorder described under 300. Overanxious reaction of childhood and adolescence Excludes: abnormal separation anxiety (309. Sibling jealousy Excludes: relationship problems associated with aggression, destruction, or other forms of conduct disturbance (312. The category of mixed disorders should only be used when there is such an admixture that this cannot be done. In early childhood the most striking symptom is disinhibited, poorly organized and poorly regulated extreme overactivity but in adolescence this may be replaced by underactivity. Impulsiveness, marked mood fluctua- tions and aggression are also common symptoms. Delays in the development of specific skills are often present and disturbed, poor relationships are common. If the hyperkinesis is symptomatic of an underlying disorder, code the underlying disorder instead. Developmental disorder of hyperkinesis Use additional code to identify any associated neurological disorder 314. Hyperkinetic conduct disorder Excludes: hyperkinesis with significant delays in specific skills (314. In each case development is related to biological maturation but it is also influenced by nonbiological factors and the coding carries no aetiological implications. Speech or language difficulties, impaired right-left differentiation, perceptuo-motor problems, and coding difficulties are frequently associated. Most commonly there is a delay in the development of normal word-sound production resulting in defects of articulation. When this occurs the coding should be made according to the skill most seriously impaired. The mixed category should be used only where the mixture of delayed skills is such that no one skill is preponderantly affected. The mental disturbance is usually mild and nonspecific and psychic factors [worry, fear, conflict, etc. In the rare instance that an overt psychiatric disorder is thought to have caused a physical condition, use a second additional code to record the psychiatric diagnosis. Where there is a specific cognitive handicap, such as in speech, the four-digit coding should be based on assessments of cognition outside the area of specific handicap. The assessment of intellectual level should be based on whatever information is available, including clinical evidence, adaptive behavior and psychometric findings. Mental retardation often involves psychiatric disturbances and may often develop as a result of some physical disease or injury. In these cases, an additional code or codes should be used to identify any associated condition, psychiatric or physical. The "late effects" include conditions specified as such, or as sequelae, which may occur at any time after the resolution of the causal condition.