*MEDCOM Pam 40-7-21
SUMMARY OF CHANGE

MEDCOM Pamphlet 40-7-21
Algorithm-Directed Troop Medical Care
This major revision-. Updates references (paragraph 3).
. Expands the MTF commander’s responsibilities (paragraph 6).
. Provides additional background information (paragraph 7).
. Provides a new paragraph on the use of ADTMC (paragraph 8).
. Revises guidance relevant to the assignment of screeners (paragraph 9).
. Simplifies training requirements (paragraph 10).
. Refines supervisory requirements (paragraph 11).
. Significantly revises the screeners’ performance evaluation requirements (paragraph 13).
. Allows the use of other approved algorithmic systems besides the ADTMC (paragraph 18).
. Deletes the use of MEDCOM Form 425-R (Internal/External Audit Form for ADTMC).
. Provides changes to the narratives that accompany the following algorithms:
SORE THROAT, A-1
EAR PAIN/DISCOMFORT/DRAINAGE, A-2
SINUS PROBLEMS/PAIN, A-4
RINGING IN THE EARS (TINNITUS), A-8
EXTREMITY PAIN NOT ASSOCIATED WITH A JOINT, B-3
NAUSEA/VOMITING/DIARRHEA, C-1
RECTAL PAIN/ITCHING/BLEEDING, C-3
CONSTIPATION, C-4
CHEST PAIN, D-2
DIZZINESS/FAINTNESS/BLACKOUT, F- 1
NUMBNESS/TINGLING, F-3
PARALYSIS/WEAKNESS, F-4
FATIGUE, G-1

MEDCOM Pam 40-7-21
FEVER/CHILLS, G-2
ACNE, J-2
SHAVING PROBLEM--PSEUDOFOLLICULITIS BARBAE (PFB)
(INGROWN HAIRS), J-3
DANDRUFF (SCALING OF THE SCALP), J-4
HAIR LOSS, J-5
ATHLETE’S FOOT (TINEA PEDIS), J-6
JOCK ITCH (TINEA CRURIS), J-7
SCALING, DEPIGMENTED SPOTS ON THE CHEST, BACK, AND UPPER ARMS
(TINEA VERSICOLOR), J-8
FEVER BLISTERS (COLD SORES), J-10
DRUG RASH, J-14
SUNBURN, K-8
. Contains changes in appendix B, List of Medications.
. Adds constipation to list of terms defined in the glossary.

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MEDCOM Pam 40-7-21
DEPARTMENT OF THE ARMY
HEADQUARTERS, UNITED STATES ARMY MEDICAL COMMAND
2050 Worth Road
Fort Sam Houston, Texas 78234-6000
MEDCOM Pamphlet
No. 40-7-21

23 June 2006

Medical Services
ALGORITHM-DIRECTED TROOP MEDICAL CARE
The word “he” (and its derivations) used in this text is generic and, except where otherwise indicated, will apply to both male and female.
PARAGRAPH
HISTORY .................................................................................................... 1
PURPOSE................................................................................................... 2
REFERENCES............................................................................................ 3
EXPLANATION OF ABBREVIATIONS AND TERMS ................................ 4
APPLICABILITY .......................................................................................... 5
RESPONSIBILITIES ................................................................................... 6
BACKGROUND .......................................................................................... 7
USE OF ADTMC ......................................................................................... 8
ASSIGNMENT OF SCREENERS............................................................... 9
TRAINING ................................................................................................... 10
SUPERVISION............................................................................................ 11
RECORDING ENCOUNTERS .................................................................... 12
PERFORMANCE IMPROVEMENT ............................................................ 13
FLIGHT/DIVING PERSONNEL: PERSONNEL RELIABILITY
PROGRAM STATUS .......................................................................... 14
TRADE NAMES .......................................................................................... 15
LOCAL MODIFICATION OF PROTOCOLS ............................................... 16
LOCAL REPRODUCTION OF THIS PAMPHLET ...................................... 17
USE OF SYSTEMS OTHER THAN ADTMC .............................................. 18

PAGE
3
3
4
4
4
4
4
5
5
6
6
6
6
6
6
6
7
7

APPENDIX A. SCREENER'S MANUAL ....................................................
APPENDIX B. LIST OF MEDICATIONS....................................................
APPENDIX C. SCREENING NOTE OF ACUTE MEDICAL CARE
(DA FORM 5181) ....................................................................................

8
252

GLOSSARY ................................................................................................

257

253

1. HISTORY. This issue publishes a major revision of this publication.
2. PURPOSE. This pamphlet serves as a guide to provide commanders of military treatment facilities
(MTFs) standardized clinical algorithms for use by screening personnel in determining the urgency and level of care that the active duty (AD) Soldier requires and, when appropriate, in providing minor treatment to him.

____________________
*This pamphlet supersedes Health Services Command (HSC) Pamphlet 40-7-21, 1 June 1992.
3

MEDCOM Pam 40-7-21
3. REFERENCES.
a. Army Regulation (AR) 40-3, Medical, Dental, and Veterinary Care.
b. AR 40-66, Medical Record Administration and Health Care Documentation.
c. AR 40-68, Clinical Quality Management.
4. EXPLANATION OF ABBREVIATIONS AND TERMS. The glossary contains definitions of abbreviations and special terms used in this pamphlet.
5. APPLICABILITY. The algorithms in this pamphlet will be used by enlisted medical personnel or the civilian equivalent who screen walk-in AD Soldiers in ambulatory care facilities including troop medical clinics (TMCs) and battalion aid stations (BASs) or AD Soldiers presenting for sick call.
6. RESPONSIBILITIES.
a. The MTF commander will–
(1) Ensure that screeners are provided adequate supervision in accordance with paragraph 11 of this pamphlet and performance evaluation by a physician, physician assistant (PA), or other qualified provider specifically assigned this responsibility.
(2) Ensure that the individual screener's scope of practice with regard to evaluating, treating, and/or determining the disposition of AD sick call patients is delineated in writing and that it is reviewed and revised at least annually.
(3) Approve the list of self-care medications, as recommended by the pharmacy and therapeutics committee (see AR 40-3) to be dispensed by screeners.
(4) Ensure implementation of the performance improvement (PI) requirements in paragraph 13 of this pamphlet.
(5) Establish a local training program for screeners to include table of organization and equipment personnel when they function as screeners.
(6) Ensure documentation of completed training in the screener’s competency assessment file
(CAF).
b. The TMC/BAS supervising medical officer will–
(1) Certify in writing that clinic personnel performing the screening function have received training and evaluation in the proper use of the algorithm-directed troop medical care (ADTMC).
(2) Ensure training, retraining, and inservice education as necessary to support the overall program. (3) Promote screener training by encouraging medical officers to see patients jointly with the screeners. 7. BACKGROUND. The ADTMC serves several purposes within the Army health care system.
a. The ADTMC system provides rapid high quality medical care to the AD Soldier. Screening by
TMC or BAS personnel is a key component of the ADTMC system. When done properly, it ensures that
Soldiers reporting to sick call are expeditiously routed to the appropriate medical care provider. When
4

MEDCOM Pam 40-7-21 done improperly, it can harm the Soldier by providing him inappropriate treatment or directing him to an inappropriate provider.
b. The ADTMC also provides medics with further training in medical care of Soldiers. Medic familiarity with acute medical conditions is enhanced by the ongoing feedback they receive from providers as part of the audit process. Increased knowledge of acute medical conditions better prepares medics for military missions in austere environments.
8. USE OF ADTMC.
a. The treatment protocols in the ADTMC system are applicable only to the care of the AD Soldier.
b. The mission of screening is to gather data about the patient's problem, provide minor medical treatment or self-care regimens in accordance with treatment protocols, or refer patients to the appropriate care provider with the appropriate urgency.
c. Screening begins when the patient walks into the TMC or BAS.
d. Screeners can render minor medical care, as incorporated in the algorithms in this pamphlet, only in TMCs, BASs, or in sick call settings.
e. The use of ADTMC (or other approved algorithmic system) is optional only when a physician, PA, or other qualified provider personally provides the evaluation, treatment, and disposition of all patients.
f. The use of ADTMC (or other approved algorithmic system) is mandatory when screening personnel provide the evaluation, treatment, and/or disposition of AD sick call patients.
g. Screeners may be approved to dispense the over-the-counter medications addressed in appendix B. Additions requested for use at the local level are authorized only if formal, documented training related to the safe and appropriate use of these medications has occurred and if they have local
Pharmacy and Therapeutic committee and commander approval.
h. Documentation of the care provided by ADTMC screeners will be on Department of the Army (DA)
Form 5181 (Screening Note of Acute Medical Care) or like form.
i. PI measures will be conducted in accordance with AR 40-68 and paragraph 13 of this pamphlet.
j. The basic premise of including treatment protocols in the algorithms is that AD Soldiers requiring health care can often be effectively treated with self-care regimens.
k. Active feedback on screener performance by supervising providers will increase medic knowledge of acute medical conditions which better prepares them for their deployed mission.
9. ASSIGNMENT OF SCREENERS.
a. Screening personnel (enlisted or civilian) assigned for duty in various clinic settings are permitted to utilize the ADTMC (or comparable system) to screen AD Soldiers during daily sick call activities.
b. The qualifications of personnel to perform screener functions can vary depending on educational background, experience, and motivation. Personnel assigned to a health care facility should not automatically be identified as screeners. Supervisors are responsible for the identification and evaluation of personnel considered as potential screeners.

5

MEDCOM Pam 40-7-21
10. TRAINING. Screeners must complete a formal training program prior to being assigned to evaluate, treat, and/or make disposition of AD Soldiers who present for care.
11. SUPERVISION. Screeners will be supervised by a physician, PA, or other qualified provider specifically assigned this responsibility.
12. RECORDING ENCOUNTERS. DA Form 5181, or like form, is for use in recording the AD patient encounter. The form is available electronically through Army Medical Department E forms system.
General instructions for use are in AR 40-66. Appendix C of this pamphlet provides special instructions for use with the ADTMC.
13. PERFORMANCE IMPROVEMENT.
a. Evaluation of screeners’ performance will be by a physician, PA, or other qualified provider specifically assigned this responsibility.
b. Screening activities of ADTMC (or comparable system) will be integrated into the local facility’s PI structure. PI activities will include, but not be limited to, the following, as required by AR 40-68:
(1) DA Form 5181 (or like form) will be reviewed on a daily basis.
(2) There will be monthly visits by the appropriate department/service chief to all clinics utilizing
ADTMC to ensure compliance with the requirements of this pamphlet. This oversight responsibility may not be delegated.
c. The supervisor will analyze these evaluations for patterns or trends related to specific performance issues for which additional training, education, or more formal corrective action may be required.
14. FLIGHT/DIVING/PERSONNEL: PERSONNEL RELIABILITY PROGRAM STATUS.
a. Only flight surgeons and/or aeromedical PAs (APAs) can perform treatment and disposition of flight personnel. When aircrew (aviation personnel) receive treatment from personnel other than a flight surgeon or an APA, the aircrew member's unit commander must receive a recommendation for grounding using DA Form 4186 (Medical Recommendation For Flying Duty). Only a flight surgeon may return aviation personnel to flying duty.
b. All Personnel Reliability Program (PRP) personnel will be seen by a physician, PA, or other provider privileged to see personnel on PRP status.
15. TRADE NAMES. The use of trade names in this pamphlet is for clarity only. It does not constitute endorsement by the Department of Defense. Screeners may not be familiar with the generic names for self-care medications; therefore, to expedite health care delivery, familiar brand names have been substituted. 16. LOCAL MODIFICATION OF PROTOCOLS.
a. There must be strict adherence to the standardized protocols contained in this pamphlet.
Personnel will not make modifications or changes to the algorithms and self-care protocols (SCPs) except as described in subparagraph b below.
b. Screeners may modify the referral/provider category disposition to meet local requirements without approval if the disposition is to an equal or higher category than the category designated in the manual.

6

MEDCOM Pam 40-7-21
17. LOCAL REPRODUCTION OF PAMPHLET. This pamphlet, including all parts, is authorized for local reproduction. 18. USE OF SYSTEMS OTHER THAN ADTMC. If a system other than the ADTMC is being considered for use, it cannot be used until approved by the U.S. Army Medical Command, ATTN: MCHO-CL-C,
2050 Worth Road, Fort Sam Houston, TX 78234-6010.

7

MEDCOM Pam 40-7-21

APPENDIX A
SCREENER’S MANUAL

8

MEDCOM Pam 40-7-21

ALGORITHMS
1. Possible dispositions of the screening algorithm are summarized as follows:
CATEGORY/LEVEL

PROVIDER SKILL LEVEL

I. PHYSICIAN STAT (MD STAT)

A medical problem exists which may be life threatening
(an emergency) requiring the immediate attention of a physician. First aid should be initiated and ambulance transportation called for if a physician is not immediately available. The scope of practice of a TMC or BAS is normally inadequate to care for these patients. The goal is to care for these patients in a facility (usually an emergency center) capable of providing advanced cardiac and trauma life support.

II. PA STAT

A medical problem exists which may develop into a life threatening emergency if not evaluated on a priority basis by a physician, PA, or other qualified provider.

III. PA TODAY

A medical condition exists which requires PA evaluation.
Findings will be recorded on DA Form 5181. Data may be obtained by an ADTMC screener, but the medical officer will ultimately make the disposition.

IV. SELF-CARE PROTOCOL (SCP)

A health condition exists for which self care is appropriate. The instructions and medications to be offered the patient are contained within the body of the protocol. EITHER THE PATIENT OR SCREENER MAY
ELECT TO OVERRULE THIS RECOMMENDATION OF
SELF CARE.
If the patient refuses the SCP, he will be referred to and be seen by a medical officer.

V. HOSPITAL CLINIC REFERRAL

A medical condition exists which wiIl be appropriately evaluated in a specialty or subspecialty clinic.
Consultation with either the PA or the supervising physician is required. When an appointment is not available within the time frame specified by the algorithm, the patient will be referred to Level III, PA
TODAY.

NOTE TO SCREENER: IF FOR ANY REASON YOU FEEL THAT THE DISPOSITION OF THE
PATTENT AS DETERMINED BY THE ALGORITHM IS INAPPROPRIATE, CONSULT THE PA OR
PHYSICIAN. RULE OF THUMB: WHEN IN DOUBT, CONSULT; IF YOU HAVE DIFFICULTY
CONSULTING, REFER! IT IS BETTER TO OVER CONSULT OR OVER REFER THAN TO TAKE THE
SLIGHTEST CHANCE WITH YOUR PATIENTS.
2. Questions concerning the disposition instructions for any particular patient should be referred to the supervising physician who is the responsible individual for all aspects of medical care within the unit.

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MEDCOM Pam 40-7-21
3. The medications to be dispensed by the screener in conjunction with the SCPs are contained in appendix B. Substitution of generic equivalent medications is permitted; however, this does not constitute authority for the addition or deletion of any categories of self-care medications.
ADDITIONAL PATIENT CARE NOTES:
1. During acute outbreaks of acute respiratory disease , basic trainees with temperatures greater than
100OF must be treated in accordance with local standing operating procedures (SOPs), not by algorithmic logic. The period most commonly associated with this problem is January through May; however, outbreaks may occur at any time.
2. Any patient returning to the TMC/BAS for the same complaint/problem that is not improving will, in all cases, be referred to a medical officer.
3. Associated complaints identified by an asterisk (*) and boldfaced type must be screened with the appropriate algorithm(s).
4. First aid measures indicated will be performed by trained personnel.
5. Where lab tests are indicated, local SOPs will be utilized. X-rays will only be ordered by a medical officer. 6. When the algorithm calls for obtaining a stool sample and performing a hemoccult test, and the patient cannot produce a stool sample, or if a rectal exam is necessary, refer the patient to the medical officer.
7. The complaint-specific vital signs are listed in the upper left comer of each algorithm. Additional vital signs may be indicated or required by local SOP but should not be taken during sorting. The end level care provider (i.e., medical officer or screener) will take these additional vital signs.
8. Procedures that require privileging (e.g., setting fractures, minor surgery, etc.) will be accomplished only by personnel appropriately trained and privileged in accordance with AR 40-68.

10

MEDCOM Pam 40-7-21
CONTENTS
Page
a. EAR, NOSE, AND THROAT (ENT) COMPLAINTS.
A-1 Sore Throat
A-2 Ear Pain/Discomfort/Drainage
A-3 Cough
A-4 Sinus Problems/Pain
A-5 Runny/Stuffy Nose
A-6 Allergy/Hay Fever
A-7 Cold
A-8 Ringing in the Ears (Tinnitus)
A-9 Wax Blockage in Ear
A-10 Hearing Problem (Loss)
A-11 Foreign Body in Ear or Nose
A-12 Ear or Nose Trauma
A-13 Hoarseness/Laryngitis
A-14 Nosebleed (Epistaxis)

16, 17
18, 19
20, 21
22, 23
24, 25
26, 27
28, 29
30, 31
32
32
32
32, 33
34, 35
37-39

b. MUSCULOSKELETAL COMPLAINTS.
B-1 Back Pain
B-2 Extremity Pain/Joint Pain
(Shoulder, Elbow, Wrist,
Hand, Hip, Knee, Ankle, or Foot)
B-3 Extremity Pain Not Associated with a Joint
B-4 Generalized Muscle Aches
(Not Joint or Low Back Pain)
B-5 Neck Pain

42, 43

45-47
49-51
52, 53
54, 55

c. GASTROINTESTINAL (GI) COMPLAINTS.
C-1
C-2
C-3
C-4
C-5

Nausea/Vomiting/Diarrhea
Abdominal Pain
Rectal Pain/Itching/Bleeding
Constipation
Difficulty When Swallowing
(Dysphagia)

59-62
64-66
69-71
72, 73
74, 75

d. CARDIORESPIRATORY COMPLAINTS.
D-1 Shortness of Breath
D-2 Chest Pain
D-3 Wheeze

78, 79
81-83
84, 85

e. GENITOURINARY COMPLAINTS.
E-1 Painful Urination (Dysuria)
Frequent Urination
E-2 Blood in Urine (Hematuria)
E-3 Testicular Pain
E-4 Problems in Voiding

88-89
90, 91
92, 93
94, 95
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MEDCOM Pam 40-7-21
Page
E-5 Urethral Discharge (Male)
E-6 Sexually Transmitted Disease (STD)

97
98, 99

f. NEUROPSYCHIATRIC COMPLAINTS.
F-1
F-2
F-3
F-4
F-5
F-6

Dizziness/Faintness/Blackout
Headache
Numbness/Tingling
Paralysis/Weakness
Drowsiness/Confusion
Depression/Nervousness/Anxiety/Tension

102-105
106-109
110, 111
113 -115
116, 117
118, 119

g. CONSTITUTIONAL COMPLAINTS.
G-1 Fatigue
G-2 Fever/Chills

122, 123
124, 125

h. EYE COMPLAINTS.
H-1 Foreign Body in Eye/Eye Injury/Eye Pain/
Itching/Discharge/Redness
H-2 Eyelid Problem
H-3 Decreased Vision
H-4 Seeing Double (Diplopia)
H-5 Seeing Spots
H-6 Request for Eyeglasses Only

128, 129
130, 131
132, 133
134, 135
136, 137
138, 139

i. GYNECOLOGY (GYN) COMPLAINTS.
I-1
I-2
I-3
I-4
I-5
I-6
I-7
I-8
I-9

Breast Problems
Suspects Pregnancy
Menstrual Problems
Vaginal Discharge, Itching,
Irritation, or Pain
Vaginal Lump, Mass, or Sore
Pelvic Pain
Vaginal Bleeding
Request for PAP or Routine Pelvic Examination
Request for Information on Contraception

142, 143
144, 145
146, 147
148, 149
150
152, 153
155-157
158, 159
160, 161

j. DERMATOLOGICAL COMPLAINTS.
J-1 Unknown Cause of Skin Disorder/Complaint
J-2 Acne
J-3 Shaving Problem-Pseudofolliculitis
Barbae (PFB) (Ingrown Hairs)
J-4 Dandruff (Scaling of the Scalp)
J-5 Hair Loss
J-6 Athlete’s Foot (Tinea Pedis)
J-7 Jock Itch (Tinea Cruris)
J-8 Scaling, Depigmented Spots on Chest, Back, and Upper Arms (Tinea Versicolor)
J-9 Boils
12

164, 165
166, 167
168, 169
170, 171
172, 173
174, 175
176, 177
178, 179
180, 181

MEDCOM Pam 40-7-21
Page
J-10
J-11
J-12
J-13
J-14
J-15
J-16
J-17
J-18

Fever Blisters (Cold Sores)
Skin Abrasions
Skin Laceration
Suture Removal
Drug Rash
Bums
Friction Blisters on Feet
Corns on Feet
Plantar Warts/Ingrown Toenail

182, 183
184, 185
186, 187
188
189, 190
192, 193
195-197
198, 199
200

k. ENVIRONMENTAL INJURY COMPLAINTS.
K-1 Heat Injury/Hyperthermia (Heat Cramps, Heat
Exhaustion, (Heat Stroke)
K-2 Hypothermia
K-3 Immersion Foot
K-4 Chapped Skin/Windburn
K-5 Frostbite
K-6 Crabs/Lice (Pediculosis)
K-7 Insect Bites (Not Crabs/Lice)
K-8 Sunburn
K-9 Contact Dermatitis (Includes Plants--Poison Ivy,
Oak, and Sumac)

202, 203
204, 205
206, 207
208, 209
210, 211
212, 213
214, 215
216, 217
218, 219

l. MISCELLANEOUS COMPLAINTS.
L-1
L-2
L-3
L-4
L-5
L-6
L-7
L-8
L-9

Prescription Refill
Wants a Vasectomy
Needs an Immunization
Exposed to Hepatitis
Dental Problems
Sores in the Mouth
Lymph Node Enlargement
Blood Pressure Check
Preparation of Replacements (POR) for Overseas
Movement Qualification
L-10 Weight Reduction
L-11 Complaint Not on List
L-12 Request for Nonprescription Medication

222, 223
225
226, 227
228, 229
230, 231
232
234, 235
236, 237
238
240, 241
242, 243
244, 245

m. MISCELLANEOUS REASONS FOR RETURN.
M-1 Showing No Signs of Improvement (Not
Getting Better)
M-2 Return Requested by Care Provider

13

248, 249
250, 251

MEDCOM Pam 40-7-21

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MEDCOM Pam 40-7-21

EAR NOSE AND THROAT COMPLAINTS
*Algorithms for

Number

Sore Throat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A-1
Ear Pain/Discomfort/Drainage . . . . . . . . . . . . . . . . . . . . . . . . A-2
Cough . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-3
Sinus Problems/Pain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-4
Runny/Stuffy Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-5
Allergy/Hay Fever . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-6
Cold . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-7
Ringing in the Ears (Tinnitus) . . . . . . . . . . . . . . . . . . . . . . . . . A-8
Wax Blockage in Ear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-9
Hearing Problem (Loss) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-10
Foreign Body in Ear or Nose. . . . . . . . . . . . . . . . . . . . . . . . . . A-11
Ear or Nose Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-12
Hoarseness/Laryngitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-13
Nosebleed (Epistaxis) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A-14

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MEDCOM Pam 40-7-21
SORE THROAT, A-1
IMPORTANT INFORMATION ON THE ALGORITHM
Blocks 1-2. If the patient has a history of recent neck or throat trauma and also has difficulty speaking or swallowing, he may have a significant injury. This patient requires
Category I evaluation.
Blocks 3-4. If the patient is not able to touch his chin to his chest and has an elevated temperature, he may have meningitis and should be evaluated by a medical officer on a priority basis. An inability to swallow should not be confused with difficulty (pain) when swallowing. An inability to swallow is manifested by drooling. If the patient cannot swallow his own saliva, a life-threatening illness may be present. Category I referral is necessary. Block 5. Difficulty (painful) when swallowing is common with a sore throat and is not a cause for immediate concern. Fever, exudate (pus) on the tonsils, or swollen tonsils, may or may not indicate a strep throat requiring antibiotic treatment. However, if any one of these three symptoms is present, the patient should be referred as Category III.
Asymmetrical tonsils may indicate peritonsillar abscess requiring Category II referral.
Block 6. An inability to clear the ears may indicate an inflammation of the eustachian tubes. This condition makes the patient susceptible to a middle ear infection. (The eustachian tube extends from the middle ear to the nasopharynx.) If this problem exists, the individual needs further evaluation.
TREATMENT PROTOCOL A-1(6)
1. Aspirin or Tylenol and Chloraseptic gargles or Cepacol lozenges may be provided to relieve the pain. Ensure the patient understands directions for use. Gargling with salt water (1/4 teaspoon of salt in 1 cup warm water) may also help.
2. Instruct the patient to return for medical assistance if the sore throat has shown no signs of improvement after 3 days of the above treatment or if the above signs or symptoms (temperature greater than 101O F, stiff neck, or an inability to swallow) develop. 16

MEDCOM Pam 40-7-21
SORE THROAT, A-1

Take complaint-specific vital sign:
Temperature

Associated Complaints:
Sinus problem
*
Allergy/hay fever
Runny/stuffy nose
Fever
Headache
Muscle aches
Hoarseness

1
Fe
Is there a history of recent throat or neck trauma?
Yes
Fever
No

2
Does the patient have difficulty speaking or swallowing? Yes
No

3
Can the patient touch his
Category II chin to his chest?
Yes
No

4 o Is his temperature 100 F or higher or is the patient unable to swallow?
Determine ability to swallow by observing the patient.
Yes
No

Stabilize the patient’s head and neck. Refer him as Category I.

Category I

5
Does he have asymmetric tonsils? Yes
No

Does he have temperature of o 101 F or higher, pus on tonsils, or swollen tonsils?
Yes to any
No to all

Category III
Obtain throat culture

Category II

Obtain throat culture

Category III
6
Can the patient clear both his ears? Yes
No

*Category IV, Treatment
Protocol A-1(6)
*NOTE: If the patient has already tried the treatment protocol or if he will not accept it, enter Category III as the disposition.

Screen for Ear Pain/Discomfort/
Drainage, A-2

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MEDCOM Pam 40-7-21

EAR PAIN/DISCOMFORT/DRAINAGE, A-2
IMPORTANT INFORMATION ON THE ALGORITHM
Blocks 1-2. Ear infections can be complicated by meningitis. A stiff neck and fever are signs of this complication. ALL PATIENTS WITH A STIFF NECK SHOULD SEE A
MEDICAL OFFICER.
Block 3. Patients with true vertigo require evaluation for an inner ear problem.
Block 4. Patients with ear drainage, pain, and decreased or sudden hearing loss, or discomfort without incapacitating vertigo but with a temperature of over 101oF require evaluation by a medical officer. They may need antibiotic treatment for a middle ear infection. Block 5. Patients without a fever whose complaint is associated with flu symptoms may try self care for their ear problem. This condition does not require antibiotics. Patients with ear drainage without vertigo, fever, and associated cold or flu symptoms may have an infection in the ear canal requiring medication and should be referred as Category III.
TREATMENT PROTOCOL A-2(5)
1. Provide the patient with a decongestant and aspirin or Tylenol and directions for the use of each medication. Teach the patient to do the modified Valsalva maneuver every
2 hours to attempt to clear the ears.
2. If the patient has a sore throat, provide him with Chloraseptic gargles or Cepacol lozenges. Gargling with salt water (1/4 teaspoon of salt in 1 cup warm water) may also help. 3. Instruct the patient to return for medical assistance if–
Dizziness develops.
His/her temperature goes above 101oF.
The ear pain is so severe as to preclude duties or activities.
There is no improvement within 24 hours.

18

MEDCOM Pam 40-7-21
EAR PAIN/DISCOMFORT/DRAINAGE, A-2

Take complaint-specific vital sign:
Associated Complaints:

Temperature

Tinnitus
Runny/stuffy nose
Allergy/hay fever
Sinus problem
Fever
Headache
Vertigo/dizziness
Stiff neck

1
Can the patient touch his
Fever
chin to his chest?
Yes
No

3a
Does he have vertigo?
Yes
NoCategory II

4

2
Is his temperature o 100 F or higher; does he have a stiff neck?
Yes to either
No to both

Category II

Category II
3b
Does he have vertigo?
Yes
No

Category II

o

Is his temperature 101 F or higher? Does he have decreased hearing and pain? Does he have discomfort with vertigo?
Yes to any
No to all

5
Are the symptoms associated with cold/flu symptoms? Yes
No

Category III

Category III

*Category IV, Treatment
Protocol A-2(5)

*NOTE:

If the patient has already tried the treatment protocol or if he will not accept it, enter Category III as the disposition Category III

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MEDCOM Pam 40-7-21
COUGH, A-3
IMPORTANT INFORMATION ON THE ALGORITHM

Block 1. Shortness of breath at rest indicates severe respiratory distress and requires immediate evaluation.
Block 2. Patients coughing up rusty/blood-streaked sputum or thick sputum with each cough require referral as Category III. Obtain a sputum sample for gram stain and gross evaluation before referral.
Block 3. In patients with temperatures of 101OF or greater, the presence of a cough may indicate an infection in the lungs and the patient should be referred as Category III.
Patients who are coughing without shortness of breath, bloody sputum, or fever over
101oF may appropriately be given self care. Their symptoms will probably go away without further intervention.
TREATMENT PROTOCOL A-3(3)
1. The most frequent causes of coughs are colds, flu, smoking, and allergies. Provide the patient with an expectorant and instructions for its use.
2. Advise the patient that:–
Smoking should be kept to a minimum.
Sucking on a cough drop or piece of hard candy may help decrease the tickle in the back of the throat.
3. Instruct the patient to return for medical assistance if–
The cough lasts longer than 2 weeks.
Large amounts of thick sputum come up with each cough.
Fever, shortness of breath, or pain develops while breathing.

20

MEDCOM Pam 40-7-21
COUGH, A-3
Take complaint-specific vital signs:
Associated Complaints:
Fever
Runny/stuffy nose
Allergy/hay fever
* Shortness of breath
Muscle aches
Cold
* Ear pain
* Sore throat
* Chest pain

Temperature

Respiration rate

1
Is the patient short of breath while at rest? (Determine the answer by observing the patient.*) Yes
No

2
Is he coughing up rusty or bloodstreaked sputum or sputum with every cough?
Yes
No

3 o Is his temperature 101 F or greater? Yes
No

Begin oxygen

Category II

Obtain sputum gross evaluation and gram stain

Category III

Category III

**Category IV, Treatment Protocol A-3(3)

*Note: Shortness of breath at rest is defined as an increased respiratory rate that does not decrease within 3 to 5 minutes rest.
**Note: If the patient has already tried the treatment protocol or if he will not accept it, enter Category III as the disposition.

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MEDCOM Pam 40-7-21
SINUS PROBLEMS/PAIN, A-4
The patient with a runny nose or stuffiness of the head may or may not have a sinus problem. IMPORTANT INFORMATION ON THE ALGORITHM
Blocks 1-3. Patients unable to touch their chin to their chest, who have fever, or who have difficulty answering questions should be referred as Category II. They may have serious complications of sinusitis or an upper respiratory infection.
Blocks 4-5. Patients with a temperature over 101oF, with yellow/green or foul-smelling nasal discharge, or dental pain should be referred as Category III due to the possibility that a sinus infection requiring antibiotic treatment exists. Patients without these findings will probably respond to self-treatment.
TREATMENT PROTOCOL A-4(5)
1. Tell the patient that the questions you asked have ruled out the likelihood of a serious problem and that self-treatment should alleviate the symptoms.
2. Provide the patient with a decongestant/nasal spray and aspirin/Tylenol. Ensure the patient understands directions for use.
3. Instruct the patient to return for medical assistance if the above signs or symptoms
(temperature exceeds 101oF, facial pain, dental pain, purulent nasal discharge, altered mental status, or stiff neck) develop or do not begin to resolve themselves within 3 days.

22

MEDCOM Pam 40-7-21
SINUS PROBLEMS/PAIN, A-4
Take complaint-specific vital sign:
Temperature
1
Can the patient touch his chin to his chest?
Yes
Fever
No

3
Is the patient having difficulty answering simple questions or
Category II is he disoriented?
Yes to either
No to both

4 o Is his temperature 101 F or higher? Yes
No

2
Is his temperature o greater than 100 F?
Yes
No

Category II

Category II
Category III

Take all vital signs.

Category III

5
Does the patient have a rusty,
*
yellow/green colored, or foulsmelling nasal discharge?
Yes to any
No to all

Category III

*Category IV, Treatment Protocol A-4(5)
*NOTE: If the patient has already tried the treatment protocol or if he will not accept it, enter Category III as the disposition.

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MEDCOM Pam 40-7-21
RUNNY/STUFFY NOSE, A-5
A runny/stuffy nose generally indicates a simple cold but may also result from allergies.
The following indicate more serious disease and require evaluation by a medical officer:
a. Symptoms are not resolved with treatment.
b. Discharge has a foul odor.
c. Discharge is rusty or yellow/green colored.

TREATMENT PROTOCOL A-5
1. Provide the patient with either a nasal decongestant or an antihistamine as indicated by his symptoms. Ensure the patient understands the directions for use.
2. Instruct the patient to return for medical assistance if–
He develops fever.
He develops facial pain.
His nasal discharge becomes rust or yellow/green colored.
He cannot perform his duties.

24

MEDCOM Pam 40-7-21
RUNNY/STUFFY NOSE, A-5
Take complaint-specific vital sign:
Associated Complaints:
Sinus Problem
Fever
Allergy/hay fever
Muscle aches
Hoarseness
*
Sore throat

Temperature

Does the patient have rusty yellow/greenish, or foulsmelling nasal discharge?
(Observe the discharge; do not use the patient’s interpretation alone.)
Yes
No

Category III

*Category IV, Treatment Protocol A-5

*NOTE: If the patient has already tried the treatment protocol or if he will not accept it, enter Category III as the disposition.

25

MEDCOM Pam 40-7-21
ALLERGY/HAY FEVER, A-6
Specific allergy/hay fever complaints include “itchy and watery” eyes or a runny or stuffy nose with sneezing. These are very common complaints. Patients who are specific about having an allergy or hay fever do not require further evaluation.
TREATMENT PROTOCOL A-6
1. Provide the patient with an antihistamine. Visine eyedrops may also be provided if the patient complains of “itchy and watery” eyes. Ensure the patient understands the directions for use and has been cautioned about drowsiness and the major side effects of antihistamines.
2. Instruct the patient to return for medical assistance if–
He develops fever.
He develops facial pain.
He develops redness of eyes or eye discharge.
His nasal discharge becomes rust or yellow/green colored.
He cannot perform his/her duties.

26

MEDCOM Pam 40-7-21
ALLERGY/HAY FEVER, A-6
Associated Complaints:
Runny nose/stuffy nose
*Sinus problem

The patient complains of allergy/hay fever symptoms. Refer patient as Category IV,
Treatment Protocol A-6.
*NOTE: If the patient has already tried the treatment protocol or if he will not accept it, enter Category III as the disposition.

27

MEDCOM Pam 40-7-21
COLD, A-7
People mean different things when they say, " I have a cold.” Most people who complain of having a cold have just that and will get better even if they receive no medication. However, some people who think they have a cold may actually have allergies, influenza (flu), strep throat, pneumonia, or even meningitis. Do not assume that everyone complaining of a cold is correct in his/her self diagnosis. Adherence by screeners to the screening manual significantly decreases the chances of overlooking a severe underlying illness that was mistakenly called a cold. ALL PATIENTS WITH A
STIFF NECK SHOULD SEE A MEDICAL OFFICER.
Screeners can best determine the patient’s specific complaint by asking, “What do you mean by a cold?” If his/her complaint can be screened by another algorithm, use that algorithm, especially if it is one of the associated complaints indicated by bold type.
If the patient’s complaint remains vague or general, use the Cold Algorithm, A-7. This algorithm is a combination of algorithms used to evaluate the most common symptomatic complaints associated with colds.
TREATMENT PROTOCOL A-7(5)
1. Make the patient more comfortable by giving him the appropriate medications, such as an antihistamine for a runny nose or a decongestant for congestion, and aspirin or
Tylenol for minor aches and pains.
2. Instruct the patient to return if he develops a temperature greater than 101oF , a productive cough, or if his symptoms do not begin to improve within the next several days. 28

MEDCOM Pam 40-7-21
COLD, A-7
Take complaint-specific vital sign:
Associated Complaints:
Temperature

*

Fever
Runny/stuffy nose
Sinus problems
Allergy/Hay fever
Shortness of breath
Muscle aches
Ear pain

*

Cough
Sore throat

*
*

1
Can the patient touch his chin to his chest?
Yes
No

3
Is he coughing up rusty or blood-streaked sputum or thick sputum with each cough? Yes to either
No to both

4
Is his nasal discharge yellow/green, or does it have a foul odor?
Yes
No

5
Is his temperature greater o than 101 F?
Yes
No

2
Is his temperature greater than o 100 F? Does he have a stiff neck? Yes to either
No to both

Category II

Category III
Category III

Category III

Category III

*Category IV, Treatment
Protocol A-7(5)
*NOTE: If the patient has already tried the treatment protocol or if he will not accept it, enter Category III as the disposition,

29

MEDCOM Pam 40-7-21
RINGING IN THE EARS (TINNITUS), A-8
IMPORTANT INFORMATION ON THE ALGORITHM
Block 1. Vertigo or “room-spinning dizziness” can be a symptom of inner ear problems and is often associated with nausea. Distinguish vertigo from light-headedness which is screened separately. (See Dizziness/Faintness/Blackout, F-1.)
Block 2. If the ringing noise is an associated symptom of a cold or flu, it should be screened by the algorithm that addresses that primary complaint.
Block 3. Ringing in the ears, if without loss of balance, is not uncommon especially following recent exposure to loud noises from situations such as weapons firing or riding in mechanized vehicles or aircraft. Generally, the ringing in the ears associated with such noises subsides within 24 hours, but may persist in persons who have long histories of exposure. Further examination is indicated in the absence of exposure to excessive noise or for symptoms lasting longer than 24 hours. Ringing in the ears, if without loss of balance, can be associated with certain medications such as aspirin, nonsteroidal anti-inflammatory agents, some diuretics, etc. It is also important to check for hearing on the follow-up visit.
TREATMENT PROTOCOL, A-8(3)
1. Advise the patient that tinnitus due to recent noise exposure should show improvement over the next 24 hours.
2. Instruct the patient to return for medical assistance if ringing does not improve or if dizziness, ear pain, or hearing loss develops.
3. Remind the patient to always use the proper hearing protection when exposed to noise. 30

MEDCOM Pam 40-7-21
RINGING IN THE EARS (TINNITUS), A-8
Take complaint-specific vital signs:
Associated Complaints:

Temperature
Blood Pressure

*
*

Runny/stuffy nose
Allergy/hay fever
Sinus problems
Fever
Dizziness/faintness
Hearing loss

Treatm(3)(5) and
1
Are the patient’s symptoms associated with vertigo?
Yes
No

2
Is the ringing the patient hears associated with ear pain, drainage, or flu/cold symptoms? Yes
No

3
Has the patient been exposed to excessive noises in the past 24 hours?
Yes
No

Screen by Ear Pain/Discomfort/Drainage, A-2

Screen other symptoms.

*Category IV, Treatment Protocol A-8(3)

*Category III
Document any medications (aspirin, nonsteroidal anti-inflammatory agents {Motrin, Advil, etc.} diuretics (Lasix, Diuril, etc.)

*NOTE: If the patient has already tried the treatment protocol or if he will not accept it, enter Category III as the disposition,

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MEDCOM Pam 40-7-21
WAX BLOCKAGE IN EAR, A-9
If a patient complains of hearing loss because of ear wax, distinguish a true complaint of hearing loss from that of bothersome wax. Both should be referred as Category III.
HEARING PROBLEM (LOSS), A-10
If a patient complains of decreased hearing, refer him as Category III. The medical officer will examine the ears and make the appropriate disposition. Many cases of decreased hearing are simply due to simple colds; other cases may need audiological testing. NOTE: Tinnitus (ringing in the ears) and ear pain are screened separately.
FOREIGN BODY IN EAR OR NOSE, A-11
If the patient complains of a foreign body in either his ear or nose, refer him as Category
III. Foreign bodies can best be removed in the treatment area/clinic or emergency center where the equipment necessary for removal is available.
EAR OR NOSE TRAUMA, A-12
Cuts, swelling, a deformity, or hearing loss secondary to trauma are evaluated by the medical officer.

32

MEDCOM Pam 40-7-21
EAR OR NOSE TRAUMA, A-12

1
Does the patient have cuts, swelling, or a deformity of the ear or nose?
Yes
No

2
Does the patient have a hearing loss?
Yes
No

Category II
*

Category III

*Category IV, Treatment
Protocol A-4(5)

*NOTE: If the patient has already tried the treatment protocol or if he will not accept it, enter Category III as the disposition.

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MEDCOM Pam 40-7-21
HOARSENESS/LARYNGITIS, A-13
If the patient complains of a sore throat in addition to hoarseness/laryngitis, the sore throat algorithm should be used.
IMPORTANT INFORMATION ON THE ALGORITHM
Block 1. Laryngitis or hoarseness associated with a cold or an upper respiratory infection (URI) within the last 10 days should be treated with self care.
Block 2. Laryngitis or hoarseness is frequently associated with heavy smoking and can be treated by decreasing smoking and self care.
Block 3. Laryngitis present for more than 10 days requires further medical evaluation to rule out serious underlying causes for this disorder. Self care is appropriate for patients whose laryngitis or hoarseness has been present less than 1 week and who have no other associated symptoms.
TREATMENT PROTOCOL A-13(1)(2)(3) Ill
1. There is no medication that will make hoarseness go away. Resting the vocal cords totally and reducing irritants (chiefly cigarette smoke) will help. If the patient must speak, he should vocalize as normally as possible. Merely reducing voice tones is difficult and strenuous. The patient may find some relief by sucking on a piece of hard candy, drinking water, or gargling with warm salt water.
2. Instruct the patient to return for medical assistance if symptoms persist for 1 week or longer. If hoarseness becomes associated with a breathy voice, difficulty in breathing, or by a choking sensation, the patient should return immediately.

34

MEDCOM Pam 40-7-21
HOARSENESS/LARYNGITIS, A-13
Take complaint-specific vital sign:
Associated Complaints:
*
Sore throat

Temperature

*

1
Has the patient had a cold or the flu in the past 10 days?
Yes
No

*Category IV, Treatment
Protocol A-13(1)(2)(3)

2
Are the patient’s complaints associated with smoking?
Yes
No

Runny nose
Fever
Muscle aches
Sinus problem
Allergy/hay fever

*Category IV, Treatment
Protocol A-13(1)(2)(3)

3
Has he had the symptoms for more than 1 week without improvement? Yes
No

Category III

*Category IV, Treatment
Protocol A-13(1)(2)(3)

*NOTE: If the patient has already tried the treatment protocol or if he will not accept it, enter Category III as the disposition.

35

MEDCOM Pam 40-7-21

36

MEDCOM Pam 40-7-21
NOSEBLEED (Epistaxis), A-14
Nosebleeds normally result from the rupture of small blood vessels inside the nose.
IMPORTANT INFORMATION ON THE ALGORITHM
Block 1. Patients who have had trauma to the nose with an associated nosebleed should be screened according to the Nose Trauma Algorithm, A-12 after the bleeding is controlled. Block 2. Patients who have a nosebleed that is easily controlled but with a history of hypertension should be referred as Category III to have their blood pressure checked after the bleeding is controlled.
Block 3. Patients with bleeding may undergo self-treatment to stop the bleeding.
Failure of the bleeding to stop will require treatment in the emergency center or the ear, nose, and throat (ENT) clinic.
Block 4. A history of nosebleeds with associated cold or hay fever symptoms is not uncommon; these problems can cause nosebleeds. The patient should undergo self treatment for cold/hay fever symptoms as this will probably control the nosebleeds. In the absence of a history of cold/hay fever symptoms, failure of self-treatment should result in a referral to the ENT clinic.
Block 5. Some patients may have a bleeding disorder and this needs to be ruled out in persistent bleeders.

37

MEDCOM Pam 40-7-21
TREATMENT PROTOCOL A-14(1)(3)(5)
1. If the bleeding is not controlled, advise the patient while in the clinic to–
a. Sit up with his head held back, not to lie down.
b. Blow his nose gently to expel mucus and clots.
c. Gently squeeze the nose with the thumb and forefinger just below the hard part of the nose for at least 5 minutes.
2. If bleeding is still not controlled, treatment in the emergency room or ENT clinic is required. 3. If the bleeding is controlled, tell the patient to avoid vigorous blowing of the nose for the next day or two. (If the room air is dry--either from heating or air conditioning--a humidifier or vaporizer often helps.)
4. Instruct the patient to return for medical assistance if the bleeding persists or recurs after trying the above measures and if the amount of blood lost at one time is enough to completely soak a handkerchief (ask the patient to bring in his handkerchief).
TREATMENT PROTOCOL A-14(4)
1. Provide the patient with an antihistamine/decongestant. Ensure the patient understands the directions for use.
2. Instruct the patient not to blow his nose vigorously as this can aggravate the nosebleed. 3. Patients should be instructed to avoid the use of aspirin, aspirin-containing products,
Motrin, or other NSAIDs.
4. Instruct the patient to return for medical assistance if he develops fever, yellow-colored nasal discharge, or if he cannot perform his duties.

38

MEDCOM Pam 40-7-21
NOSEBLEED (Epistaxis), A-14
Take complaint-specific vital sign:
Associated Complaints:
Runny nose
*
Sinus problems
Allergy/hay fever
Fever
Muscle aches

Blood Pressure

1
Does the patient have a historyFever trauma of recent to the nose?
Yes
No

Treatment Protocol A-14(1)(3)(5) and then screen as Ear or Nose Trauma A-12.

2
Does he have a history of hypertension? Yes
No

Category III

3
Is he bleeding now?
Yes
No

*Category IV, Treatment Protocol
A-14(1)(3)(5).

4
Is the nosebleed associated with a cold or hay fever?
Yes
No

*Category IV, Treatment Protocol
A-14(4).

*Category IV, Treatment Protocol A-14(1)(3)(5), paragraph 3.

5
Does the patient have frequent nosebleeds?
Yes
No

*Category IV, Treatment
Protocol A-14(1)(3)(5).

*NOTE: If the patient has already tried the treatment protocol or if he will not accept it, enter Category III as the disposition.

*Category IV, Treatment Protocol
A-14(1)(3)(5), paragraph 4.

39

MEDCOM Pam 40-7-21

40

MEDCOM Pam 40-7-21
MUSCULOSKELETAL COMPLAINTS
*Algorithms for

Number

Back Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B-1
Extremity Pain/Joint Pain (Shoulder, Elbow, Wrist,
Hand, Hip, Knee, Ankle, or Foot) . . . . . . . . . . . . . . . . B-2
Extremity Pain Not Associated with a Joint . . . . . . . . . . . . . . B-3
Generalized Muscle Aches (Not Joint or Low-Back Pain) . . . B-4
Neck Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B-5

41

MEDCOM Pam 40-7-21
BACK PAIN, B-1
IMPORTANT INFORMATION ON THE ALGORITHM
Blocks 1-2. Back pain associated with complaints of dysuria (painful or frequent urination in male and female patients), nausea, vomiting, diarrhea, abdominal pain, or flu symptoms would be screened using the appropriate algorithms for those complaints.
Back pain associated with these complaints will usually go away when the underlying cause is properly treated.
Block 3. Back pain associated with fever in the absence of any of the complaints in
Blocks 1 and 2 may have a serious cause and should be evaluated by a medical officer.
Block 4. Back pain associated with pain running down into the legs below the knee may represent a “ruptured disc” and requires evaluation by a medical officer.
Block 5. Back pain associated with direct trauma to the back (meaning that the patient got hit or fell on his back) within the last 72 hours may indicate the presence of a severe back problem that requires evaluation now.
NOTE: In the absence of any of the preceding conditions, self care is appropriate.
111 - TREATMENT PROTOCOL B-1(5)
1. Low back pain is extremely common in Soldiers. The best treatment is aspirin or
Tylenol (two tablets every 4 hours) and ice packs. Provide the patient with aspirin or
Tylenol, analgesic balm, and instructions for ice massage.
2. A bedboard, an extra firm mattress, or sleeping on a mattress on the floor may also be of some help in dealing with low back pain. In general, the best treatment is preventive–an exercise program to strengthen the muscles of the abdomen and back. If available, give the patient a back-problem-exercise handout from the medical treatment facility. 3. Instruct the patient to return for medical assistance if pain becomes so severe as to prevent performance of normal duties/activities or if any of the symptoms become worse. 42

MEDCOM Pam 40-7-21
BACK PAIN, B-1
Take complaint-specific vital sign:
Temperature
1
Is the back pain associated with dysuria and/or
Fever
frequency of urination?
Yes
No hen screen as E ar or Nos

2
Is the back pain associated with nausea, vomiting, diarrhea, or abdominal pain? Yes
No

3
Is the patient’s temperature o 101 F or greater?
Yes
No

4
Does the pain radiate into a leg or both legs below the knee? Yes
No

Screen as Painful Urination (Dysuria)/Frequent Urination, E-1

Screen as Nausea/Vomiting/Diarrhea, C-1 or Abdominal Pain. C-2

Category III

Category III

*
5
Has the patient had back trauma within the past 72 hours? Yes
No

Obtain urine specimen for analysis.

Category II

*Category IV, Treatment Protocol B-1(5)
*NOTE: If the patient has already tried the treatment protocol or if he will not accept it, enter Category III as the disposition.

43

MEDCOM Pam 40-7-21

44

MEDCOM Pam 40-7-21
EXTREMITY PAIN/JOINT PAIN, B-2
(Shoulder, Elbow, Wrist, Hand, Hip, Knee, Ankle, or Foot)
These are very common complaints and screening is designed to separate those patients requiring further evaluation from those who can safely care for themselves.
IMPORTANT INFORMATION ON THE ALGORITHM
Block 1. A history of the occurrence or the absence of trauma in the past 72 hours is important in determining proper treatment. (Trauma includes joint injury due to getting hit, falling on, or twisting.)
Block 2. The absence of pulse, a lack of sensation, or loss of function distal to the injury indicates possible severe injury that might result in loss of an extremity; these patients are sent to a physician on an emergency basis, Category I.
Block 3. Laceration injuries require evaluation and may require closure. Prompt referral to Category II is appropriate.
Block 4. Obvious deformities indicate a fracture, dislocation, or significant sprain and will require referral as Category III after immobilization.
Block 5. Hand injuries have a high potential for disability. All hand injuries should be evaluated by the medical officer.
Block 6. Pain in the ankles, knees, hips, elbows, or shoulders which does not prevent full weight bearing or full range of motion (ROM) of the extremity even though pain is present can be treated by self care.
Block 7. In the absence of trauma, the presence of a temperature greater than
101O F may represent an infection of the joint. Patients with a fever are sent to the medical officer immediately. Patients with swelling and/or redness of a joint should likewise be sent to the medical officer to determine the cause of the inflammation.
Block 8. In the absence of trauma, fever, redness/swelling, or a history of pain lasting less than 3 weeks, self care is appropriate.

45

MEDCOM Pam 40-7-21
TREATMENT PROTOCOL B-2(6)(8)
Most strains and sprains are treated with immobilization, ice, compression, elevation, and analgesia.
1. Advise the patient to avoid or discontinue the activity that may have caused the problem. This may require a temporary profile. Immobilization of the area with an arm sling to rest both shoulder and elbow, an ace bandage to provide support, or a crutch or cane to take weight off the injured extremity may be appropriate. Instruct the patient to work the injured part through its range of motion at least twice each day to preserve mobility. If possible, this is best done after a 20-minute application of ice. The range of motion exercise should not be vigorous enough to cause pain.
2. Provide the patient with aspirin or Tylenol and directions to take two tablets or capsules every 4 hours. If swelling is present, tell the patient that an ice pack should be applied to provide relief. If swelling is not present, you may give the patient analgesic balm to apply in addition to ice massage.
3. Instruct the patient (and record the instructions) to return for medical assistance if:
. The pain continues longer than 3 weeks.
. Swelling worsens rather than improves within the next 24 hours.
. The pain is worse 24 hours after the initial visit.

46

MEDCOM Pam 40-7-21
EXTREMITY PAIN/JOINT PAIN, B-2
(Shoulder, Elbow, Wrist, Hand, Hip, Knee, Ankle, or Foot)
2
Are the distal pulses and sense of touch distal to the injury normal?
Yes
No

1
Has the patient experienced trauma to the joint in the past
Fever
72 hours?
Yes
No

7
Is the patient’s temperature o 101 F or higher or is the effected joint red or swollen?
Yes
No

3
Is a laceration present?
Yes
No
Category II

Immobilize the injured extremity before transporting or referring the patient. Category I
Immobilize the injured extremity before transporting or referring the patient. Category II
4
Is there an obvious deformity present?
Yes
No

Immobilize the injured extremity before transporting or referring the patient. Category II
8
Has the pain been present for 3 weeks or longer?
Yes
No

*Category IV, Treatment
Protocol B-2(6)(8)

Category III

5
Is the pain within the hand? Yes
No

6
Does the pain prevent weight bearing or normal motion? Yes
No

Category III

Category III

Category IV, Treatment
Protocol B-2(6)(8)

*Note: If the patient has already tried the treatment protocol or if he will not accept it, enter Category III as the disposition.

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MEDCOM Pam 40-7-21

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MEDCOM Pam 40-7-21
EXTREMITY PAIN NOT ASSOCIATED WITH A JOINT, B-3
IMPORTANT INFORMATION ON THE ALGORITHM
Block 1. Direct trauma means that the extremity was struck by something such as a baseball bat or car bumper. It does not mean the pain that follows running, jumping, calisthenics, or other strenuous exercise in which a direct blow did not occur.
Block 2. A deformed extremity means the extremity is bent in a place that an arm or leg would not normally bend and may indicate a broken bone requiring immediate evaluation. Block 3. In an arm or leg that has been fractured, the absence of a pulse or the sense of touch distal to the injury may indicate that the arteries or nerves going down the extremity have been injured by the same process that caused the fracture. This is a medical emergency; the patient must be immediately referred as Category I after proper splinting. Block 4. Indirect trauma means no blow was made directly to the sore area. Such pain often follows participation in calisthenics, sports, or other strenuous activity. This pain is often referred to as a “pulled muscle” or a strain. It is usually not serious. Pain in the absence of a history of direct trauma or indirect trauma (recent vigorous activity) may indicate a significant underlying disease requiring further medical evaluation.
Block 5. Pain resulting from participation in strenuous activity, calisthenics, or sports
(over-use syndrome) generally is not serious. However, if the joint distal and/or proximal to the affected area does not function correctly, torn tendons or ligaments or muscles may be the problem requiring immediate evaluation by a medical officer.
Block 6. Calf pain following participation in calisthenics, sports, or other strenuous activity is probably due to overuse. The pain occurs with use of the extremity (kinetic pain). In a few instances, calf pain may indicate a tom Achilles tendon, ruptured blood vessels, ruptured muscle, or blood clots in the calf. This pain will be present when the leg is at rest (static pain) as well as when moved. These conditions can be potentially serious and require referral as Category III.
Block 7. If the pain is severe, the patient may have compartment syndrome; this requires immediate medical attention, Category II.

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TREATMENT PROTOCOL B-3(5)
1. Seldom does minimal direct trauma to an extremity break a bone; however, it can cause considerable local tissue damage with accompanying pain, swelling, redness, and tenderness.
2. Moderate pain can best be controlled with Tylenol or aspirin. It will usually last 3 to 6 days and will lessen with time and rest. Swelling is best controlled by ice applications.
Ace wraps and elevation of the affected area may be indicated.
3. Injuries following this pattern do not require x-rays or further evaluation. The patient should be instructed to return for further evaluation if the pain increases to the point that the normal use of his joints is affected or if a skin color change other than normal bruising is noted.

TREATMENT PROTOCOL B-3(7)
1. The patient is most likely suffering from a “pulled muscle,” (that is, muscle strain).
Pain will continue for several days.
2. Tylenol or aspirin, ice applications (when possible), and analgesic balm will offer pain relief. Instruct the patient to apply the balm to the affected area, as needed.
3. Instruct the patient to return for further evaluation if any of the following conditions are noted:
a. Pain that increases or does not begin to get better or lasts longer than 5 to 6 days. b. Significant swelling or skin color change.
c. Soreness in uninjured areas or difficulty in joint movement.
d. Lower leg pain with passive (manipulation by the screener) flexion or extension of the foot.

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EXTREMITY PAIN NOT ASSOCIATED WITH A JOINT, B-3

1
Is the patient’s pain due to direct trauma?
Yes
No

4
Is the pain due to indirect trauma, exercise, or overuse? refer as
Yes
No

2
Is any deformity of the extremity seen?
Yes
No

Category III

5
Does the pain make normal use impossible?
Yes
No

3
Are his distal pulses and sense of touch distal to the injury normal? Yes
No

Immobilize the injured extremity before transporting or referring the patient.
Category II

Category I
6
Is there static and kinetic calf pain?
Yes
No

7
Does the patient have normal function of proximal and distal joint?
Yes
No

Category III

*Category IV, Treatment
Protocol B-3(5)

*Category IV, Treatment
Protocol B-3(7).

Category II

*NOTE: If the patient has already tried the treatment protocol or if he will not accept it, enter Category III as the disposition.

51

Splint the affected part and refer as
Category II

MEDCOM Pam 40-7-21
GENERALIZED MUSCLE ACHES, B-4
(Not Joint or Low-Back Pain)
Generalized muscle aches refer to an aching sensation in muscles of the extremities, trunk, or neck. The medical term is myalgia. The most common cause of myalgia is a febrile illness. Sore muscles after overexertion are common although the patient does not usually seek medical attention for this. This complaint does not mean joint or low back pain, but rather pain in other areas.
IMPORTANT INFORMATION ON THE ALGORITHM
Blocks 1-3. Headache is very common in viral infections that produce myalgia. A stiff neck, however, is not expected. If a stiff neck and fever are present, meningitis must be ruled out.
Block 4. Myalgia is frequently associated with certain respiratory infections such as influenza. If the patient has symptoms such as cough, runny nose, or sore throat, the appropriate screening sequence will lead to the correct disposition.
Block 5. Viral gastroenteritis is sometimes associated with myalgia. Again, screening the primary symptom will guide the disposition.
In the absences of any of the symptoms in Blocks 1,4, or 5, self care is appropriate.

TREATMENT PROTOCOL B-4(5)
1. Muscle aches result from an abnormal amount of use by the patient. All muscles are normally used every day, but in different degrees. These muscle aches and pains are not dangerous and will usually go away in 3 to 4 days. In general, the treatment for muscle aches and pains is more of the same activity that produced the pain in the first place so that the muscles can get used to that activity.
2. Advise the patient to take aspirin or Tylenol (two tablets every 4 hours) and to use warm soaks (wet towels or wash cloths) to obtain relief. Instruct the patient to apply it to the affected area, as needed.
3. Advise the patient to return for medical assistance if the pain has not improved in 4 to 5 days or if it becomes severe enough to preclude performance of normal duties and activities. 52

MEDCOM Pam 40-7-21
GENERALIZED MUSCLE ACHES, B-4
(Not Joint or Low Back Pain)
Take complaint-specific vital sign:
Temperature
1
Does the patient have a headache? Yes
No

Category III

4
Does he have associated cold/flu symptoms?
Yes
No

5
Does he have associated nausea, vomiting, or diarrhea?
Yes
No

2 o Is his temperature 100 F or higher? Yes
No

Screen other symptoms

3
Can he touch his chin to his chest?
Yes
No

Screen other symptoms

Category II

Screen as Nausea/Vomiting/Diarrhea, C-1

*Category IV, Treatment
Protocol B-4(5)

*NOTE: If the patient has already tried the treatment protocol or if he will not accept it, enter Category III as the disposition.

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NECK PAIN, B-5
This term refers to pain in the back or sides of the neck. If the patient has soreness in other muscles as well, follow the Generalized Muscle Aches, B-4. If the pain is in the front of the neck, follow the Sore Throat, A-1.
IMPORTANT INFORMATION ON THE ALGORITHM
Blocks 1-4. Neck pain with fever, history of trauma, or inability to touch chin to chest warrants careful evaluation. In the absence of signs or symptoms of trauma, meningitis, or flu, self care is appropriate.
TREATMENT PROTOCOL B-5(4)
1. Neck pain which is not due to meningitis, a pinched nerve, or flu is best treated with aspirin or Tylenol and ice packs. Provide the patient with aspirin or Tylenol (two tablets every 4 hours), an analgesic balm, and instructions for ice massage.
2. Instruct the patient to return for medical assistance if a fever develops; if symptoms are not relieved in 2 days; if pain, numbness, or tingling develops in one or both arms; or if the symptoms worsen.

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NECK PAIN, B-5
Take complaint-specific vital sign:
Temperature

.

1
Does the patient have a history of head or neck trauma?
Yes
No

2
Is the patient’s temperature o 100 F or higher?
Yes
No

3
Can the patient touch his chin to his chest?
Yes
No

Refer to Category II after immobilizing the patient’s head and neck Category II

4
Are flu or upper respiratory infection symptoms present?
Yes
No

Screen symptoms

Category III
*Category IV, Treatment
Protocol B-5(4)

*NOTE: If the patient has already tried the treatment protocol or if he will not accept it, enter Category III as the disposition.

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GASTROINTESTINAL (GI) COMPLAINTS
*Algorithms for

Number

Nausea/Vomiting/Diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C-1
Abdominal Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C-2
Rectal Pain/Itching/Bleeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C-3
Constipation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C-4
Difficulty When Swallowing (Dysphagia) . . . . . . . . . . . . . . . . . . . . . . C-5
.

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NAUSEA/VOMITING/DIARRHEA, C-1
The symptoms of nausea, vomiting, and diarrhea are screened together because they frequently accompany one another. In screening any or all of the symptoms, the algorithm is to be used in exactly the same way. Nausea means a feeling of sickness to the stomach with an inclination to vomit. Diarrhea means loose or liquid bowel movements of increased frequency.
IMPORTANT INFORMATION ON THE ALGORITHM
Block 1. Recent head injury is serious because bleeding inside the skull can cause increased intracranial pressure. Increased intracranial pressure directly triggers episodes of vomiting.
Block 2. A patient who is visibly distressed with pain, is clutching his abdomen, or is bent over should be referred as Category II for comfort and because of possible serious disease. Block 3. Bloody or “coffee ground” vomitus may represent GI bleeding requiring immediate treatment. Blood looks like coffee grounds because of the action of gastric juices on blood. Black or bloody stools may also represent internal hemorrhage requiring immediate treatment.
Blocks 4-5. A patient who is pregnant but who has not registered with the Obstetrics
(OB) clinic should be referred there after Category III evaluation. If a clinic is available and the patient is registered, refer the patient to be seen today. If the patient cannot be seen by the OB clinic today, the patient should be referred as Category III. If a clinic is not established, the patient should be referred as Category III.
Blocks 6-7. Nausea, vomiting, or diarrhea of less than 1 week’s duration and not associated with an elevated temperature, postural symptoms, dehydration, or any of the above problems is unlikely to be due to serious illness. Self care is appropriate.
Nausea, vomiting, or diarrhea lasting longer than 1 week requires detailed evaluation to include stool specimen for enteric pathogens, ova, and parasites. The severity of the patient’s symptoms will determine how quickly the evaluation should occur.
Block 8. Fever indicates an infectious disease. The patient should be referred as
Category III.

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TREATMENT PROTOCOL C-1(8)
1. Diet control is very important in treating nausea, vomiting, or diarrhea. Only clear liquids (e.g., 7-Up, ginger ale, broth, water, or Kool-aid) are needed. Solid foods should be avoided. The patient with nausea or vomiting may have ice chips to suck on. Once vomiting is under control, the patient may start drinking small amounts of clear liquids, gradually adding more liquids, and then adding solids as tolerated. The patient with severe or persistent vomiting will require IV fluids and referral as Category II.
2. Imodium or Pepto-Bismol may be given to the patient for the symptomatic control of diarrhea, but the best treatment is not to interfere with the mechanical cleansing of the gut. Medication can actually prolong the problem.
3. Advise the patient to return for medical assistance if the symptoms last more than 2 days, if blood appears in his vomit or in his stools, or if he becomes dizzy and/or faints upon standing. Vomiting that is severe enough to prevent the patient from keeping anything (even clear liquids) down for 24 hours or symptoms that make normal duty performance impossible are also causes for a prompt return visit.
4. Instruct the patient to return for further medical evaluation if he develops abdominal pain that becomes severe enough to prevent his performance of normal duties.

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NAUSEA/VOMITING/DIARRHEA, C-1
Take complaint-specific vital signs:
Temperature
Pulse rate (If > 90, take the patient’s blood pressure while he is lying down and then when he is standing.)
1
Is vomiting associated with head trauma suffered within the past 72 hours?
Yes Fever
No

2
Is the patient severe?
(The patient is clutching his abdomen or is bent over.) (Determine the answer by observing the patient.) Yes
No

3
Are the symptoms associated with bloody or coffee ground vomitus or black or bloody stools?
Yes
No

Category II

Category II

Take all vital signs and do a hemocult on specimen

Category II
4
Is the patient pregnant?
Yes
No

Continued on next page

Continued on next page

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Continued from previous page

NO

YES

5
Is the patient registered with OB clinic?
Yes
No

Category III

Category III

6
Has the symptom lasted over 1 week?
Yes
No

Obtain stool specimen for ova and parasites.

7
Is the patient uncomfortable now? Yes
No

8
Is the patient’s o temperature 100 F or higher? Yes
No

Category II

Category III
Category III

*Category IV, Treatment
Protocol C-1(8)

*NOTE: If the patient has already tried the treatment protocol or if he will not accept it, enter Category III as the disposition.

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ABDOMINAL PAIN, C-2
Abdominal pain is pain anywhere below the ribs and above the groin in the front half of the body. The back may also hurt, but if the pain is confined to the back, screen using
Back Pain, B-1. At times, it may be difficult to distinguish pain in the upper abdomen from that in the lower chest; therefore, a cardiac problem could be causing the pain. If the patient's pulse or blood pressure is abnormal, he should be evaluated as a priority.
IMPORTANT INFORMATION ON THE ALGORITHM
Block 1. Patients with severe abdominal pain should be referred as Category II.
Blocks 2-3. Abdominal pain frequently accompanies nausea and diarrhea. Evaluation by Nausea/Vomiting/Diarrhea, C-1 is appropriate if the patient has cramping abdominal pain associated with vomiting. The patient who complains of increasing abdominal pain followed by vomiting should be referred immediately as Category II; surgical intervention may be indicated.
Block 4. Black or bloody stools may indicate bleeding in the gastrointestinal tract. The patient should be referred as Category II.
Block 5. Abdominal pain associated with recent abdominal trauma could indicate a lifethreatening situation such as a ruptured spleen. The patient should be referred as
Category II.
Blocks 6-8. Abdominal pain in pregnancy could represent a complication of pregnancy.
Category III is the proper disposition for this complaint. If the patient is not registered with the OB clinic, she should be referred there after Category III evaluation.
Block 9. A different group of diseases, many of them gynecologic in nature, affect the pelvic region.

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MEDCOM Pam 40-7-21
ABDOMINAL PAIN, C-2
Take complaint-specific vital sign:
Temperature

1
Is the patient in severe pain?
(Determine the answer by observing the patient.)
Yes
No

Take all vital signs.
Category II

2
Does the patient have nausea?
Has he been vomiting or does he have diarrhea?
Yes to any
No to all

4
Are the patient’s stools black or bloody? Yes
No

3
Did abdominal pain precede the vomiting?
Yes
No

Do hemocult on specimen. Take all vital signs Screen as Nausea/Vomiting/
Diarrhea, C-1

Category II

5
Did the patient experience abdominal trauma within the past 72 hours?
Yes
No

Take all vital signs.

Category II

Continue on next page.

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Category II

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Continued from previous page

No

6
Is the patient female?
Yes
No

7
Is the patient pregnant?
(Pregnancy must be proven, not just suspected by the patient. Order urine human chorionic gonadotropin
(HCG) test if pregnancy is suspected.) Yes
No

9
Is the pain in the lower abdomen (pelvic pain)? (This question applies to females only.) Yes
No

Category III

Take all vital signs.

8
Is the patient registered with the OB clinic? Yes today No

Category III
Screen as Pelvic Pain,
I-6
Make appointment in OB clinic after evaluation.

Take all vital signs.

Category III

66

Category V if OB clinic today, otherwise
Category III.

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RECTAL PAIN/ITCHING/BLEEDING, C-3
IMPORTANT INFORMATION ON THE ALGORITHM
Block 1. A patient who has a proven history of hemorrhoids (determined by reviewing his medical record) and then develops the symptoms again, probably has a recurrence of hemorrhoids. Self care is appropriate if examination reveals hemorrhoids.
Block 2. Although rectal pain or bleeding can be signs of serious disease of the colon or large intestine, most people with itching (and no other symptoms) do not have a serious disease.
Block 3. Gastrointestinal bleeding associated with nausea, vomiting, and diarrhea may represent serious bleeding from the stomach or upper gut. This bleeding associated with dizziness on standing may represent a large amount of blood loss and requires immediate referral as Category II.
Block 4. Black or maroon stools may be caused by large amounts of blood from the lower gut. This condition needs immediate referral as Category II.
Block 5. If the patient has only seen blood on the toilet tissue or on the outside of the stool and has not had nausea, vomiting, diarrhea, or black/maroon stools, he may simply have hemorrhoids or an anal fissure. The patient should still be classified as a
Category III in order to rule out other more serious causes of bleeding.

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TREATMENT PROTOCOL C-3(1)
Hemorrhoids are the most common cause of these symptoms. Hemorrhoids are enlarged veins around the rectum that protrude; get rubbed; and/or become sore, raw, and painful. Hemorrhoids are not dangerous but can be extremely uncomfortable.
1. Diet control is important in the management of patients with these symptoms. To decrease the amount of irritation, the stool needs to be softened by including lots of water-absorbing fiber. Advise the patient to ensure adequate intake of fluids (8 glasses a day) and eat bran cereal, whole wheat bread, and fresh fruits and vegetables. A stool softener or bulking agent may be indicated.
2. Tell the patient that cleanliness is also important. The area should be kept clean by washing with warm water and blotting (rather than wiping) dry.
3. Suppositories and anesthetic ointment can help hemorrhoidal symptoms. Instruct the patient in their use.
4. Instruct the patient to return for evaluation if the symptoms last longer than 1 week or if the problem recurs.

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MEDCOM Pam 40-7-21
RECTAL PAIN/ITCHING/BLEEDING, C-3
Take complaint-specific vital signs:
Associated Complaints:
*Blood Pressure
Temperature

1
Are the symptoms associated with known
Fever
hemorrhoids?
Yes
No

2
Is the patient itching only?
Yes
No

Constipation

*Category IV, Treatment Protocol
C-3(1)

Obtain stool for ova and parasites.

Category III

3
Is the bleeding associated with nausea, vomiting, diarrhea, or dizziness?
Yes
No

4
Are the patient’s stools black or maroon?
Yes
No

5
Is blood present only on toilet paper or on the outside of the stool?
Yes
No

Do hemocult on specimen. Take the patient’s orthostatic blood pressure.**

Do hemocult on specimen. Take the patient’s orthostatic blood pressure**.

Category II.

Category II.

Category III

*Category IV, Treatment Protocol C-4

*Note: If the patient has already tried the treatment protocol or
If he will not accept it, enter Category III as the disposition.

**NOTE Take the patient’s blood pressure while he is lying down and then when he is standing.

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CONSTIPATION, C-4
IMPORTANT INFORMATION ON THE ALGORITHM
Constipation means infrequent or difficult bowel movements. Patients use the word to mean many things--painful defecation, narrowing of the stools, or not having a “regular daily” bowel movement. Normal bowel habits differ from patient to patient; therefore, a wide variation exists in what patients consider to be normal or to be a problem.
Because constipation and hemorrhoids commonly occur together, rectal bleeding may be falsely attributed to these causes. This can be a dangerous mistake. Rectal bleeding must be screened as a separate problem. Constipation not associated with rectal bleeding may be appropriately treated through self care.
TREATMENT PROTOCOL C-4
1. The most important step in treating constipation is to alter the diet so that it contains plenty of fiber. Fiber is that part of food which is not absorbed into the body but instead remains in the intestines and absorbs water to form the bulk of the bowel movements.
Without proper bulk, the large and small intestines cannot work properly, and this causes constipation. Fiber is present in bran cereal, whole wheat bread, fresh fruits, and vegetables. Ensure that the patient is taking adequate water (8 glasses a day).
2. Laxatives can be used on a one-time basis but should not be used repeatedly because the body can become dependent on them. Not everyone has a bowel movement every day. Bowel movements may occur as often as three times a day or once every 3 days and still be normal. Discomfort and a change in pattern are more reliable guides to a diagnosis of constipation.
3. Instruct the patient to return for medical assistance if abdominal pain develops, if the interval between movements is 4 days or longer, or if blood appears in his stools.

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CONSTIPATION, C-4

Is the patient’s constipation associated with rectal bleeding? Yes
No

Screen as Rectal Pain/Itching/Bleeding, C-3

*Category IV, Treatment Protocol, C-4

*NOTE: If the patient has already tried the treatment protocol or if he will not accept it, enter Category III as the disposition.

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DIFFICULTY WHEN SWALLOWING (DYSPHAGIA), C-5
Dysphagia means difficulty or pain when swallowing.
IMPORTANT INFORMATION ON THE ALGORITHM
Block 1. Dysphagia frequently accompanies a severe sore throat. However, MAKE
CERTAIN that dysphagia did not precede the sore throat. Causes of dysphagia not associated with a sore throat may require extensive evaluation.
Block 2. If the patient is comfortable, refer him as Category III for further evaluation. If the patient is uncomfortable, he may be in serious difficulty; therefore, refer him to
Category II immediately.

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DIFFICULTY WHEN SWALLOWING (DYSPHAGIA), C-5
Take complaint-specific vital sign:
Temperature
1

__

Has the difficulty swallowing been preceded by a sore throat? Yes
No

2
Is the patient uncomfortable now? Yes
No

Screen as Sore Throat, A-1

Category II

Category III

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CARDIORESPIRATORY COMPLAINTS
*Algorithms for

Number

Shortness of Breath . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D-1
Chest Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D-2
Wheeze . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . D-3

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SHORTNESS OF BREATH, D-1
This term refers to a sensation of not getting enough air. “Air hunger” or “feeling of suffocation” is descriptive of this sensation. This symptom is aggravated by exertion.
IMPORTANT INFORMATION ON THE ALGORITHM
Block 1. Troubled breathing is not always the same as shortness of breath. If it is caused by a stuffy nose, chest pain, persistent cough, or generalized fatigue, screen according to the appropriate algorithm.
Block 2. The patient who is truly short of breath at rest with one of the findings in this block is in significant respiratory distress and should be seen by a physician immediately. Such a situation is usually obvious to you and the patient. Prior to the patient’s transfer-. Put him at rest in the semi-Fowler position.
. Give him oxygen at 4 to 6 liters per minute.
. Start an IV of D5W, or normal saline, to keep his veins open.
Block 3 & 4. Chest pain associated with shortness of breath may indicate serious heart or lung disease. However, patients with upper respiratory infection symptoms may experience mild shortness of breath and mild chest discomfort that is interpreted as pain. These combinations of symptoms are best referred by a medical officer as
Category II.
Block 5. Cough, A-3 or Wheeze, D-3 will direct you to an appropriate degree of shortness of breath. If the shortness of breath is not obvious and there is no chest pain, cough, or wheeze, disposition to Category III is appropriate.

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SHORTNESS OF BREATH, D-1
Take complaint-specific vital signs:
Temperature
Pulse
Respiration
Blood Pressure
1
Is the patient short of breath at rest?
(Determine the answer by observing the patient.) Yes
No

3
Does the patient have nt- patient— chest pain? associated Yes
No

2
Is the patient cyanotic
(bluish) or does he have a history of heart trouble or is he 35 years or older?
(Determine cyanosis by observing patient.)
Yes to any
No

Category I
Prior to referring the patient•
•

Give him oxygen at 4 to 6 liters per minute.

•

Start an IV as ordered to by MO. Keep his veins open.

Screen as Chest Pain, D-2

4
Are there any abnormal vital signs?
Yes
No

5
Is the symptom associated with coughing/wheezing?
Yes
No

Put him at rest in a semi-Fowler position.

Screen as either
Cough, A-3 or
Wheeze, D-3

Give oxygen at 4 to 6 liters per minute

Category II
Category III

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Screen as Chest Pain, D-2

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CHEST PAIN, D-2
Chest pain means pain anywhere in the chest area, but it needs to be distinguished from back pain and generalized muscle aches which should be screened separately.
When the patient’s chief complaint is chest pain, be especially alert to his general appearance. While chest pain in the young is not generally associated with serious disease, all complaints of chest pain must be considered potentially serious regardless of the age of the patient. Even young persons can be at risk if they are smokers or have diabetes mellitus, hypertension, or a family history of heart attacks.
IMPORTANT INFORMATION ON THE ALGORITHM
Blocks 1-3. Substernal (beneath the breast bone) or left anterior chest pain in a patient over 40 years of age strongly suggests the possibility of a heart attack. This is especially true if it is accompanied by anxiety, sweating, severe weakness, or radiating pain to the neck, jaw, or down the left arm. Such a patient must be-. Evaluated rapidly and monitored closely,
. Given first aid, and
. Started on treatment as described in the NOTE for this algorithm.
Patient with chest pain associated with shortness of breath at rest or an irregular pulse should be referred as Category I. It is highly possible that the patient may have a serious disease of the lungs or heart.
Block 4. A patient with chest pain made worse by coughing or deep breathing should be referred to Category II.
Block 5. A patient with a sore chest that is tender to the touch implies a musculoskeletal syndrome as does pain made worse by twisting movements of the chest wall. Such pain can be treated with self care. Pain that is not clearly described by the above should be referred as Category III.

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TREATMENT PROTOCOL D-2(5)
1. The patient should be able to deal effectively with a mild musculoskeletal syndrome
(pain arising from the chest wall). This is usually caused by injury to the muscle, bone, or cartilage that makes up the chest wall and may be treated with aspirin or Tylenol.
(Any “heat rub” may also be applied in accordance with the manufacturer’s instructions.)
Advise the patient to follow instructions for any medications given.
2. Instruct the patient to return for medical assistance if-. Pain becomes severe.
. Pain persists beyond 4 days.
. Shortness of breath develops.
. An irregular pulse develops.
. Dizziness develops.

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CHEST PAIN, D-2
Take complaint-specific vital signs:
Temperature
Pulse
Respiration
Blood Pressure
1
Is the patient’s pain substernal or left anterior in
Fever
location and is the patient
40 years old or older?
Yes
No

Prior to evacuation as Category I, put the patient in a semi-Fowler position, start an IV as ordered by MO to keep the veins open, and give oxygen at 4 to 6 liters per minute.
Category I

2
Is his pulse irregular?
Yes
No

Prior to evacuation as Category I, put the patient in a semi-Fowler position, start an IV as ordered by MO to keep the veins open and give oxygen at 4 to 6 liters per minute.

Category I

3
Is patient short of breath at rest? (Determine the answer by observing the patient.) Yes
No

Prior to evacuation as Category I, put the patient in a semi-Fowler position, start an IV as ordered by MO to keep the veins open, and give oxygen at 4 to 6 liters per minute.

Category I
4
Is the pain made worse by cough or deep breath?
Yes
No

5
Is the chest tender to touch or is the pain made worse by twisting of thorax?
Yes
No

Category III

Category II

*Category IV, Treatment
Protocol D-2(5)

*NOTE: If the patient has already tried the treatment protocol or if he will not accept it, enter Category III as the disposition.

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WHEEZE, D-3
A wheeze is a dry “musical” whistling sound produced by air forced through narrowed passages. It may or may not be heard by someone near the patient. Gurgling or crackling respiratory noises are not considered wheezing.
IMPORTANT INFORMATION ON THE ALGORITHM

Block 1. Shortness of breath at rest is indicative of severe respiratory distress and requires immediate evaluation.
Block 2. In patients with signs of cyanosis (bluish appearance), or 35 years or older, or with a history of heart trouble, mild wheezing can indicate a serious condition that should be referred to Category I.
Block 3. The presence of wheezing may indicate significant infection in the lungs. The patient should be referred as Category II. In the absence of obvious wheezing, the patient should be referred as Category III.

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WHEEZE, D-3
Take complaint-specific vital signs:

Associated Complaints:
Allergy/hay fever
Shortness of breath

Temperature
Pulse
Respiration
Blood Pressure

1
Is the patient short of breath at rest?
(Determine the answer by observing the patient.)
Yes
No

2
Is the patient-•

Cyanotic (turning blue) or •

Does he have a history of heart trouble or

•

Is he 35 years old or older? Yes to any
No
3
Is the patient obviously wheezing now? (Determine the answer by observing the patient.)
Yes
No

Start oxygen at 4 to 6 liters per minute and refer to Category II

Note: Place the cyanotic
Patient in a semi-Fowler position, start oxygen at
4 to 6 liters per minute, and start an IV as ordered by MO to keep the veins open.

Category I

Category III

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GENITOURINARY COMPLAINTS
*Algorithms for

Number

Painful Urination (Dysuria)/Frequent Urination . . . . . . . . . . . . . . . . . E-1
Blood in Urine (Hematuria) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E-2
Testicular Pain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E-3
Problems in Voiding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E-4
Urethral Discharge (Male) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E-5
Sexually Transmitted Disease (STD) . . . . . . . . . . . . . . . . . . . . . . . . E-6

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PAINFUL URINATION (DYSURIA)/FREQUENT URINATION, E-1
Dysuria means difficulty, pain, or burning sensation with urination (“voiding” or “passing water”). Frequent urination means “voiding” or “passing water” more often than normal.
Urgency means feeling the sensation of a full bladder even though it is not.
IMPORTANT INFORMATION ON THE ALGORITHM
Block 1. A patient with dysuria and/or frequent urination and high fever might have a serious kidney infection requiring admission to the hospital. Evaluation and disposition are expedited by referring the patient to Category II.
Blocks 2 and 3. Male patients with urethral discharge from any cause frequently have associated dysuria. The symptom(s) may be the result of a sexually transmitted disease, but this diagnosis can only be confirmed by laboratory tests and should not be assumed by the screener. Screen using the Urethral Discharge (Male), E-5. Dysuria and/or frequent urination that is not associated with an obvious urethral discharge is not common. Of the other possible causes, most are referred initially as Category III.

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PAINFUL URINATION (DYSURIA)/FREQUENT URINATION, E-1
Take complaint-specific vital sign:
Temperature

1
Has the Fever patient had fever o above 101 F in the past
24 hours?
Yes
No

Obtain clean-catch urine for urinalysis and urine culture.

Category II

2
Is the patient a female?
Yes
No

Obtain clean-catch urine for urinalysis and urine culture.

Category III

3
Are his symptoms associated with urethral discharge? Yes
No

Screen as Urethral
Discharge (Male), E-5

Category III

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BLOOD IN URINE (HEMATURIA), E-2
Hematuria means blood in the urine. Fresh blood gives urine a pink or red color while older blood causes the urine to appear brownish, resembling cola. A blood-tinged urethral discharge of any type should be distinguished from blood in the urine and screened using Urethral Discharge (Male), E-5.
IMPORTANT INFORMATION ON THE ALGORITHM
Block 1. The passing of blood clots during urination indicates active bleeding and a potential emergency; the patient should be referred as Category I immediately.
Block 2. Dysuria means pain or burning on urination (“voiding” or “passing water”).
Block 3. Frequent urination means voiding or passing water more often than normal.
Urgency is the sensation of a full bladder when it is not.
Block 4. A ruptured kidney may not manifest itself immediately after injury. Any blow or fall that the patient can recall must be referred as Category II. Otherwise, the patient can be referred as Category III.

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BLOOD IN URINE (HEMATURIA), E-2
Take complaint-specific vital signs:
Blood pressure
Pulse rate
Temperature
Note: Obtain clean-catch urine for routine and microscopic analysis and culture sensitivity. 1
Is the patient passing clots of blood?
Fever
Yes
No

2
Is there associated dysuria? Yes
No

3
Is there associated frequency/urgency? Yes
No

4
Has the patient had trauma to the pelvis, abdominal, or back within the past week?
Yes
No
Category III

Category I

Screen as Painful
Urination
(Dysuria)/Frequent
Urination, E-1

Screen as Painful
Urination
(Dysuria)/Frequent
Urination, E-1

Category II

Category III

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TESTICULAR PAIN, E-3
This term may be described as pain in the testes, gonads, “balls,” or “crotch.” It is impossible to give a purely quantitative definition of “severe” or “moderate.”
IMPORTANT INFORMATION ON THE ALGORITHM
Observe the patient. A patient in severe pain will usually have a distressed look on his face or walk slowly with an abnormal gait.
Severe testicular pain may signify serious disease; therefore, immediate evaluation is necessary to avoid possible surgical removal. This complaint should be taken seriously.

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TESTICULAR PAIN, E-3
Take complaint-specific vital sign:
Temperature

Is pain severe? (Answer by observing the patient.)
Fever
Yes
No

Category II

Category III

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PROBLEMS IN VOIDING, E-4
Problems in voiding may range from difficulty initiating the urinary stream, to decreased force of stream, to dribbling urination, to complete inability to void.
IMPORTANT INFORMATION ON THE ALGORITHM
Block 1. Complete inability to void is a medical emergency and requires immediate treatment. Block 2. Difficulty in voiding may be associated with dysuria or frequent urination in patients with a urinary tract infection. Screen using Painful Urination (Dysuria)/Frequent
Urination, E-1.

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PROBLEMS IN VOIDING, E-4
Take complaint-specific vital sign:
Temperature
NOTE: Obtain urine for analysis.
1
Is the patient unable to void? Fever
Yes
No

2
Does he have dysuria?
Yes
No

Category II

Screen as Painful
Urination
(Dysuria)/Frequent
Urination, E-1

Category III

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URETHRAL DISCHARGE (MALE), E-5
There is usually little difficulty in distinguishing discharge (pus) from urine. The pus is thicker and more opaque than urine. The patient may complain of dripping from the penis or say he has the “clap.” The discharge may be blood-tinged and, if so, needs to be distinguished from blood in the urine.
In young, sexually active males, sexually transmitted disease (STD) is by far the most common cause of urethral discharge. In older males, other causes are probable.
Proper evaluation on a timely basis is essential. Obtain a urethral smear for gram stain from the patient complaining of a urethral discharge. The patient should be referred as
Category III.

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SEXUALLY TRANSMITTED DISEASE (STD), E-6
Patients frequently show concern that they may have a sexually transmitted disease
(STD); however, they seldom use that term. More frequently, they will express concern about “VD” (venereal disease), “bad blood,” or the “clap.” For screening purposes, it is not important that the patient correctly define these terms. It is sufficient that they have symptom(s), or in the absence of symptoms, believe they may have been exposed to an infection through sexual contact. Sexually transmitted diseases include but are not limited to those traditionally classified as venereal diseases. Some are potentially lifethreatening; others are not. Some infections can be cured through treatment; others cannot be cured at the present time. Sometimes symptomatic relief is available. All patients, with or without symptom(s), need to be evaluated by a medical officer.
IMPORTANT INFORMATION ON THE ALGORITHM
Patients (with or without symptoms) should be advised to avoid sexual contact until they have been evaluated by a medical officer.
Block 1. All female patients will be referred to a medical officer.
Block 2. Male patients with a chancre (an elevated, painless, ulceration (sore), usually on the penis) or with a urethral discharge should be seen by a medical officer.
Block 3. Male patients without a chancre or urethral discharge but complaining of difficulty urinating should be screened under Problems in Voiding, E-4. Patients who have neither lesions nor discharge consistent with STD nor dysuria need further evaluation by a medical officer to determine what is wrong.

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SEXUALLY TRANSMITTED DISEASE (STD), E-6
Associated Complaints:
Difficulty in urination
Penile discharge
Presence of a chancre or lesion 1
Is the patient a female?
Yes
Fever
No

2
Are any of the following present: chancre, lesion, venereal wart, and/or discharge? (Determine the answer by observing the patient.)
Yes
No

Category III

Obtain rapid plasma reagin
(RPR) test; gram stain and culture of discharge, urinalysis

Category III

3
Is the patient having difficulty in urination?
Yes
No

Screen as Problems in voiding, E-4

Category III

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NEUROPSYCHIATRIC COMPLAINTS
Algorithms for

Number

Dizziness/Fainting/Blackout . . . . . . . . . . . . . . . . . . . . . . . . . . F-1
Headache . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . F-2
Numbness/Tingling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . F-3
Paralysis/Weakness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . F-4
Drowsiness/Confusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . F-5
Depression/Nervousness/Anxiety/Tension . . . . . . . . . . . . . . . F-6

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DIZZINESS/FAINTNESS/BLACKOUT, F- 1
The term “dizzy” or “dizziness” may be used by the patient to mean a number of different symptoms. It is useful to try and distinguish among faintness and blackouts, vertigo, confusion, malaise, muscle weakness, and other sensations. True vertigo refers to an illusion where the room seems to be spinning about or the floor seems to be moving. It may be likened to severe seasickness or the feeling experienced immediately after getting off a fast merry-go-round. It is often accompanied by nausea.
Vertigo is not to be confused with faintness or light-headedness which is a feeling of unsteadiness or beginning to fall. Blackout refers to a complete loss of consciousness.
Question others who observed this fainting or blackout episode specifically looking for causes of the event (trauma?) or any unusual observations made, such as spontaneous movements during the blackout, position of the patient, etc.

IMPORTANT INFORMATION ON THE ALGORITHM

Orthostatic blood pressures should be taken for patients with this complaint. The patient’s blood pressure is taken first with the patient supine and then again after the patient has been standing for several minutes.
Block 1. If the patient does not have normal blood pressure or temperature reading, refer him as Category II for evaluation.
Block 2. Intoxication by drugs or alcohol can be a cause for dizziness, fainting, or blacking out. However, it is an unusual cause during normal duty hours. Patients who are intoxicated should be referred as Category III.
Blocks 3-4. A patient who loses consciousness from his dizziness or faintness may have a significantly more serious illness than one who does not lose consciousness. In a patient who has lost consciousness and is unable to walk unassisted within 10 minutes of the loss of consciousness, a serious underlying disease is probable. The patient should be referred as Category I immediately.
Block 5. Patients who require assistance to walk may also have a serious underlying disease and should be referred as Category II immediately.
Block 6. The patient with true vertigo may be able to walk without assistance which does not always represent a true emergency; therefore, refer the patient to Category III for evaluation.
Block 7. Dizziness and faintness are commonly associated with flu-like symptoms. If the patient has flu-like symptoms, he should be screened.

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Block 8. Dizziness and faintness severe enough to prevent carrying out normal military duties should be referred as Category III.

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DIZZINESS/FAINTNESS/BLACKOUT, F-1
Take complaint-specific vital signs:
Temperature
Pulse rate
Blood pressure (postural).
1
Are blood pressure and temperature normal?
Fever
Yes
No

2
Does the patient act intoxicated or smell of alcohol? Yes
No

Category II

Category III

3
Has the patient lost consciousness? Yes
No

5
Can the patient walk without assistance?
Yes
No

4
Is the patient presently alert, and could he walk unassisted within 10 minutes after losing consciousness? Yes
No

Category II

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Continued from previous page
Yes

6
Are the symptoms associated with true vertigo? Yes
No

7
Are the symptoms associated with flu symptoms? Yes
No

8
Do the symptoms prevent the patient from performing his normal military duties?
Yes
No

Category III

Screen other symptoms

Record complaints
Category III

Category III

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HEADACHE, F-2
Strictly speaking, the word, “headache” refers to pain anywhere above the neck.
However, pain that is confined to or predominantly in the eyes, ears, or throat should be screened using the appropriate algorithm.
IMPORTANT INFORMATION ON THE ALGORITHM
Block 1. The patient with a headache and a history of head trauma within the past week should be referred as Category II.
Blocks 2-3. Inability to touch the chin to the chest is usually due to muscle pain or spasm. The most serious condition that could cause this is meningitis which is a medical emergency. Meningitis can occur in military personnel, especially among recruits. It must be specifically ruled out when the patient has a headache associated with fever. Once screened, such cases should be referred as Category II.
Blocks 4-5. The patient with a headache who is also drowsy or confused may have a serious disease. If there is some question as to whether or not the patient is confused, ask him simple questions such as his name, day of the week, the year, where he is now, or who is the President of the United States. Patients who cannot answer these simple questions or who have recent visual problems should be referred as Category II.
Block 6. The patient with a headache who also has nausea and vomiting should be screened for the other symptoms.
Blocks 7-8. The patient with a headache who also has numbness or tingling should be screened as Numbness/Tingling, F-3. If he has elevated blood pressure, he should be referred as Category III.
Blocks 9-10. A patient whose headache has persisted longer than 5 days or that causes him to awaken at night should be referred as Category III.
Block 11. The patient with a headache and other upper respiratory infection complaints should be screened using the appropriate algorithm(s).

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TREATMENT PROTOCOL F-2(11)
1. Headache is one of the most common complaints. In the absence of fever, severe pain, or confusion, serious disease is extremely unlikely.
2. Instruct the patient to take two tablets or capsules of aspirin or Tylenol every 4 hours and to return if the headache persists longer than another day, if fever or confusion occurs, or if the pain is so severe that performance of normal duties is impossible.

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HEADACHE, F-2
Take complaint-specific vital signs:
Temperature
Blood pressure
1
Does the patient have a history of head trauma in
Fever
the past week?
Yes
No

Take all vital signs
Category II

2
Can the patient touch his chin to his chest?
Yes
No

4
Is the patient too drowsy or confused to answer questions accurately?
(Determine the answer by observing the patient.)
Yes
No

5
Does he have recent visual problems?
Yes
No

3 o Is his temperature 100 F or higher?
Yes
No

Take all vital signs
Category II

Category II

Continue on next page

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Continued from previous page
No

6
Does he have nausea or is he vomiting?
Yes
No

7
Is he experiencing numbness or tingling sensations? Yes
No

8
Does he have an increased blood pressure? Yes
No

9
Has his headache persisted longer than 5 days? Yes
No

10
Does his headache wake him up at night? Is it always on the same side?
Is it aggravated by coughing? Yes
No

11
Are upper respiratory infection/symptoms present?
Yes
No

Screen other symptoms

Screen as numbness Tingling, F-3
Do not refer to Category IV.

Category III

Category III

Category III

Screen for appropriate complaint(s).

*NOTE: If patient has already tried the treatment protocol or he will not accept it, enter Category III as the disposition.

*Category IV, Treatment
Protocol F-2(11).

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NUMBNESS/TINGLING, F-3
(Dysesthesia/Paresthesia)
This condition refers to any abnormality in sensation of the skin. Numbness is often used to describe a state of decreased sensation. The patient often perceives the involved area as being “asleep.” However, “numbness” may be used by the patient to describe muscle weakness, malaise, confusion, or abnormal sensation including tingling. Tingling is an alteration in the type of sensation that is perceived such as a prickling sensation--a “pins and needles” sensation.
IMPORTANT INFORMATION ON THE ALGORITHM
Block 1. Screen the patient for other associated complaints.
Block 2. Numbness/tingling confined to one area of the body (that is, focal) is more likely to have a serious cause than generalized numbness and tingling.
Block 3. If the patient has symptoms now, examination may reveal the cause. It is less likely that the cause for numbness and tingling will be determined after the symptoms subside. Block 4. Generalized numbness or tingling associated with loss of consciousness, possible low blood sugar responses to insulin, or in conjunction with abdominal pain are indications for referral as Category II.
Block 5. Generalized numbness or tingling without any of the above symptoms in a patient who has a respiratory rate greater than 14 respirations per minute may be due to involuntarily breathing more deeply and quickly than normal in response to nervousness. Breathing in this way is called “hyperventilation” and causes the amount of carbon dioxide dissolved in the blood to decrease. This can cause numbness, tingling, and even muscle cramping. The patients are often unaware that they are breathing in this way and it may not be obvious to you observing them. Remember, however, that numbness and tingling in the absence of other findings is not always due to hyperventilation. If any doubt exists, the patient should be referred as Category
III.
TREATMENT PROTOCOL F-3(5)
Explain hyperventilation (see Block 5, above) to the patient. Instruct the patient to sit down and breathe quietly, mouth closed, with shallow (not deep) breaths at no more than 12 respirations per minute. If this breathing pattern does not resolve the patient’s symptoms within 5 to 10 minutes, he should be referred as Category III.

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NUMBNESS/TINGLING, F-3
Take complaint-specific vital signs:

Associated Complaints:
Weakness
*

Pulse rate
Respiration rate

1
Are the numbness/tingling symptoms associated with other complaints?
Yes
No

*

Screen other complaints

2
Are these symptoms confined to one area?
Yes
No

4
Has the patient-a. Lost consciousness?
b. Taken insulin?
c. Developed abdominal pain? Yes to any
No

5
Is the patient’s respiration rate greater than 14?
Yes
No

Category III

Paralysis

3
Are these symptoms present now?
Yes
No

Category II

Category III

Category II

*Category IV, Treatment
Protocol F-3(5)

*NOTE: If the patient has already tried the treatment protocol or if he will not accept it, enter Category III as the disposition.

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PARALYSIS/WEAKNESS, F-4
Paralysis/weakness is a condition that refers to a loss of muscular strength resulting in difficulty or inability to move a body part. A complete loss of muscular strength is paralysis; a partial loss is weakness. The patient who complains of being “weak all over” is often describing a manifestation of fatigue or depression.
IMPORTANT INFORMATION ON THE ALGORITHM
Block 1. Of more concern is loss of muscular strength or sensation that is focal in nature. This means that the weakness is confined to one area of the body commonly an arm, leg, one side of the body, or one side of the face.
Block 2. A focal deficit is of particular concern in patients older than 35 years in whom a stroke may be the cause of this symptom. Such patients should be referred as
Category II.
Block 3. Younger patients who have had similar symptoms in the past do not usually have an emergency cause for focal paralysis or weakness. They can be evaluated on a routine basis by the medical officer. An older patient, or a patient who never had a focal paralysis or weakness before, may have an acute problem involving the nervous system or brain. He should be evaluated by the medical officer immediately.
Block 4. A patient who has weakness all over his body associated with flu or upper respiratory infection (URI) symptoms is probably feeling weakness due to other symptoms. Block 5. A patient with weakness which interferes with normal duties needs medical officer evaluation today as these symptoms can be early manifestations of neurologic disease. If he can perform normal activities, self care is appropriate.

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TREATMENT PROTOCOL F-4(5)
1. Generalized weakness of this nature is most likely due to fatigue or depression. The most important factor in treating this condition is careful consideration of the cause.
2. There are no simple cures for the most common fatigue syndromes. Taking a vacation, changing jobs, and undertaking new activities (if possible) may be helpful.
“Pep pills” do not work and can be dangerous; the rebound usually makes the problem worse. Tranquilizers only serve to intensify the fatigue.
3. Advise the patient of the above treatment and request that he return if the problem worsens or if new symptoms develop. Offer a routine mental hygiene appointment, and, if it is accepted by the patient, phone the local mental health facility to make the appointment. 114

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PARALYSIS/WEAKNESS, F-4
Take complaint-specific vital signs:
Blood pressure
Temperature

1
Is the patient’s weakness only on one side?
Yes
No

4
Is the patient’s weakness associated with flu or URI symptoms? Yes
No

Take all vital signs

Screen other symptoms 2
Is the patient 35 years of age or older?
Yes
No

3
Is this the first occurrence of these symptoms?
Yes
No

Category II

Category II

Category III
5
Does the patient’s weakness prevent normal activities? Yes
No

Category III

*Category IV, Treatment
Protocol F-4(5)

*NOTE: If the patient has already tried the treatment protocol or if he will not accept it, enter Category III as the disposition.

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DROWSINESS/CONFUSION, F-5
Drowsiness and confusion may appear together. Drowsiness means that the patient is not alert; he appears sleepy. Confusion means the patient has trouble understanding simple questions, his attention span is short, and his responses are inaccurate. These symptoms may be observed even when the patient is relating other complaints.
IMPORTANT INFORMATION ON THE ALGORITHM
Block 1. If the patient’s drowsiness or confusion does not significantly interfere with your ability to obtain a history, the symptoms are considered mild.
Block 2. Mild drowsiness or confusion may be difficult to distinguish from the fatigue or malaise that accompanies many acute and chronic illnesses. Screen the patient’s other complaints, but be certain that the disposition to a medical officer is made for today. If there is no other complaint or if this is the patient’s only expressed problem, then he should be referred as Category III.
Block 3. Drowsiness/confusion associated with significant fever may indicate meningitis or some other serious infection. Refer the patient to Category II for evaluation.
Block 4. Many medications can cause drowsiness or confusion. Most commonly, these symptoms will occur within the first several days after starting a new medication. The patient who has recently been started on medications (e.g., antihistamines, tranquilizers, muscle relaxants, and some analgesics), has normal vital signs, and has no other indication of the cause for his drowsiness or confusion should be referred as
Category III. The patient who has not recently been started on medication and has no other explanation for his drowsiness/confusion should be referred as Category II. This is necessary so that possible serious causes for his condition may be detected.
Block 5. Mild drowsiness/confusion in a patient with normal vital signs is of less concern and can be routinely referred as Category III. Any abnormal vital signs associated with drowsiness or confusion may indicate a more serious problem and should be referred as Category II.

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DROWSINESS/CONFUSION, F-5
Take complaint-specific vital sign:
Temperature
1
Is the patient alert and oriented? (You may determine this answer by observing the patient and his ability to give a history.) Yes
No

3 o Is his temperature 100 F or higher?
Yes
No

4
Has the patient been on new medication in the past two weeks?
Yes
No

2
Are his symptoms associated with other complaints? Yes
No

Category II

Category III

Category III

Take-Pulse rate
Blood Pressure
Respiration rate

5
Are all the patient’s vital signs normal?
Yes
No

Category III

Category II

117

Screen other complaints, but do not screen to
Category IV even if called for by the algorithm.

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DEPRESSION/NERVOUSNESS/ANXIETY/TENSION, F-6
The terms, “depression/nervousness/anxiety/tension” and the common complaints of
“nerves” or “being upset” all refer to problems of mood. The patient does not feel well, but it may be due to a physical problem. Everyone experiences these feelings from time to time. When suicidal or homicidal ideas are admitted, however, or when symptoms become continuous or interfere with daily functioning, the complaint should be considered serious.
IMPORTANT INFORMATION ON THE ALGORITHM
Blocks 1-4. The severely nervous patient may be tearful or so restless that it is difficult for him to sit for the interview. He may be so withdrawn that it is difficult to get him to answer questions. Because the patient may become worse if he has to sit and wait for a period of time in a busy waiting room with other patients, he is referred to Category II.
Certain drugs can cause these symptoms. Note every medication, if any, the patient is taking. Also ask how much medication the patient took; a large amount could indicate an attempted suicide. Refer to Category II. If the symptoms are mild and other complaints are present, it is best to focus on the additional complaints.
Block 5. If no other complaints are present, a patient with mild symptoms may accept or decline an appointment in the mental health clinic today.

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DEPRESSION/NERVOUSNESS/ANXIETY/TENSION, F-6
1
Does the patient show signs of severe
Fever
nervousness now? (The answer is determined by observing the patient’s behavior.) Yes
No

2
Ask the patient: “Are you having ideas about harming yourself or anyone else?”
Yes
No

3
Is the patient taking any medication? Yes
No

4
Does the patient have other complaints?
Yes
No

5
Is a mental health appointment for today accepted by the patient?
Yes
No

Category II (Take all vital signs.)

Category II

Category III

Gather data on other complaints but do not evaluate as Category IV even if called for by the algorithm.

Refer to Mental Health.

Category III

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CONSTITUTIONAL COMPLAINTS
*Algorithms for

Number

Fatigue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . G-1
Fever/Chills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . G-2

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FATIGUE, G-1
Fatigue is a state of increased discomfort and decreased efficiency resulting from prolonged or excessive exertion or emotional distress. While it is often not caused by a specific disease, it may be a presenting symptom of a potentially serious condition including depression with suicidal risk. If the patient has other specific complaints, suggesting underlying illness or there are any symptoms of depression, the patient should be evaluated immediately. Otherwise, Category IV care is indicated.
TREATMENT PROTOCOL G-1
1. Advise the patient that vitamins are rarely helpful, that “pep pills” do not work (the rebound usually makes the problem worse), and that tranquilizers generally intensify fatigue. Taking a vacation, if possible, or undertaking new activities is often helpful.
The most helpful actions are–
. Identifying the problem causing the fatigue such as work stress, marital discord, or lack of rest or sleep. Provide information on proper sleep hygiene. If not a suicidal risk (which would require immediate referral) suggest various available options for counseling, including mental health, Army community services, and the chaplain.
. Working on the problem rather than on the symptom.
2. Instruct the patient to return for medical assistance only-. If other symptoms develop.
. If the fatigue makes normal activities impossible.
. If fatigue persists for more than 2-3 days.

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FATIGUE, G-1
Take complaint-specific vital sign:
Temperature

Does the patient have other associated symptoms or fever?
Yes
No

Screen other symptoms

*Category IV, Treatment
Protocol G-1.

*NOTE: If the patient has already tried the treatment protocol or if he will not accept it, enter Category III as the disposition.

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FEVER/CHILLS, G-2
Fever/chills are usually associated with an acute illness with other obvious symptoms.
Before assuming the patient has isolated fever/chills, be sure to ask him specifically about other symptoms such as headache, rash, dysuria, sore throat, cough, and muscle aches. If the patient’s temperature is greater than 10l°F or if his symptoms have persisted for more than 48 hours, refer him to Category III evaluation. If the associated symptoms result in different categories of treatment, then the higher level of care should be selected.

TREATMENT PROTOCOL G-2(3)
1. Drink extra fluids-at least one glass of water every hour. Take one or two tablets of
Tylenol every 3 to 4 hours as needed.
2. Return for medical assistance if fever persists despite self care or if other symptoms develop. 124

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FEVER/CHILLS, G-2
Take complaint-specific vital sign:
Temperature
Associated Complaints:
Malaise
1
Does the patient have other associated
Fever
symptoms? (Ask the patient specifically and document if he has any of the following symptoms: headache, rash, dysuria, sore throat, cough, and muscle aches before assuming no other symptoms are present.)
Yes
No

2
Is the patient’s o temperature 101 F or greater? Yes
No

3
Have the patient’s symptoms been present for more than 48 hours?
Yes
No

Screen other symptoms

Category III

Category III

*Category IV, Treatment
Protocol G-2(3).
*NOTE: If the patient has already tried the treatment protocol or if he will not accept it, enter Category III as the disposition.

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EYE COMPLAINTS
Algorithms for

Number

Foreign Body in Eye/Eye Injury;
Eye Pain/Itching/Discharge/Redness . . . . . . . . . . . . . . . . . . . H-1
Eyelid Problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .H-2
Decreased Vision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . H-3
Seeing Double (Diplopia) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . H-4
Seeing Spots . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . H-5
Request for Eyeglasses Only. . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . H-6

NOTE: Test and record visual acuity for every complaint.

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FOREIGN BODY IN EYE/EYE INJURY;
EYE PAIN/ITCHING/DISCHARGE/REDNESS, H-1
IMPORTANT INFORMATION ON THE ALGORITHM
Block 1. The patient does not need to be positive that something is in his eye. Most patients can distinguish the specific sensation due to a foreign body. Refer him to
Category II care. If the patient was exposed to fast moving metal or glass slivers from an explosion, hammering, or welding, take caution. These particles can actually penetrate the eye and symptoms then disappear rapidly. A history of a foreign body that is now “getting better” should still be screened as a foreign body. All eye injuries should be similarly referred; always patch the patient’s eye before referring him. If one suspects a penetrating foreign body injury to the eye, do not patch the eye directly.
Instead, use a protective metal fox shield if available. If a fox shield is not available, tape a protective cup over the eye (e.g., tape a Styrofoam cup cut in half over the injured eye).
Block 2. Pain includes burning sensations. The membrane that lines the eye and eyelids may be inflamed. A discharge often causes crusting on the eyelids. These symptoms most commonly indicate conjunctivitis or “pink eye.” If the patient also reports an eye injury, a foreign body in his eye, decreased vision, or diplopia (double vision), conjunctivitis is less likely. Screen these symptoms in addition to evaluating the patient’s complaint of discomfort.

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FOREIGN BODY IN EYE/EYE INJURY;
EYE PAIN/ITCHING/DISCHARGE/REDNESS, H-1
Test and record visual acuity.
1
Does the patient have an associated eye injury or a foreign body in his eye?
Yes
No

2
Does the patient have associated decreased vision or diplopia (double vision)? Yes
No

Category II

Screen associated symptoms

Category III

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EYELID PROBLEM, H-2
Patients with a variety of problems, as well as some systemic diseases, may present with eyelid complaints.
IMPORTANT INFORMATION ON THE ALGORITHM
Block 1. Any eye trauma should be evaluated by a medical officer. Be sure to patch the injured eye with a dry, sterile gauze dressing to prevent further injury to the eye if-. The medical officer is not physically present, and
. The ophthalmology clinic is more than 10 minutes away.
Block 2. Some primary diseases and infections of the eye may spread and involve the lids. Other infections are localized and do not normally become serious. Differentiate between these causes to determine the urgency of referral.

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EYELID PROBLEM, H-2
Test and record visual acuity.
1
Is the problem associated with an eye trauma?
Yes
No

2
Is the problem associated with eye pain, discharge, significant redness, or swelling? Yes
No

*Category II

Category II

Category III

*NOTE: If the medical officer is not physically present, patch the patient’s eye and refer him to ophthalmology.

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DECREASED VISION, H-3
Decreased vision can mean that images are less distinct or that a portion of the visual field is “blacked out.”
IMPORTANT INFORMATION ON THE ALGORITHM
Block 1. Decreased vision that occurs following trauma may indicate a serious injury that requires immediate treatment.
Block 2. Visual disturbances of the type requiring eyeglasses usually come on gradually. Rapid onset of decreased vision signifies a more serious problem.
Block 3. The usual types of visual problems (such as those requiring eyeglasses) are not limited to one area of the field of vision. The patient may volunteer the fact that only part of the visual field is involved. If the decrease or loss of vision involves a distinct part of the visual field and is acute, the cause may be serious and immediate evaluation is required.

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DECREASED VISION, H-3
Test and record visual acuity.

1
Is patient’s decreased vision associated with head or eye trauma in the last 72 hours?
Yes
No

2
Was onset within the last
7 days?
Yes
No

3
Is there involvement of only one eye or part of the visual field?
Yes
No

Stabilize the patient’s head and neck before evacuating him.

Category II

Category II

Category III

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SEEING DOUBLE (DIPLOPIA), H-4
Double vision means seeing two images of a single object.
IMPORTANT INFORMATION ON THE ALGORITHM
Blocks 1-2. Double vision of recent onset or following injury may represent a serious problem in the brain or skull and the patient should be referred as Category I.
Block 3. Intoxication is a common cause of double vision but should not occur during duty hours. If the patient appears intoxicated, he should be referred as Category II.
Block 4. Double vision associated with eye pain, discharge, or redness should be referred as Category II for further evaluation.
Block 5. A long-standing history of double vision or double vision caused by new eyeglasses may well indicate a need for evaluation of the eyeglass prescription. The patient should be given an appointment at the optometry clinic. Patients with none of the conditions in blocks 1-5 and no prior episodes of diplopia present a diagnostic problem that should be evaluated by an optometrist/ophthalmologist.

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SEEING DOUBLE (DIPLOPIA), H-4
Take and record visual acuity.
1
Was the patient’s onset of double vision associated with history of trauma to the head, neck, or back within the last 72 hours?
Yes
No

2
Does the patient have difficulty walking or speaking? (Determine the answer by observing the patient.) Yes
No

3
Is the patient intoxicated or does he appear to be so? (Determine the answer by observing the patient.) Yes
No

4
Is the double vision associated with eye pain, itching, discharge, or redness, or was the onset within the last 5 days?
Yes
No

5
Has the patient had this problem before, does it come and go, or is it due to new eyeglasses?
Yes
No

Category I-Stabilize the head and neck for evacuation. Category I

Category II

Category II

Category III

Category III
NOTE: Covering one eye prior to referral should temporarily relieve the symptoms. The patient should not drive or perform any duty requiring depth perception.

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SEEING SPOTS, H-5
The patient may refer to the spots as stars, flashes, or floaters.
IMPORTANT INFORMATION ON THE ALGORITHM
Blocks 1-2. The patient complaining of seeing spots associated with decreased vision or headache requires referral to Category II care.
Block 3. When this symptom is of recent onset, the patient should be examined today by an optometrist/ophthalmologist. Otherwise, referral to Category III care is appropriate. 136

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SEEING SPOTS, H-5
Test and record visual acuity.
1
Is the condition associated with recently decreased vision?
Yes
No

2
Is the condition associated with headache? Yes
No

3
Has the condition been present for fewer than 7 days? Yes
No

Screen as Decreased Vision, H-3

Screen as Headache, F-2

Category II

Category III

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REQUEST FOR EYEGLASSES ONLY, H-6
This algorithm is specifically for patients who request a routine check for glasses or protective mask inserts. NOTE that protective mask inserts are not usually provided to personnel with uncorrected vision of 20/40 or better.
IMPORTANT INFORMATION ON THE ALGORITHM
Block 1. The common problems of nearsightedness or farsightedness usually progress slowly. Rapid onset of visual problems should be evaluated promptly.
Block 2. If the patient has any other eye complaints, screen according to the appropriate algorithm in this section.

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REQUEST FOR EYEGLASSES ONLY, H-6
Test and record visual acuity and compare with any previous evaluations.
1
Is decrease in vision of recent onset (fewer than
7 days)?
Yes
No

2
Does the patient have any other complaints?
(Specifically ask the patient about (and document) eye complaints such as redness, pain, discharge, double vision, or seeing spots; screen them if present.) Yes
No

Screen as Decreased Vision, H-3

Screen other complaints

*Category V, Optometry (routine)

*NOTE: Do not send patient to the optometry clinic for protective mask inserts unless uncorrected vision (as documented in the health record) of worse than 20/40 has been corrected with spectacles.

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GYNECOLOGY (GYN) COMPLAINTS
Algorithms for

Number

Breast Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I-1
Suspects Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I-2
Menstrual Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I-3
Vaginal Discharge. Itching, Irritation, or Pain . . . . . . . . . . . . . I-4
Vaginal Lump, Mass, or Sore . . . . . . . . . . . . . . . . . . . . . . . . . I-5
Pelvic Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I-6
Vaginal Bleeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I-7
Request for PAP or Routine Pelvic Examination . . . . . . . . . . 1-8
Request for Information on Contraception . . . . . . . . . . . . . . . I-9

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BREAST PROBLEMS, I-1
IMPORTANT INFORMATION ON THE ALGORITHM
Nursing mothers often have problems with cracked or infected nipples or have difficulty when the child is weaned. Other breast problems, including lumps and soreness, should be referred as Category III.

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BREAST PROBLEMS, I-1
Take complaint-specific vital sign:
Temperature

All breast problems should be referred as Category III.

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SUSPECTS PREGNANCY, I-2
IMPORTANT INFORMATION ON THE ALGORITHM
Serum tests for pregnancy, beta human chorionic gonadotrophin (HCG) determinations, are quite accurate and are positive a few days after the missed menstrual period. A serum beta HCG obtained about two weeks after the patient should have had a menstrual period based upon her normal cycle should be positive.

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SUSPECTS PREGNANCY, I-2
(Patient with menses at least two weeks late.)
Order beta HCG
1
Was beta HCG positive?
Yes
No

Refer to OB clinic for prenatal care.

Repeat beta HCG in 2-3 weeks.

2
Was beta HCG positive?
Yes
No

Refer to OB clinic for prenatal care.

Refer to gynecology for appointment today. If not available, Category III

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MENSTRUAL PROBLEMS, I-3
This algorithm is meant to cover all types of menstrual difficulties not covered in other flow charts. If the problems are missed periods (possible pregnancy), vaginal bleeding, or abdominal pain, screen according to the appropriate algorithm.
The most common problems are irregular or painful periods. You do not need to define the problem. This algorithm is used to determine how quickly the patient needs to be seen. TREATMENT PROTOCOL I-3(4)(5)
1. Bothersome menstrual cramping usually lasts about 24 hours. It may be relieved by aspirin or Tylenol (two tablets every 4 hours). Seldom is discomfort such that the patient is unable to perform normal activities.
2. Give the patient symptomatic medication and instructions for use.
3. Instruct the patient to return if the problem prevents performance of normal duties. A medical officer will evaluate the patient.

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MENSTRUAL PROBLEMS, I-3
Take complaint-specific vital signs:
Temperature
Blood Pressure

1
Is the patient incapacitated by the pain? Yes
No

3
Is this a new problem of recent onset (past 7 days)? Yes
No

4
Is this the patient’s
“usual” menstrual cramping? Yes
No

5
Is this a recurrent menstrual problem?
Yes
No

2
Is the patient presently having vaginal bleeding?
Yes
No

Category III

Category I

Category II

Category IV
Protocol 1-3(4)(5)

Category V-GYN clinic (routine)

*Category IV, Treatment
Protocol 1-3(4)(5)

*NOTE: If the patient has already tried the treatment protocol or if she will not accept it, enter Category III as the disposition.

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VAGINAL DISCHARGE, ITCHING, IRRITATION, OR PAIN, I-4
External pain or burning with urination are often confused with symptoms of urinary tract infection. If a patient has external or vaginal discomfort along with symptoms suggesting a urinary tract infection (frequency, urgency, and internal dysuria), she should be screened as Painful Urination (Dysuria)/Frequent Urination, E-1.

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VAGINAL DISCHARGE, ITCHING, IRRITATION, OR PAIN, I-4

1
Is there dysuria with frequency? Yes
No

Screen and Painful Urination
(Dysuria)/Frequent Urination, E-1

Category III

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VAGINAL LUMP, MASS, OR SORE, I-5
All vaginal lumps, masses, or sores should be referred as Category III.

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PELVIC PAIN, I-6
IMPORTANT INFORMATION ON THE ALGORITHM
Block 1. If a patient has pelvic pain along with symptoms suggesting a urinary tract infection, she should be screened as Painful Urination (Dysuria)/Frequent Urination, E1.
Block 2. Screen as Vaginal Bleeding, 1-7.
Blocks 3-4. Most patients with vaginal discharge, itching, irritation, or mild pain may be more appropriately evaluated by the medical officer on an appointment basis. Patients with more severe pain, pain which is present only during physical activity or intercourse, or pain associated with irregular menses should be sent to the medical officer for a more thorough evaluation.

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PELVIC PAIN, I-6
Take complaint-specific vital sign:
Temperature

1
Is the patient experiencing dysuria and/or frequent urination with urgency?
Yes
No

2
Does the patient have vaginal bleeding?
Yes
No

3
Does the patient have any one of the following?
a. Pelvic pain with physical activity?
b. Pelvic pain with intercourse? c. Irregular menses?
Yes to any
No to all

Screen as Painful Urination
(Dysuria)/Frequent Urination, E-1

Screen as Vaginal Bleeding, 1-7

4
Is the pain severe and has it lasted more than a week? Yes
No

Category III
Category III

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Take all vital signs
Category II

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VAGINAL BLEEDING, I-7
To help clarify dispositions for vaginal bleeding, ask the patient how many pads
(sanitary napkins or tampons) she has used. This means the equivalent of fully soaked pads (many women change pads before they are really saturated with blood). Try your best to use these estimates.
IMPORTANT INFORMATION ON THE ALGORITHM
Blocks 1-3. If this bleeding represents a period that is more than 1 week late or if the previous period consisted of only a small amount of spotting, then pregnancy is possible. Pregnant patients (proven by a pregnancy test) with bleeding should be referred as Category I due to possible spontaneous abortion (miscarriage) or some other serious complication of pregnancy. Follow the algorithm precisely. If in doubt, treat as if pregnant.
Block 4. Massive bleeding (when a patient soaks more than one pad per hour) needs immediate attention.
Block 5. Gynecologists feel that more than 10 pads per day (other than on the first day of menses) is “abnormal.” These patients, as well as those with pain, should be referred to Category III.
Block 6. Prolonged bleeding over 10 days may be seen in women on birth control pills.
Because of the potential for chronic blood loss and anemia, the patient should be referred to Category III today.
Block 7. Prolonged “spotting" (more than 10 days) in patients who are on birth control pills is not unusual and usually not life threatening. Therefore, referral to Category III within 1 week is appropriate. If the patient is not on birth control pills and is having prolonged bleeding, a referral to Category III today is indicated.
Block 8. Post-menopausal bleeding is bleeding in a woman who has passed through menopause (“change of life”). Menopause means the cessation of menstruation in the female, usually occurring between the ages of 46 and 50. A woman over 40 who has not had a menstrual period for over 6 months should be considered post-menopausal.
Bleeding after menopause represents a possible neoplasm and requires evaluation in the obstetrics/gynecology clinic.

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VAGINAL BLEEDING, I-7
Take complaint-specific vital signs:

Associated Complaints:
Menstrual problem

Pulse
Blood Pressure (orthostatic)
1
Is the patient possibly pregnant? Yes
No

2
Is she in labor or in the last 3 months of pregnancy? Yes
No

Start IV as ordered by
MO to keep veins open.

Category I

4
Is she bleeding severely
(over one pad per hour)?
Yes
No

3
Is the patient bleeding severely (over one pad per hour)?
Yes
No

Start IV as ordered by
MO to keep veins open.

Category II

5
Does the patient have heavy bleeding (over 10 pads per day) or is the patient having significant observable discomfort?
Yes
No

Start IV as ordered by
MO to keep veins open.

Category I
Category II

Category II

Continued on next page.

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Continued from previous page.

No

6
Is the patient having prolonged bleeding (over
10 days)?
Yes
No

Order hematocrit

Category III
7
Is the patient on birth control pills? Is the patient spotting? Yes
No

8
Is this postmenopausal bleeding? Yes
No

Category III

Category III

Category III

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REQUEST FOR PAP OR ROUTINE PELVIC EXAMINATION, I-8
A Pap test is a microscopic examination of cells to detect the presence of a cancerous process. IMPORTANT INFORMATION ON THE ALGORITHM
Block 1. If the patient is requesting a Pap test due to symptoms such as menstrual problems, screen according to the appropriate algorithm.
Block 2. Women who have had abnormal or suspicious Pap tests may be asked to have examinations more frequently-for example, every 3 to 6 months. Otherwise, it is
Army Medical Department (AMEDD) policy to recommend yearly Pap tests on every woman beginning in the late teens and continuing throughout her lifetime. Pap tests are done at the (enter appropriate name) clinic on an appointment basis. Call (enter telephone number) for an appointment.

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REQUEST FOR PAP OR ROUTINE PELVIC EXAMINATION, I-8
1
Is the patient having a pelvic or GYN problem at the present time?
Yes
No

2
Has the patient had an examination in the last year? Yes
No

Screen according to appropriate algorithm.

Tell the patient to return in 1 year unless she has been specifically told otherwise by a physician.

Category III

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REQUEST FOR INFORMATION ON CONTRACEPTION, I-9
IMPORTANT INFORMATION ON THE ALGORITHM
Block 1. If the patient is requesting information on how to prevent pregnancy
(contraception) but presents with no specific problem, advise her to make an appointment in the appropriate clinic by calling (enter telephone number). If she has any specific complaints, screen them using the appropriate algorithm. Document the first day of the last menstrual period.

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REQUEST FOR INFORMATION ON CONTRACEPTION, I-9

1
Does the patient have any specific GYN problems? Yes
No

Screen according to appropriate algorithm

Category III Record first day of last menstrual period.

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DERMATOLOGICAL COMPLAINTS
The format of this section is slightly different from the other major-complaint sections of this manual. This is because patients with a skin disorder or complaint usually know the cause and simply want something to treat it. Therefore, the dermatology section deals with specific conditions rather than symptoms.
The first algorithm of this section is designed to separate complaints with a known cause from those that have an unknown origin. If the patient knows the cause of the complaint, the screener must refer to the appropriate algorithm-. To ensure the symptoms presented are characteristic of the suggested cause.
. To direct the patient to the proper level of health care, or
. To prescribe self care, dependent on the severity of the condition.

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DERMATOLOGICAL COMPLAINTS
*Algorithms for

Number

Unknown Cause of Skin Disorder Complaint . . . . . . . . . . . . . . . . . . J-1
Acne . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . J-2
Shaving Problem-Pseudofolliculitis Barbae (PFB)
(Ingrown Hairs) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . J-3
Dandruff (Scaling of the Scalp) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . J-4
Hair Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . J-5
Athlete's Foot (Tinea Pedis) .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . J-6
Jock Itch (Tinea Cruris) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . J-7
Scaling, Depigmented Spots on Chest, Back, and Upper
Arm (Tinea Versicolor) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . J-8
Boils . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . J-9
Fever Blisters (Cold Sores) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . J-10
Skin Abrasions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . J-11
Skin Laceration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . J-12
Suture Removal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . J-13
Drug Rash . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . J-14
Burns. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . J-15
Friction Blisters on Feet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . J-16
Corns on Feet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . J-17
Plantar Warts/lngrown Toenail . . . . . . . . . . . . . . . . . . . . . . . . . . . . . J-18

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UNKNOWN CAUSE OF SKIN DISORDER COMPLAINT, J-1
If the cause of the condition is unknown to the patient, this first algorithm provides the level of health care provider for referral or self-care protocol.
IMPORTANT INFORMATION ON THE ALGORITHM
Block 1. If the patient knows the cause of the sore, that should determine the appropriate algorithm to use.
Block 2. Any unknown lesion that persists for 4 weeks or more and shows no sign of improvement may represent a problem requiring referral as Category III care.
Block 3. A lesion of an unknown cause that has changed color or oozes blood or any type of fluid may indicate a condition requiring referral as Category III care.
Blocks 4 and 5. Advise the patient–
. That the treatment protocol must be followed for 2 to 3 weeks.
. To return in 2 to 3 weeks so that the provider can determine if the sore has completely healed or shows signs of significant improvement.
. To return immediately for reevaluation if the sore worsens.

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UNKNOWN CAUSE OF SKIN DISORDER COMPLAINT, J-1
Associated Complaints:
Any dermatology-related complaint 1
The patient knows the cause of the sore?
Yes
No

2
Has the lesion been present more than 4 weeks with no signs of improvement? Yes
No

3
Is the lesion oozing blood or fluid? Has the lesion changed color?
Yes
No

4
Has the patient been following any treatment protocol for the past 2 to 3 weeks? Yes
No

Screen Cause

Category III

Category III

5
Has the treatment failed?
Yes
No

Category III

Continue treatment

165

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MEDCOM Pam 40-7-21
ACNE, J-2
Acne is caused by plugged oil glands. The oily material may form a ‘whitehead” or develop a dark colored “blackhead” when exposed to the air. Pimples develop when these plugged glands become inflamed and bacteria begin breaking down the oilproducing irritating substances as by-products. Acne is a common condition occurring primarily in the late teens and early twenties. Acne may be extremely upsetting to the young Soldier. The seriousness of this condition or its importance to the patient must not be underestimated. With proper treatment, acne can be improved thus avoiding scarring. IMPORTANT INFORMATION ON THE ALGORITHM
Block 1. If the patient complains of acne but shows no signs of whiteheads, blackheads, or blemishes, the diagnosis of acne is doubtful. The patient should be referred as Category III.
Block 2. Inflamed lesions on the face and back should be treated to avoid permanent scarring or the development of a condition that does not respond to therapy.
TREATMENT PROTOCOL J-2(2)
111
1. Twice daily, wash (but avoid scrubbing) affected area with unscented soap and warm water. Pat dry.
NOTE:
Do not use cold cream, face cream, or any greasy or oily products on affected area.
2. Benzol peroxide 5% gel once or twice daily to acne-prone areas.

166

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ACNE, J-2
Associated Complaints:
Blackheads
Blemishes
Pitting of the skin

1
Are blackheads or blemishes present?
Yes
No

2
Are numerous inflamed lesions on the face and the back present? Yes
No

Category III

Category III

*Category IV, Treatment
Protocol J-2(2).

*NOTE: If the patient has already tried the treatment protocol or if he will not accept it, enter Category III as the disposition.

167

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SHAVING PROBLEM-PSEUDOFOLLICULITIS BARBAE-PFB
(INGROWN HAIRS), J-3
Pseudofolliculitis Barbae is a chronic condition of the beard area resulting from the reentry of the growing hair into the upper layer of the skin or facial hairs becoming trapped in the upper layer of the skin. The genetic predisposition of the AfricanAmerican male to tight coiling hair makes him highly susceptible to this condition. The most common locations for lesions are the face and neck. The lesions can be painful and interfere with shaving although they rarely become secondarily infected.
Permanent scarring is possible. The development of many shaving bumps can make the Soldier self-conscious. The patient should be referred as Category III. The medical officer can determine the degree of severity and treat the condition accordingly to avoid permanent scarring and to improve the patient's complexion.

168

MEDCOM Pam 40-7-21
SHAVING PROBLEM-PSEUDOFOLLICULITIS BARBAE (PFB)
(INGROWN HAIRS), J-3
Associated Complaints:
Crusted lesions
Lesions oozing pus
Curly hair ends embedded in face
Pain
Secondary infection on face

Refer the patient complaining of shaving problems to Category III.

169

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DANDRUFF (SCALING OF THE SCALP), J-4
Dandruff is the dry scaly material that falls from the scalp. It is associated with itching of the scalp.
IMPORTANT INFORMATION ON THE ALGORITHM
Block 1. If the scalp does not itch or scale, it may not be dandruff. Patients who do not show the characteristic sign of dandruff (scaling) should be further screened to determine the cause of their complaint.
Block 2. The presence of lesions indicates a degree of seriousness that is beyond self care. These patients should be referred as Category III.
Blocks 3 and 4. The normal time for a patient to respond to dandruff treatment is 2 to 3 weeks. If therapy fails, the patient should be reevaluated as Category III.

TREATMENT PROTOCOL J-4(3)
Advise the patient to1. Use an anti-dandruff shampoo daily to control mild flaking.
2. Massage the shampoo well into the scalp.
3. Leave the shampoo on the scalp for at least one minute.
4. Rinse thoroughly with clean water.
5 . Repeat the procedure.

170

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DANDRUFF (SCALING OF THE SCALP), J-4
Associated Complaints:
Fine scaling of scalp
Itching of scalp

1
Is the patient’s scalp itching and scaling? (Dandruff must be observed on patient.) Yes
No

2
Are the lesions present on the patient’s face?
Yes
No

Category III

Screen for other complaints 3
Has the patient been following the treatment protocol for the last 2 to 3 weeks?
Yes
No

4
Has treatment failed to work? Yes
No

*Category IV, Treatment
Protocol J-4(3)

Category III

*Category IV, continue treatment

*NOTE: If the patient has already tried the treatment protocol or if he will not accept it, enter Category III as the disposition.

171

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HAIR LOSS, J-5
While most hair loss is natural and hereditary, any hair loss that is sudden or extreme in nature can result from a fungus infection or other forms of illness or as a result of using certain medications. When treated promptly and properly, hair growth typically resumes. All cases of hair loss should be assessed by a medical officer.

172

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HAIR LOSS, J-5
Associated Complaints:
Patches of hair loss
Baldness

The patient complaining of hair loss should be referred as Category III.

173

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ATHLETE’S FOOT (TINEA PEDIS), J-6
Athlete’s foot is a fungal infection. The patient usually complains of scaling or blistering-with or without itching--on the bottom of the feet or between the toes. Thickening and/or discoloration of the toenails can also occur. The presence of athlete’s foot fungus can be confirmed by a potassium hydroxide (KOH) test.
IMPORTANT INFORMATION ON THE ALGORITHM
Block 1. If the patient complains of athlete’s foot but does not have the typical lesions, refer him to the medical officer for further evaluation.
Block 2. The presence of red streaks, vesicles, or oozing fluid on the foot indicates a possible secondary bacterial infection. The patient should be referred as Category III.
Blocks 3 and 4. If self care does not show signs of improvement after 7 to 10 days, refer the patient to the medical officer for reevaluation and alternate treatment.
TREATMENT PROTOCOL J-6(3)(4)
Advise the patient to1. Dry his feet carefully after washing them.
2. Change socks and shoes at least once daily.
3. Sprinkle foot powder in boots or shoes when they are not being worn.
4. Apply an antifungal foot ointment or powder between the toes twice daily for
10 days.
5. Soak his feet twice daily for 30 minutes in Domeboro’s solution of two tablets per pint of water. (This solution may be saved for reuse.)

174

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ATHLETE’S FOOT (TINEA PEDIS), J-6
1
Are scaling and fissuring present between the patient’s toes and/or sole of the foot? Is the skin red and does it itch? (Observe the patient’s foot for scaling, fissuring, and redness.)
Yes to any
No

Category III

2
Are red streaks, vesicles, or oozing fluid present in the affected area?
Refer to
Yes to any
No to all

Category III

Obtain specimen for KOH evaluation (Micro II slip)

3
Has the patient been following the treatment protocol for 7 to 10 days? Yes to any
No to all

*Category IV, Treatment
Protocol J-6(3)(4).
4
Has treatment failed?
Yes to any
No to all

Category III

*Category IV, Treatment
Protocol J-6(3)(4)

*NOTE: If the patient has already tried the treatment protocol or if he will not accept it, enter Category III as the disposition.

175

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JOCK ITCH (TINEA CRURIS), J-7
Jock itch is a fungal infection in the folds of the groin and the inner thighs. It is most commonly found in younger men. This condition is aggravated when the person sweats, wears restrictive garments, and does not or is unable to wash and dry himself carefully on a daily basis. Red areas with dandruff-like scales develop on either side of the inner thighs and there may be itching. Spread of the infection beyond the groin area and involvement of the penis is uncommon.
IMPORTANT INFORMATION ON THE ALGORITHM
Block 1. The presence of red, itching, blistering, or scaling lesions in the folds of the groin and inner thighs is characteristic of this tinea cruris. In the absence of typical symptoms, other causes of rashes may exist. The patient should be referred as
Category III.
Block 2. If pus is present, the lesion is no longer simple jock itch. Refer the patient to
Category III care to avoid further spread of the bacterial infection.
Block 3. The treatment protocol should eliminate the symptoms in 10 to 14 days. If the treatment fails, the patient should be referred as Category III. However, initial treatment must be given time to work before the patient is further evaluated.
TREATMENT PROTOCOL J-7(3)(4)
1. Wash the folds of the groin and thighs with mild soap twice a day. Completely dry yourself after washing.
2. Wear loose-fitting clothes (boxer shorts rather than jockey shorts).
3. Apply antifungal solution/cream to the affected area twice daily for 10 to 14 days. To prevent recurrence, continue treatment for 1 week after symptoms disappear.
4. If the condition has not improved after 14 days of treatment, return for further evaluation. 176

MEDCOM Pam 40-7-21
JOCK ITCH (TINEA CRURIS), J-7
Associated Complaints:
Blisters
Lesions
Scaling
Redness
Oozing of fluid in area of the groin or inner thighs
1
Does the patient have itching, redness, blisters, and/or lesions in the groin and/or inner thighs?
(Determine the answer by observing the patient.)
Yes
No

2
Is oozing fluid present? Yes
No

Category III

Category III

3
Has the patient been following the treatment protocol for the last 10 to 14 days?
Yes
No

*Category IV, Treatment
Protocol J-7(3)(4)

4
Has treatment failed?
Yes
No

Category III

*Category IV, Continue treatment *NOTE: If the patient has already tried the treatment protocol or if he will not accept it, enter Category III as the disposition.

177

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SCALING, DEPIGMENTED SPOTS ON THE CHEST,
BACK, AND UPPER ARMS (TINEA VERSICOLOR), J-8
Tinea versicolor is a common superficial fungal infection that appears as “spots” (lighter or darker than surrounding skin) on the neck, chest, back, and arms usually with no other symptoms.
The rash is typically scaly and painless. Its color is pink, yellowish-tan, brown, or white.
The patient should be referred as Category III.

178

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SCALING, DEPIGMENTED SPOTS ON THE CHEST,
BACK, AND UPPER ARMS (TINEA VERSICOLOR), J-8
Associated Complaints:
Lack of skin pigmentation in patches primarily on the chest and back
Patches do not tan when exposed to the sun.

Refer as Category III the patient who has scaling and depigmented spots on the chest and back.

179

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BOILS, J-9
A boil is usually caused by bacteria that enters through a hair follicle. A painful nodule enclosing a core of pus forms in the skin. Tenderness, swelling, and pain are present around the area of inflammation. An extremely large boil or numerous boils can produce fever. Boils are also known as furuncles if they have a single core or carbuncles if they have multiple cores. The patient should be referred as Category III.

180

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BOILS, J-9
Take complaint-specific vital sign:
Temperature

Associated Complaints:
Localized tenderness and pain Elevated temperature

Refer as Category III the patient with a boil(s). The patient should apply moist heat for
20 minutes every 4 hours until seen.

181

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FEVER BLISTERS (COLD SORES), J-10
Fever blisters result from an acute viral infection that frequently occurs around the mouth or on the lips. Fever blisters are both recurrent and painful.
IMPORTANT INFORMATION ON THE ALGORITHM
Block 1. Vesicles around the mouth or on the lips with pain are typical symptoms of fever blisters. The patient should be referred as Category III.
Block 2. Large clusters of vesicles or lesions oozing pus may represent a herpes virus or bacterial infection. This infection can spread. The patient should be referred as
Category III. The patient should NOT be prescribed the self-care protocol.

182

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FEVER BLISTER (COLD SORES), J-10

Associated Complaints:
Superficial vesicles
Burning discomfort
1
Are painful vesicles present only around the patient’s lips and/or his mouth?
Yes
No

Category III

2
Does the patient have large clusters of vesicles or vesicles that are oozing fluid?
Yes
No

Category III

*Category IV, Treatment
Protocol J-10(2)

*NOTE: If the patient has already tried the treatment protocol or if he will not accept it, enter Category III as the disposition.

183

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SKIN ABRASIONS, J-11
Skin abrasions are caused when the skin is rubbed raw such as when a knee or elbow is scraped. While this type of injury is painful, it normally requires only minor treatment.
IMPORTANT INFORMATION ON THE ALGORITHM
Block 1. If more than scraping of the skin has occurred, the patient should be screened under Skin Laceration, J-12.
Block 2. Unusually large areas of abrasions or abrasions associated with evidence of infection such as pus or fever should be further evaluated by the medical officer.
TREATMENT PROTOCOL J-ll(2) 111
1. Gently wash affected area with a skin cleaner (Betadine).
2. Apply antibacterial ointment (Bacitracin) 2 to 3 times daily.
3. Apply a protective sterile dressing.

184

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SKIN ABRASIONS, J-11
___________________
Associated Complaints:
Scraping skin with or without bleeding
___________________

Take complaint-specific vital sign:
Temperature

1
Does the patient have scraping of the skin only?
Yes
No

Screen as Skin Laceration, J-12

2
Is the area unusually tender to the touch? Are red streaks or oozing fluid present? Does the patient have a o temperature of 100 F or greater? Yes
No

Category III

*Category IV, Treatment
Protocol J-11(2)

*NOTE: If the patient has already tried the treatment protocol or if he will not accept it, enter Category III as the disposition.

185

MEDCOM Pam 40-7-21
SKIN LACERATION, J-12
IMPORTANT INFORMATION ON THE ALGORITHM
Block 1. Injury to the portion of the skin containing blood vessels and nerves causes bleeding and pain. This type of injury requires the immediate attention of a medical officer, especially when the injury is caused by an animal or human bite.
Block 2. A laceration located over a joint, on a foot or hand, or the face requires evaluation by a medical officer.
Block 3. Even shallow cuts with signs of inflammation or longer than 1-inch should be referred as Category III.
Block 4. If the edges of the wound can be brought together easily and there are no signs of infection, self care is appropriate. Steri-strips may be applied to keep the edges of the skin together. Patients with injuries where the edges of the wound cannot be brought in close proximity or which show signs of infection should be referred as
Category III.
TREATMENT PROTOCOL J-12(4) 11
1. Clean the area around the wound with a generous application of soap and water, then irrigate the wound with jets of sterile normal saline using a syringe. Do not leave any dirt, glass, metal, or other foreign material in the wound.
2. Keep the area clean and dry and return in 24 to 48 hours for reevaluation.
3. Return for additional assistance if the wound becomes red and swollen, oozes pus, or becomes separated.

186

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SKIN LACERATION, J-12

1
Is the patient’s cut the result of a puncture wound or an animal or human bite? Is it a large wound? Yes to any
No

2
Is the laceration located over a joint, on a foot or hand, or the face?
Yes
No

3
Is the cut shallow (skin only), less than 1-inch long, and without signs of inflammation? Yes to all
No

Category III

Category III

4
Can the edges of wound be brought together easily? Yes
No

*Category IV, Treatment
Protocol J-12(4)

Category III

Category III

*NOTE: If the patient has already tried the treatment protocol or if he will not accept it, enter Category III as the disposition.

187

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SUTURE REMOVAL, J-13
Refer as Category III the patient who needs to have sutures removed.
Suture should be removed when:
. The wound has healed (within 5 to 10 days).
. The suture line is clean.
. No pus, redness, or swelling is present.
Document the appearance of the wound (sutured laceration).

188

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DRUG RASH, J-14
Drugs can cause acute widespread rash of small red spots over the entire body in individuals with sensitivity to them. This is usually associated with itching and can interfere with sleep or the performance of normal duties or activities. The rash results when the entire body reacts to the drug itself and may develop early in treatment or after the drug has been taken for a period of time.
IMPORTANT INFORMATION ON THE ALGORITHM
Block 1. Patients who feel that they may have a drug reaction but have not started a new drug within the last 2 weeks may be suffering from another condition. The patient should be referred as Category III.
Block 2. A "no" response to this question makes the diagnosis of drug reaction less likely. The patient should be referred as Category III.
Block 3. Presence of widespread, elevated lesions (hives), or obvious wheezing indicates a possible life-threatening reaction. The patient should either be sent to the emergency center or to see a medical officer immediately, Category I care.

189

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DRUG RASH, J-14
Take complaint-specific vital signs:
Temperature
Pulse
Respiration
Blood Pressure

1
Has medication been prescribed to the patient within the last 5 days?
Yes
No

Associated Complaints:
Red lesions on the chest, abdomen, and extremities
Wheezing

2
Are red lesions present?
Are they associated with itching? Yes to either
No to both

Category III
Category III

3
Are the lesions widespread and elevated? Is it obvious that the patient is wheezing? Yes to either
No to both

Category III

*Provide emergency first aid prior to evacuation

**NOTE: If the patient has already tried the treatment protocol or if he will not accept it, enter Category III as the disposition.

190

*Category I

MEDCOM Pam 40-7-21

191

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BURNS, J-15
A burn is defined as any injury to the outer layer of skin or deeper tissue caused by heat, chemicals, or electricity. Minor burns are characterized by redness, pain, and tenderness. More severe burns may not have these symptoms.
IMPORTANT INFORMATION ON THE ALGORITHM
Block 1. If the burn is a result of overexposure to the sun, the patient should be screened under Sunburn, K-8.
Block 2. A serious medical condition may exist; refer as Category I.
Block 3. Blisters or charring of the skin indicate second or third degree burns and should be evaluated immediately.
Block 4. Even extensive first degree burns may become infected and are painful to the patient. These patients should be seen by the medical officer. Patients with minor first degree burns should be treated by self care.
TREATMENT PROTOCOL J-l5(5) I1
1. Apply cold packs to affected area to relieve pain.
2. Leave area open to the air.
3. Take two tablets of Tylenol or aspirin every 4 hours for pain.

192

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BURNS, J-15
1
Is the patient’s burn due to overexposure to the sun? Yes
No

2
Is the patient short of breath or complaining of difficulty breathing? Does the patient appear confused or drowsy?
Yes to any
No

3
Are the burns second or third degree?
Yes
No

4
Are the burns extensive covering more than 25% of the body?
Yes
No

5
Is the patient uncomfortable or in pain?
Yes
No

Screen as Sunburn, K-8

Category I

Category II

Category II

Category II

*Category IV, Treatment
Protocol J-15(5).
*NOTE: If the patient has already tried the treatment protocol or if he will not accept it, enter Category III as the disposition.

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194

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FRICTION BLISTERS ON FEET, J-16
IMPORTANT INFORMATION ON THE ALGORITHM
Block 1. Infected blisters can become serious health hazards and should be referred to the medical officer for further evaluation and treatment. Uninfected blisters have their own treatment protocol.
Block 2. Ruptured blisters have their own treatment protocol.
TREATMENT PROTOCOL J-l6(2A) Ill
1. Prepare the skin with alcohol or Betadine.
2. Remove the dead skin with sterile scissors. If sterile instruments are not available or personnel have not been taught to perform the procedure, skip this step and proceed to step 3.
3. Wash area with Betadine and apply an antibacterial ointment to the blister only.
4. Cover a large area of surrounding undamaged skin and the treated blister with a protective dressing of moleskin between treatments. An adhesive solution such as tincture of benzoin or a surgical adhesive may be applied to the skin around the blister to improve the adhesion of the moleskin.
5. Instruct the patient to wear two pairs of socks when wearing combat boots (a thin pair of nonabsorbent, noncotton socks under the boot socks) and to check for proper fit of boots.
6. Instruct the patient to return for further evaluation if-. The protective dressing begins to come off.
. He develops blisters that make wearing shoes or boots impossible.
. He is disabled by pain.
. He has signs of infection.
7. The patient should be reevaluated every 24 hours.

195

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TREATMENT PROTOCOL J-l6(2B)
1. Prepare the skin with alcohol or Betadine. Puncture the blister with a sterile needle to allow fluid to drain.
2. Apply surgical adhesive tincture of benzoin to the surrounding normal skin and let it air-dry for 30 seconds. (If sterile instruments are not available or personnel have not been taught to perform this procedure, skip this step. The patient should be referred as
Category III).
3. Apply an antibacterial ointment to the blister only.
4. Cover the area with a protective dressing as described in paragraph 4, Treatment
Protocol J-l6(2A), above.
5. Instruct the patient to wear two pairs of socks when wearing combat boots (a thin pair of nonabsorbent, noncotton socks under the boot socks) and to check for proper fit of boots.

196

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FRICTION BLISTERS ON FEET, J-16
Associated complaints:
Discomfort or pain while walking or wearing constricting footwear.

1
Does the patient have any signs of infection?
Yes
No

2
Are any blisters ruptured?
Yes
No

Category III

*Category IV, Treatment
Protocol J-16(2A)

*Category IV, Treatment
Protocol J-16(2B)

*NOTE: If the patient has already tried the treatment protocol or if he will not accept it, enter Category III as the disposition.

197

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CORNS ON FEET, J-17
A corn is a benign growth characterized by a thick hard area on the sole of the foot or toes. Tenderness occurs especially during weight-bearing on the foot and afterpain is common. IMPORTANT INFORMATION ON THE ALGORITHM
Block 1. Thickening of the hard surface on the sole of the foot can be related to plantar warts or cancerous tumors. These growths can be painful and interfere with daily activities such as walking or running. They should be differentiated from simple corns by the medical officer before any treatment is given.
Block 2. A patient complaining of severe pain while walking or wearing footwear should be treated by the medical officer to expedite the Soldier’s return to duty.
Block 3. Pain that significantly interferes with the performance of normal duties/activities falls into the same category and should be referred to the medical officer for evaluation and treatment.
Block 4. A history of diabetes may be significant. If the patient does not indicate diabetes (either in himself or his family), self care is appropriate; otherwise, the patient should be referred to the medical officer for evaluation and treatment.
TREATMENT PROTOCOL J-17(3)(4)
1. Soak the patient’s foot in warm water for 20 minutes.
2. Pare corns down with scalpel blade reducing enough hard skin until the lesion is flexible or until the patient can stand or bear weight on foot without discomfort. Do not pare the corn down to cause bleeding.
CAUTION: If the person performing the treatment protocol has not been taught how to perform this procedure, instruct the patient to return for follow-up treatment with the medical officer.
3. Instruct patient on weekly self-debridement. Self care can be given using a pumice stone. 4. The patient will need a special insole constructed for his shoe.
5. Refer the patient to the medical officer if limited motion of the toes exists, if a severe hammer or mallet toe deformity exists, if the skin bleeds freely when pared, or if an insole is required.

198

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CORNS ON FEET, J-17
Associated complaints:
Discomfort or pain during or after walking or wearing constricting footwear. 1
Does the patient have a hard mass on the sole of his foot? (Determine the answer by observing the patient’s foot.)
Yes
No

Category III

4
Does the patient have a history of diabetes?
Yes
No

2
Does the patient complain of pain in his foot during or after walking or wearing footwear? Yes
No

3
Is the pain of a degree that would result in a significant interference in normal duty?
Yes
No

Category III

Category III

*Category IV, Treatment
Protocol J-17(3)(4).

*Category IV, Treatment
Protocol J-17(3)(4).

*NOTE: If the patient has already tried the treatment protocol or if he will not accept it, enter Category III as the disposition.

199

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PLANTAR WARTS/INGROWN TOENAIL, J-18
A plantar wart is a benign growth of skin on the foot. An ingrown toenail is a toenail that extends into the flesh of the toe along its lateral margins. Both may be painful. If the patient is complaining only of foot pain and does not know the cause, screen by following Extremity Pain, B-3.
1. All such problems are evaluated by the medical officer.
2. If the patient is limping because of his foot problem, he should be seen as soon as possible for treatment or early referral.

200

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ENVIRONMENTAL INJURY COMPLAINTS
*Algorithms for

Number

Heat Injury/Hyperthermia (Heat Cramps, Heat
Exhaustion, Heatstroke) . . . . . . . . . . . . . . . . . . . . . . . . . . . K-1
Hypothermia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . K-2
Immersion Foot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . K-3
Chapped Skin/Windburn . . . . . . . . . . . . . . . . . . . . . . . . . . . . K-4
Frostbite . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . K-5
Crabs/Lice (Pediculosis) . . . . . . . . . . . . . . . . . . . . . . . . . . . . K-6
Insect Bites (Not Crabs/ Lice) . . . . . . . . . . . . . . . . . . . . . . . . K-7
Sunburn . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . K-8
Contact Dermatitis (Includes Plants--Poison Ivy,
Oak, and Sumac) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . K-9

201

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HEAT INJURY/HYPERTHERMIA, K-1
(Heat Cramps, Heat Exhaustion, Heatstroke)
Heat injury results from exposure to excessive temperatures with or without accompanying strenuous physical activity. An excessive loss of water and salt from the body or a breakdown of the body’s cooling mechanism causes heat injury.
IMPORTANT INFORMATION ON THE ALGORITHM
Block 1. A “yes” response to any of the questions may indicate heatstroke. Heatstroke is characterized by high body temperature (>l03oF), confusion, delirium, coma, and, in most cases, an absence of sweating. The development of heatstroke represents a breakdown of the body’s heat regulating mechanism. Heatstroke is not necessarily preceded by heat exhaustion or heat cramps. Death may follow very rapidly. This condition has a high mortality rate and is a medical emergency. Lowering the body temperature is the most important objective in the treatment of heatstroke. The longer the high temperature continues, the greater the threat to life or risk of permanent damage. Dousing the patient with water and gently fanning him allows for evaporative cooling. Measures must be taken to prevent the patient from shivering. An intravenous infusion should be started and the patient’s body temperature should be monitored. Block 2. A “yes” response to questions may indicate heat exhaustion (prostration) which occurs as a result of an excessive loss of water and salt from the body. The syndrome is characterized by profuse perspiration, pallor, and perhaps low blood pressure. The mortality rate from this disorder, if treated, is extremely low. Moving the patient to a cool area for rest and the administration of fluids (orally or intravenous infusion, depending on severity of symptoms) will result in prompt recovery. Untreated heat exhaustion may progress to heatstroke.
Block 3. A “yes” response to these questions indicates heat cramps. These are painful cramps of voluntary muscles which result from excessive loss of salt from the body.
Muscles of the extremities and the abdominal wall are usually involved. Body temperature is normal. Heat cramps can be promptly relieved by replacing salt and fluid orally and placing the individual in a cool environment.
TREATMENT PROTOCOL K-1(3)
Place the patient in a cool or shaded place. Give the patient at least one liter of cool water to drink in the first 30 minutes and then at least one liter of water per hour the next
2 hours. Advise the patient to decrease his activity for the next 24 hours. If the patient’s symptoms do not begin to resolve themselves within 30 minutes, if they get worse, or if the patient’s temperature exceeds 101OF, refer the patient to the medical officer. 202

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HEAT INJURY/HYPERTHERMIA, K-1
(Heat Cramps, Heat Exhaustion, Heatstroke)
Take complaint-specific vital signs:
Rectal temperature
Blood pressure
Pulse rate

1
Does the patient appear confused, delirious, or unresponsive? Is his skin dry? Is his temperature o greater than 103 F?
Yes to any
No to all

Associated Complaints:
Headache
General weakness
Dizziness
Cold, sweaty skin
Cramping at the extremities and abdominal muscles

1. Douse the patient with water.
2. Start an IV as ordered by the doctor or PA.
3. Monitor his body temperature.

Category I

2
Is the patient sweating profusely; does he complain of headache, weakness, dizziness, and/or nausea?
Yes
No

3
Is the patient complaining of painful cramps of the extremities and/or abdominal muscles and is his body temperature normal? Yes
No

Category II

ICategory II

*Category IV, Treatment
Protocol K-1(3).

*NOTE: If the patient has already tried the treatment protocol or if he will not accept it, enter Category III as the disposition.

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HYPOTHERMIA, K-2
IMPORTANT INFORMATION ON THE ALGORITHM
Block 1. Hypothermia, or a lower than normal body temperature, can be the result of heat loss from exposure to cold or wet environments, from inadequate heat production due to poor nutrition or exhaustion, or from inaccurate heat regulation from using drugs such as nicotine, alcohol, and medications with anticholinergic side affects.
Block 2. A person can lose body heat faster than he can produce it, especially when poor nutrition and exhaustion are also present. Examples of incidents causing heat loss follow: a. A person exposed to cold temperatures.
J b. A person exposed to a cold wet environment where the insulating value of clothing may be lost.
c. A person exposed to warm wet environments or who has been swimming may lose heat faster than he can produce it. This is especially true when poor nutrition and exhaustion are also present.
Block 3. The first symptom of hypothermia is often mental. The victim is relatively unresponsive or uncooperative. Exposure plus a decreased level of alertness when the body temperature is less than 96oF indicates possible hypothermia. These signs and symptoms without a lowered body temperature may or may not be indicative of a problem. A medical officer should evaluate anyone who shows evidence of decreased mental alertness.
Block 4. Patients without a history of recent exposure may be mildly hypothermic from other causes, especially if they are children or elderly persons. In the absence of a lowered body temperature and/or a history of exposure, hypothermia is not likely.
Screen other complaints, if any, and consult the medical officer.

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HYPOTHERMIA, K-2
Take complaint-specific vital sign:
Temperature

1
Is the patient’s body temperature less than o 96 F?
Yes
No

Category III

2
Has the patient been exposed to a cold/wet environment? Yes
No

3
Is the patient fully alert?
Yes
No

4
Are there any other complaints? Yes
No

Category III
Category III

Category II

205

Screen other complaints

MEDCOM Pam 40-7-21
IMMERSION FOOT, K-3
Immersion foot usually results when the skin is exposed to wet, cold foot gear or from outright immersion of the feet at temperatures below 50oF. It may also occur following prolonged exposure at temperatures greater to 50oF.
IMPORTANT INFORMATION ON THE ALGORITHM
Block 1. Skin that is white and wrinkled is characteristic of immersion foot. Patients may also complain of swelling of the foot or pain while walking.
Block 2. Signs of infection (streaks, redness, or swollen glands in the lower legs) indicate a potentially serious condition that should be evaluated by the medical officer now. Block 3. A 7-day treatment regimen is required for treatment to be effective and for improvement to show. If there is no improvement after 1 week, the patient should be reevaluated for an alternate form of treatment.
TREATMENT PROTOCOL K-3(3)(4)
1. Keep your skin warm and dry.
2. Limit your activities for 3 to 4 days.
3. Return if the condition becomes worse or if signs of infection develop.

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IMMERSION FOOT, K-3
Associated complaints:
Take complaint-specific vital sign:

Skin is white and wrinkled
Swelling of the feet
Patient complains of pain while walking

Temperature

1
Is the patient’s skin around the affected area white? Are his feet swollen? Does he complain of pain while walking? Does he have a o fever of 100 F or greater?
Yes to any
No to all

Category III

2
Are there red streaks or general redness of the affected area? Does the patient have swollen glands in the groin or temperature o above 100 F?
Yes to any
No to all

Category II

3
Has the patient been following treatment protocol for at least 7 days? Yes
No

*Category IV, Treatment
Protocol K-3(3)(4).

4
Has the treatment failed?
Yes
No

Category III

Continue treatment

*NOTE: If the patient has already tried the treatment protocol or if he will not accept it, enter Category III as the disposition.
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CHAPPED SKIN/WINDBURN, K-4
Chapping is the unusually rapid drying of skin due to exposure to a hot or cold dry wind which draws water out of the skin. Generally, it is not a medical problem unless cracking or fissuring with a secondary infection takes place. The involved skin heals as new skin cells develop.
IMPORTANT INFORMATION ON THE ALGORITHM
Block 1. Since exposure to wind causes chapping, involvement of areas other than the hands and face makes this diagnosis unlikely, and the patient should be referred to the medical officer.
Block 2. Same reasoning applies as in Block 1.
Block 3. Presence of inflammation other than simple skin redness warns of the possibility of infection and requires referral to a medical officer for evaluation.
Block 4. In cool or cold weather and if normal sensation is absent, a more severe injury such as frostbite and/or significant burn becomes a possibility. Patient must be referred to medical officer for evaluation.
TREATMENT PROTOCOL K-4(4) Ill
Cover the involved area so it is no longer exposed to the drying wind. Symptomatic improvement may occur with the use of an oil base hand cream or cold cream;
Vaseline; lip balm may be used for the lips. The application of cream will also decrease wind effects.

208

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CHAPPED SKIN/WINDBURN, K-4

Associated Complaints:
Affected area is dry, rough and may be cracked 1
Is involved area on hands or face?
Yes
No

2
Has the patient been exposed to hot or cold dry wind?
Yes
No

Category III

3
Are there signs of inflammation other than skin redness?
Yes
No

Category III

Category III

4
Is sensation normal over involved area?
Yes
No

*Category IV,
Treatment
Protocol K-4(4)

Category III

*NOTE: If the patient has already tried the treatment protocol or if he will not accept it, enter Category III as the disposition.

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FROSTBITE, K-5
Frostbite is a condition that results from the skin (usually on the toes, fingers, or face) being exposed to extremely cold weather for an extended period of time. In severe cases, permanent destruction of tissues may occur from the crystallization of tissue water in the skin and adjacent tissues. The lower the temperature and the higher the wind, the shorter the time required to produce injury.
FROSTBITE IS A VERY SERIOUS CONDITION. Often, it is extremely difficult to determine the extent of the damage of the affected area; immediate evaluation is appropriate. 210

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FROSTBITE, K-5

Associated Complaints:
Pain, redness, and loss of feeling in the affected area Skin around the affected area is white and has waxy appearance

Refer the patient with frostbite symptoms to Category II care.

211

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CRABS/LICE (PEDICULOSIS), K-6
Crabs/lice are tiny insects that are visible to the naked eye that infest the hairy areas of the body (groin, underarms, and scalp). The insects deposit their eggs (nits) and attach them at the base of hair shafts. These shiny oval bodies are also visible to the naked eye. The bite of the insect causes intense itching which can cause a serious secondary infection. The three forms of blood-sucking lice are named--Head lice (pediculus humanus capitis),
-Body lice (pediculus humanus humanus), and
-Pubic lice (pthirus pubis), also known as crabs.
These insects require a diet of human blood. The adult insect will die a few days after removal from the body. The possibility of spreading infection to close associates by intimate contact or common use of clothing, beds, or toilet articles is real. Crabs/lice can be seen moving in and about the hairs. Effective treatment generally requires-- A pediculicide.
- Instructions on laundering clothing and bed linens.
Refer the patient to Category III if a nonprescription pediculicide (Rid) is not available.

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CRABS/LICE (PEDICULOSIS), K-6

Associated Complaints:
Intense itching
Scratch marks in affected area Refer the patient with crabs/lice to Category III if a nonprescription pediculicide (Rid) is not available.

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INSECT BITES (NOT CRABS/LICE), K-7
Insect bites are characterized by itching, local swelling, mild pain, and redness. All of these reactions represent a local reaction to the sting of the insect. Document any history of tick bites.
IMPORTANT INFORMATION ON THE ALGORITHM
Block 1. Swelling or pain located at a distance from the site of the original bite along with respiratory wheezing, shortness of breath, or hives indicates a systemic allergic reaction. These symptoms represent a life-threatening situation. Send the patient either to the emergency center or to see a medical officer immediately. Use a bee sting kit if emergency first aid is indicated.
Block 2. When ticks bite, the mouth parts will frequently remain behind. Remove these with tweezers before the treatment protocol is used.
Block 3. If the patient complains of an insect bite but the screener is unable to find a typical insect-bite-related symptom, the problem may indicate another form of illness. In this case, the patient should be referred as Category III.
TREATMENT PROTOCOL K-7(2)(3)(4) Ill
1. Remove any stinger or biting apparatus left in the bite site. Cleanse with Betadine solution. 2. Apply Calamine lotion or hydrocortisone 0.5% (1%, if available) cream 3 or 4 times daily. 3. Apply cold compress or ice pack.
4. If condition worsens or symptoms persists for more than 48 hours, return for further evaluation. 214

MEDCOM Pam 40-7-21
INSECT BITES (NOT CRABS/LICE), K-7

Take complaint-specific vital signs:
Temperature
Pulse
Respiration
Blood pressure

1
Does the patient have swelling or pain not at bite site, respiratory wheezing, shortness of breath, or hives?
Yes to any
No to all

2
Is a part of the insect present in skin?
Yes
No

3
Is the pain moderate to severe? Is there a blister or ulcer at the bite site?
Yes
No

4
Is there only localized swelling, itching, pain, and redness?
Yes
No

Associated Complaints:
Itching
Swelling (hives)
Shortness of breath
Wheezing
General discomfort
Redness of affected area

Category I

*Category IV, Treatment
Protocol K-7(2)(3)(4).

Category III

*Category IV, Treatment
Protocol K-7(2)(3)(4).

Category III

*NOTE: IF the patient has already tried the treatment protocol or if he will not accept it, enter Category III as the disposition.

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SUNBURN, K-8
Sunburn is generalized redness of the skin produced by overexposure to sunlight.
Sunburn should be avoided since repeated overexposure to the sun over a long period of time can damage the skin permanently. This overexposure has been confirmed as contributing to skin cancer.
IMPORTANT INFORMATION ON THE ALGORITHM
Block 1. The patient who does not have typical sunburn symptoms should be referred to the medical officer for evaluation.
Block 2. Patients with severe burns (characterized by the presence of blisters) or generalized weakness that can be associated with heat exhaustion should not be treated with self care and should be seen by the medical officer.
Block 3. If the patient is unable to perform daily duties due to sunburn, he should be seen by the medical officer.

TREATMENT PROTOCOL K-8(3)
1. Take two aspirin tablets every 4 hours for 2 to 3 days.

216

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SUNBURN, K-8

Take complaint-specific vital sign:
Temperature

1
Is the patient’s skin painful to the touch? Is the area red that was exposed to the sun?
Is he complaining of general discomfort?
Yes to any
No to all

Category III

Associated Complaints:
General discomfort
Redness of skin
Pain on contact

2
Does the patient have blisters (not just peeling)? Does he complain of general weakness? Does the burn cover 25% of his body? Yes to any
No to all

3
Does the patient show signs of inability to perform normal duties? Yes
No

Category III

Category III

*Category IV, Treatment
Protocol K-8(3).

*NOTE: If the patient has already tried the treatment protocol or if he will not accept it, enter Category III as the disposition.

217

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CONTACT DERMATITIS (INCLUDES PLANTS--POISON
IVY, OAK, AND SUMAC), K-9
Contact dermatitis results when the skin comes in contact with anything in the environment that causes an inflammatory reaction. Such items can be shoe materials, watchbands, earrings, and poison ivy. Poison ivy is the most common example of this group. The skin reaction to poison ivy is caused by the oil secreted from the ivy leaves.
The oil can be transported directly from the plant to the skin by way of a person’s hand or it may even be inhaled if the plants are being burned. A poison ivy rash is usually confined to the arms, legs, or face since these body parts readily come in contact with the plant. Other contact dermatitis reflects the area of contact. Symptoms usually develop within 24 to 48 hours of contact and are characterized by itching, redness, minor swelling, and the formation of blisters. The blisters can break resulting in oozing fluid and a crusted appearance. Contrary to popular belief, the fluid from broken blisters does not cause more lesions; only the plant oil on further contact can do that.
IMPORTANT INFORMATION ON THE ALGORITHM
Block 1. The absence of typical poison ivy symptoms makes other causes for the rash likely. Refer the patient to Category III care.
Block 2. Numerous blisters involving large areas or major complaints of pain require that the patient be referred to Category III care.
Blocks 3 and 4. The patient should be instructed to continue the prescribed treatment unless his condition becomes worse or, if after 5 to 7 days, the condition fails to show signs of improvement. In any unimproved or worsened case, the treatment should be considered a failure, and the patient should be reevaluated by the medical officer.
TREATMENT PROTOCOL K-9(3)(4) 111
1. Avoid further contact with the plant.
2. If the area is small and if intense itching with blistering is evident, apply Burrow’s solution compresses every 4 hours for 30 minutes. This will provide relief.
3. Apply hydrocortisone 1% cream to the affected area 3 to 4 times daily.
4. If condition worsens or if symptoms persist for more than 7 days, return for further evaluation. 218

MEDCOM Pam 40-7-21
CONTACT DERMATITIS (INCLUDES PLANTS--POISON IVY,
OAK, AND SUMAC), K-9
Take complaint-specific vital signs:
Temperature
Pulse
Respiration
Blood Pressure

1
Did the patient have a sudden onset of itching, redness, or blisters that are crusted or oozing fluid? Yes to any
No to all

Associated Complaints:
Itching
Redness
Swelling
Blisters, either crusted or oozing fluid

2
Are there numerous blisters involving a large area or is there severe pain?
Yes to either
No to both

Category III

Category III

3
Has the patient been following the treatment protocol for 5 to 7 days?
Yes
No

4
Has the treatment failed?
Yes
C
No

Category III

*Category IV, Treatment
Protocol K-9(3)(4)

*NOTE: If the patient has already tried the treatment protocol or if he will not accept it, enter Category III as the disposition.

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220

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MISCELLANEOUS COMPLAINTS
*Algorithms for

Number

Prescription Refill . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L-1
Wants a Vasectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L-2
Needs an Immunization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L-3
Exposed to Hepatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L-4
Dental Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L-5
Sores in the Mouth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L-6
Lymph Node Enlargement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L-7
Blood Pressure Check . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L-8
Preparation of Replacements (POR) for Overseas
Movement Qualification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L-9
Weight Reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L-10
Complaint Not on List . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L-11
Request for Nonprescription Medication . . . . . . . . . . . . . . . . . . . . . . L-12

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PRESCRIPTION REFILL, L-1
Use this algorithm for all prescription refills except birth control pills.
IMPORTANT INFORMATION ON THE ALGORITHM
Some patients request a refill of medication prescribed for an acute illness. Patients are normally given enough medication initially to cover the anticipated period of illness. If the patient wants additional medication, the illness may not be responding to the treatment as expected. In this case, the patient needs to be rescreened by his complaints. The only exception would be the patient who lost his original prescription.
Patients who require refills of long-term medications should be evaluated by the medical officer to make certain the underlying problem is being appropriately treated.

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PRESCRIPTION REFILL, L-1

Has the patient been on medication over 1 month?
Yes
No

Category III

Screen Complaint

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224

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WANTS A VASECTOMY, L-2
For the patient who wants a vasectomy, schedule a routine appointment with a medical officer, Category III.

225

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NEEDS AN IMMUNIZATION, L-3
Routine immunizations are normally provided only at scheduled times. If the immunization is required prior to the next scheduled time, the patient must be seen by the medical officer.

226

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NEEDS AN IMMUNIZATION, L-3

Is the immunization required prior to the next routine immunization time?
Yes
No

Category III

Routine immunization at scheduled times

227

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EXPOSED TO HEPATITIS, L-4
Refer all patients who know or suspect exposure to hepatitis to Category III care.
These patients may require gamma globulin injections. If the patient has any symptoms, screen them.

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EXPOSED TO HEPATITIS, L-4

Does the patient have any other complaints?
Yes
No

Screen specific complaint, but do not screen to self-care protocol even if called for by the algorithm.

Category III

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DENTAL PROBLEMS, L-5
Problems with the teeth are usually self-evident. However, pain in and around the teeth may be associated with other types of illnesses. Always inquire about other complaints before referring the patient to a dentist.

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DENTAL PROBLEMS, L-5

1
Does the patient have any other complaints?
Yes
No

2
Is the patient in pain?
Yes
No

Screen other complaint

Category III

Dental Clinic (routine)

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SORES IN THE MOUTH, L-6
Sores in the mouth are usually inflammatory or ulcerative in nature and may be associated with many upper respiratory infections or may result from trauma. Refer patients with sores in the mouth to Category III care.

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LYMPH NODE ENLARGEMENT, L-7
The patient may complain of swollen glands, a swelling, or a lump. Enlarged lymph nodes are most commonly found in the neck, armpits, and groin. Localized swellings in other areas are less likely to represent lymph nodes. A lymph node enlargement may result from an inflammation in the area of the body drained by node or from systemic illness. In the former case, the enlarged nodes are likely to be confined to that area. In the latter case, lymph nodes in several areas of the body may be involved.
IMPORTANT INFORMATION ON THE ALGORITHM
Block 1. Other more specific complaints may give a clue to the cause of the lymph node enlargement. If the node(s) are in the neck, specifically ask about URI symptoms.
If in the armpit or groin, ask about sores in the arms or legs, respectively. Most lymph node enlargements secondary to local inflammation will subside within 2 weeks if the primary problem has subsided. Persistence of lymph node enlargement beyond this time raises the possibility of more serious disease that must be evaluated by a medical officer. 234

MEDCOM Pam 40-7-21
LYMPH NODE ENLARGEMENT, L-7

Take complaint-specific vital sign:
Temperature

Does the patient have any other complaints?
Yes
No

Screen other complaints.

Category III

235

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BLOOD PRESSURE CHECK, L-8
IMPORTANT INFORMATION ON THE ALGORITHM
Block 1. Patients who have been told to have their blood pressures checked need to have it checked at times directed by the medical officer. Upon completion of the checks, results are reported to the responsible medical officer.
Block 2. If this is the final day of the check, the patient should be referred to the ordering medical officer. If not, the patient should be reminded to come back for all future parts of the blood pressure check.
Block 3. Patients who were not told by the medical officer to have their blood pressure checked but simply want it checked may well have other complaints that need to be evaluated. If so, screen those complaints.
Block 4. If the patient does not have other complaints, obtain his blood pressure if the equipment is available. Refer the patient to Category III care if his blood pressure is greater than 140/90 (greater than 140 systolic and/or greater than 90 diastolic). Blood pressure should be checked in both arms. Any significant difference in readings between the arms should be reported to the medical officer immediately while the patient waits.

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BLOOD PRESSURE CHECK, L-8
Take complaint-specific vital signs:
Blood pressure
Pulse

1
Was the patient’s blood pressure check ordered by medical personnel?
Yes
No

2
Is this the final day of the check? Yes
No

Category III

If equipment is available, take and record blood pressure reading. Tell patient to come to all ordered visits
3
Does the patient have a specific complaint he wishes evaluated?
Yes
No

4
Record the blood pressure.
Is blood pressure 140/90 or less? Yes
No

Screen other complaints

Category III

237

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PREPARATION OF REPLACEMENTS (POR) FOR OVERSEAS
MOVEMENT QUALIFICATIONS, L-9
Active duty personnel on orders for overseas assignments require review of their medical records to determine if they have a medical condition that would preclude the assignment and to ensure their immunizations are current.
Refer the member who needs to be POR qualified to Category III.

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WEIGHT REDUCTION, L-10
Individuals who come on sick call requesting assistance with weight control or diet therapy to reduce their weight should be seen by the dietitian if there are no medical problems that require evaluation. If a dietitian is unavailable, the patient should be seen by a doctor.

240

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WEIGHT REDUCTION, L-10

Is there a medical problem that the patient wants evaluated? Yes
No

Screen complaint. If the patient is eventually referred, instruct him to ask the care provider whether he should be on a weight program after complaint is evaluated.

Category III

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COMPLAINT NOT ON LIST, L-11
Any patient with a complaint not covered in this screening manual must be referred to the medical officer for disposition. If the patient complains of any symptoms, take the patient’s vital signs. If all vital signs are normal, referral will normally be as Category III.
NOTE
If, for any reason, you feel that the disposition of the patient as determined by the algorithms is inappropriate, do not hesitate to consult the medical officer.

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COMPLAINT NOT ON LIST, L-11
If the patient’s complaint is not listed among the algorithms, refer as Category Ill.

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REQUEST FOR NONPRESCRIPTION MEDICATIONS, L-12
This algorithm refers to patients requesting specific nonprescription medications for self care. Medications are not to be handed out to people who are seeking to fill their medicine cabinets just in case they get ill. Since nonprescription medications can be dangerous if not properly used, the patient should be screened first to ensure that the medication requested is appropriate for his immediate symptoms.

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REQUEST FOR NONPRESCRIPTION MEDICATIONS, L-12
Screen appropriate complaint to ensure that the requested medication is suitable for the patient’s immediate symptoms.

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MISCELLANEOUS REASONS FOR RETURN
*Algorithms for

Number

Showing No Signs of Improvement (Not Getting Better) . . . . . . . . . M-1
Return Requested by Care Provider . . . . . . . . . . . . . . . . . . . . . . . . . M-2

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SHOWING NO SIGNS OF IMPROVEMENT (NOT GETTING BETTER), M-1
This refers to a patient who returns even though he was not told to do so by the original care provider. He should not be given self care as his is not a new problem and, therefore, is more likely to require detailed evaluation. Refer all such patients to a medical officer.

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SHOWING NO SIGNS OF IMPROVEMENT
(NOT GETTING BETTER), M-1
Rescreen the patient, but do not recommend self care even if called for by the algorithm. 249

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RETURN REQUESTED BY CARE PROVIDER, M-2
This refers only to patients originally seen by a medical officer or in a specialty clinic.
Many patients are told to return for follow up. Write the name of the original care provider on the screening note and explain to the patient that if that individual is not on duty at the time, someone else will see him. If the patient seems acutely ill, rescreen him by complaint prior to referral.

250

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RETURN REQUESTED BY CARE PROVIDER, M-2
If possible, refer the patient to the same care provider either as Category III or Category
II.

251

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APPENDIX B
LIST OF MEDICATIONS
The following is a list of medications prescribed in the SCPs. Medications can be deleted, but cannot be added.
Analgesic balm (Ben Gay)
Anesthetic ointment
Antibacterial ointment
Antidandruff shampoo
Antifungal foot ointment, powder, or solution
Antihistamine (Benedryl)
Aspirin (enteric coated)
Betadine
Bulking agent
Calamine Lotion
Decongestant (limit to one box due to potential drug diversion problems)
Domeboro’s Solution
Expectorants (Robitussin)
Gargle
Heat rub
Hemorrhoidal suppositories
Hydrocortisone 0.5% or 1% cream
Ibuprofen 200 mg
Imodium
Nasal spray decongestant
Pepto-Bismol
Stool softener
Throat lozenges (Cepacol lozenges)
Tylenol (325 mg tabs)

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APPENDIX C
SCREENING NOTE OF ACUTE MEDICAL CARE, DA FORM 5181
1. To ensure appropriate documentation of patient care, screeners will use DA Form
5181 (Screening Note of Acute Medical Care) to record the use of ADTMC in TMCs and
BASs. The form will be a permanent part of the patient’s health record. Use of this form is mandatory when screeners provide treatment and disposition of active duty patients. 2. The form is available electronically through the AMEDD E-Forms Program. A copy for local reproduction is at the end of this appendix if electronic forms are not available.
3. Special instructions.
a. Vital signs-Record as required by individual algorithm.
b. Algorithm/Code – Using the patient’s chief complaint, enter the algorithmic code in parentheses following the algorithm title (e.g., Headache, F-2). If the patient presents two related chief complaints, the more serious of the two must be determined and the appropriate algorithm utilized. When two complaints appear to be unrelated or if the screener is unable to determine the more serious of the two, each complaint will be screened separately utilizing both spaces.
c. Algorithm summary--Following the flow chart for the selected algorithm, the screener must summarize–by numbered narrative statements--the question and answer for each box number until an end-point is reached. In certain instances (e.g., Extremity
Pain/Joint Pain, B-2), the logic may involve skipping one or more boxes. In this case,
DO NOT enter a response for any boxes skipped.
d. Comments. If the algorithm disposition results in a level I, II, or III, the screener may gather more subjective data, examine the patient where appropriate, and make a tentative assessment. At the point of assessment, there must be evidence of the direct involvement of the medical officer. The medical officer must physically evaluate the patient, confirm the screener’s data, independently assess the patient’s complaint, and direct the plan of care. This evidence will be a note, in the medical officer’s handwriting on DA Form 5181. Post script signatures and comments are prohibited.
e. Final Disposition. Check the health care provider level indicated by the algorithm endpoint. If an SCP is called for, the screener must enter the protocol number. The screener will enter prescribed medications in the “comments” section. If two algorithms are used and the endpoints direct the patient to different health care provider levels, the screener will enter the higher level.

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f. Record of Acute Medical Care (reverse side). Entries in this section are for use by a medical officer for documentation of further evaluation and treatment of complaints previously screened.
4. This form will accompany the patient to the next level of care and be a part of the health record when evaluation and audit are complete.

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GLOSSARY

Section I
Abbreviations
AD
Active duty
ADTMC
Algorithm-directed troop medical care
AMEDD
Army Medical Department
APA
Aeromedical physician assistant
AR
Army regulation
BAS
Battalion aid station
CAF
Competency assessment file
DA
Department of the Army
GI
Gastrointestinal
GYN
Gynecology
HCG
Human chorionic gonadotrophin
KOH
Potassium hydroxide
MEDCOM
U.S. Army Medical Command
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MTF
Military treatment facility
OB
Obstetrics
PA
Physician assistant
PFB
Pseudofolliculitis Barbae
PI
Performance improvement
POR
Preparation for replacements
PRP
Personnel Reliability Program
SCP
Self-care protocol
SOP
Standing operating procedure
STD
Sexually transmitted disease
TMC
Troop Medical Clinic
URI
Upper respiratory infection
Section II
Terms
Occasionally the screening aidman may be uncertain of the definition of some of the medical terms used in this manual. Since many battalion aid stations do not have access to a medical dictionary, the following glossary of terms is provided.
Acne. A common skin condition occurring primarily in the late teens and early twenties but may continue into the thirties. Heredity, diet, hygiene, stress, and general illness can aggravate acne and be extremely upsetting to the young Soldier. Acne is caused
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MEDCOM Pam 40-7-21 by plugged oil glands. The oily material that is secreted develops a dark color when exposed to the air, forming what is known as a “blackhead.” These plugged glands may become infIamed, and pimples develop when bacteria begin breaking down the oil thereby producing irritating substances as by-products. With proper treatment, acne can be improved, thus avoiding scarring and lifelong side effects.
Athlete’s foot. Athlete’s foot is the result of a fungal infection that usually starts with scaling and/or fissuring between the toes accompanied by intense itching. It is not uncommon for the infection to spread to other portions of the foot, especially around the toenail. The presence of athlete’s foot fungus can be confirmed by a potassium hydroxide test at the TMC.
Atrophy. Degeneration, wasting away.
Boil. Also known as a furuncle if it has a single “core”, or carbuncle if multiple cores. A painful nodule formed in the skin by inflammation enclosing a core. It is caused by bacteria which generally enter through a follicle. Tenderness, swelling, and pain are present around the area of redness. Extremely large or numerous boils can produce fever. Burn. Any localized injury to the outer layer of skin caused by heat and characterized by redness, pain, and/or blisters. The three degrees of burns are:
First Degree (characterized by redness)
Second Degree (characterized by blistering)
Third Degree (characterized by a leathery, whitish appearance; results when the outer layer of skin is destroyed).
Chancre. The primary sore of syphilis characterized by an elevated painless ulceration which indicates the point of entry of the infection.
Competency assessment file. A repository for a variety of relevant professionally oriented data and information that are accumulated throughout the individual’s tenure in the organization. The CAF should contain information that relates to or may influence clinical performance; it is not a personnel or counseling folder. The first line supervisor maintains the competency assessment file for non privileged health care personnel working within the AMEDD. See AR 40-68 for additional discussion of the CAF.
Confusion. A disturbance in the patient’s understanding to the point that simple questions directed to the patient are not understood.
Conjunctivitis. Inflammation of the membrane that lines the eye and eyelids; also referred to as “pink eye.”
Constipation. Infrequent or difficult bowel movements.
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Constitutional. Affecting the entire body; not local.
Contact dermatitis (poison ivy). Results when the skin comes in contact with anything in the environment that causes an inflammatory reaction in the skin (e.g., shoe materials, watchband, earrings, etc.). Poison ivy is the most common cause of contact dermatitis. The specific cause of the skin reaction in poison ivy is the oil secreted by the leaves. This oil can be transported directly from the plant to the skin by way of a person’s hand or even inhaled if the plants are being burned. A poison ivy rash is usually confined to the arms, legs, or face since these body parts readily come in contact with the plant. Symptoms usually develop within 24-48 hours of contact and are characterized by itching, redness, minor swelling, and the formation of blisters. The blisters can break resulting in oozing fluid and a crusted appearance. Contrary to popular belief, the fluid from broken blisters does not cause more lesions; only the plant oil can do that.
Contraception. The prevention of pregnancy.
Dandruff. A condition affecting the epidermal (outer) skin layer of the scalp characterized by itching and scaling of the scalp. More serious cases of dandruff can affect the facial areas as well.
Dermis. See Skin.
Diarrhea. Loose or liquid bowel movements of abnormal frequency.
Diastolic pressure. A measure of the blood pressure during the stage of dilation of the heart while it fills with blood; the low point of a blood pressure reading.
Diplopia. Seeing two images of a single object; double vision.
Drug reaction (rash). An acute widespread temporary reddish eruption on the skin which can develop in individuals sensitive to a particular drug (prescription or nonprescription). The rash is characterized by itching that can interfere with sleep or performance of normal duties/activities. The rash results from the entire body reacting to the drug itself and usually develops early in treatment rather than after the drug has been taken for a period of time.
Dysphagia. Difficulty in swallowing.
Dysuria. Difficulty in or pain during urination.
Epidermis. See Skin.
Epistaxis. Nosebleed (normally resulting from the rupture of small blood vessels inside the nose).
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Eustachian tube. Auditory tube, channel extending from the middle ear to the nasal passages. Exudate. A substance found out of the normal or usual place deposited in or on tissue, usually resulting from inflammation.
Fatigue. State of increased discomfort and decreased efficiency resulting from prolonged or excessive exertion.
Fissure. A line-like crack in the skin.
Frostbite. The condition that results from the skin being exposed to extremely cold weather for an extended period of time (usually the toes, fingers, or face are affected).
In severe cases, permanent destruction of tissues may occur from the crystallization of tissue water in the skin and adjacent tissues.
Gastroenteritis. Inflammation of the stomach and intestines.
Hair follicle. See Skin.
Hair loss. While most hair loss is natural and hereditary, any hair loss that is sudden or extreme in nature can result from a severe infection, caustic chemicals, or drugs. When treated promptly and properly, hair growth can resume.
Heat Injury. The result of exposure to excessive temperatures with or without accompanying strenuous activity. The cause of heat injury is an excessive loss of water and salt from the body or a breakdown of the body’s cooling mechanism.
Hematuria. Blood in urine.
Hemorrhoids. Expansion of one or more veins in the rectal area resulting from an increase in venous pressure.
Hypertension. Persistently high blood pressure.
Hyperventilation. Abnormally prolonged, rapid, and deep breathing causing an increased amount of air to enter the lungs resulting in a decrease in the level of carbon dioxide (Co) dissolved in the blood.
Immunologic. Pertaining to that branch of medicine dealing with the response of the body to the introduction of foreign substances (antigens) such as bacteria, viruses, and ragweed pollen.
Jock itch (Tinea Cruris). Caused by a fungal infection and aggravated by sweating, restrictive garments, and a failure or inability to wash and dry carefully on a daily basis.
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This type of infection causes intense itching that can be disabling. In addition to intense itching, red areas with many small blisters and dandruff-like scales develop on either side of the scrotum. Spread of the infection beyond the groin area and involvement of the scrotum and/or penis is uncommon. A secondary bacterial infection can develop which can render the patient seriously ill.
Laryngitis. Inflammation of the larynx which may be accompanied by throat dryness, soreness, hoarseness, cough, and/or difficulty in swallowing.
Lesions. A wound, injury, or pathological alteration of tissue.
Malaise. A vague feeling of body discomfort.
Medical officer. As used in this pamphlet, includes the following health care providers: physicians, physician assistants, and other qualified provider.
Meninges. The three membranes that surround the brain and spinal cord.
Menopause. Cessation of menstruation in the female, usually occurring between the ages of 46 and 50.
Menstrual period. The cyclic uterine bleeding which normally occurs in females at approximately 4-week intervals during the reproductive years in the absence of pregnancy. Myalgia. Pain in a muscle or muscles.
Nausea. An unpleasant sensation that one may vomit (sick to the stomach).
Neoplasm. Any new or abnormal growth (tumor). Everyone develops neoplasm during their lifetime, but most neoplasms are not cancerous.
Pap exam. A microscopic examination of cells to detect the presence of a cancerous process. Pediculosis (crabs). This condition affects hairy areas such as the groin, underarms, and scalp and is the result of infestation by tiny insects that are visible to the naked eye.
The bite of the insect causes intense itching which can result in a serious secondary infection. The three forms of blood-sucking crabs are-Head lice (pediculosis capitis)
Body lice (pediculosis corporis)
Pubic lice (pediculosis pubis) also known as “crabs.”
These insects require a diet of human blood. The adult insect will die a few days after removal from the body; nits must receive a blood meal within 24 hours of hatching or they too will die. The possibility of spreading infection to close associates by intimate
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MEDCOM Pam 40-7-21 contact or common use of clothing, beds, or toilet articles is real and should be considered. Pseudofolliculitis barbae (shaving problem). A chronic condition characterized by inflammation of the beard area resulting from reentry of the growing hair into the upper layer of the skin. It can occur in any male with curly hair. The genetic predisposition of the black male to tight coiling hair makes him highly susceptible to this condition. The most common locations for lesions are the face and neck. The lesions can be painful and interfere with shaving although they rarely become secondarily infected.
Sebaceous gland. See Skin.
Skin. The skin is the largest organ of the body and its main duty is to protect man from the external environment. As a result of our constant exposure to a potentially harmful environment, diseases of the skin are common in all occupations and can cause many forms of disability.
PRINCIPLE STRUCTURES OF THE SKIN
a. Horny layer (stratum corneum). The outer layer of the skin. This outer layer is composed of dead, tightly-packed layers of cells that develop in the deeper layers of the skin, have moved upward, and are slowly being rubbed off or shed. This layer of dead skin is watertight thus protecting the body from water seeping in and out of the body.
b. Epidermis. Composed of living cells which, as they mature, serve as a constant renewal source for stratum corneum. The epidermis contains the pigment cells which determine skin color. The epidermis does not contain blood vessels, hair roots, or sweat glands. Damage to this layer does not result in scarring, but chronic or repeated damage can alter the number of pigment cells in the layer resulting in an overall change in the color of the skin. An example of this effect is a suntan. The darker color is a result of an increase in the pigment cells following injury of the epidermis by the ultraviolet rays of the sun.
c. Dermis. The supporting layer of the skin containing blood and lymph vessels, sweat glands, and hair follicles. Injury to the dermis can often result in bleeding. Found in the dermis are–
(1) Hair follicles. Originate deep in the dermis and are composed of tightlypacked cells serving to support the growth of the hairshaft. Injury to either the dermis or deeper layers can cause death of the hair follicle and result in the absence of hair after the injury heals.
(2) Sweat glands. Are also located deep in the dermis and are capable of secreting salt and water which rise up through the dermis and epidermis to the surface
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MEDCOM Pam 40-7-21 of the skin through pores. Evaporation of this sweat is part of the body's natural cooling process. (3) Oil glands (sebaceous glands). Are connected to the hair follicle and have as a primary duty the secretion of an oily substance called “sebum.” This sebum reaches the surface through the channel that the hair shaft occupies. This substance is not to be confused with sweat which is made up mostly of water.
d. Subcutaneous tissue. Situated beneath the dermis and filled with large arteries, veins, nerves, lymph gland, and supportive tissue. Within the subcutaneous layer, fat (adipose) tissue is distributed. Injury to this layer will always result in scarring.
Injury or illness to the skin can involve any or all of these parts. Signs and symptoms of diseases of the skin depend on the degree of the injury or illness and the structures affected. Skin Laceration. Caused by any injury that results in damage to the outer layer of skin.
If the injury is to a portion of the skin carrying blood vessels or nerves, bleeding and pain often result. A skin laceration involving a puncture wound or animal/human bite may require a tetanus shot and is serious due to the possible spread of infection.
Spinal meningitis. Inflammation of the meninges of the spinal cord.
Stratum corneum. See Skin.
Subcutaneous tissue. See Skin.
Sunburn. Result of overexposure of the skin to sunlight and characterized by a general redness of the skin. Fair-skinned individuals are more prone to freckling and sunburn quickly and frequently. Repeated overexposure to the sun should be avoided as permanent skin damage characterized by atrophy, dryness, wrinkling, and discolored areas can develop.
Sweat gland. See Skin.
Systolic pressure. A measure of the blood pressure during which the blood is driven from the heart throughout the body to the extremities; the high point of a blood pressure reading. Tina versicolor. Common superficial fungal infection which appears on the chest, back, arms, and abdomen usually with no other symptom. A patient with this condition complains only of the unsightly yellowish-tan or brown scaly lesions which may be localized in small patches or cover large areas of skin. Normally, the rash is sharply demarcated. Affected areas do not tan and become more noticeable during the summer. The responsible fungus is abundant in warm moist climates.
Trauma. A wound or injury (whether physical or psychological).
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Trench foot. Results from prolonged exposure to wet, cold foot gear or outright immersion of the feet at temperatures usually below 50oF. At 50oF, exposure of 12 hours or more will cause injury. A shorter duration of exposure is needed at or near
32oF. The duration of exposure needed for trench foot decreases as the temperature approaches freezing.
URI. Upper respiratory infection.
UTI. Urinary tract infection.
Vertigo. An illusion of movement; sensation as if the external world were revolving around the patient or the patient himself was revolving in space. Not to be confused with dizziness which is a feeling of unsteadiness.
Vesicle. Superficial elevations of the skin formed by free fluid beneath the skin layer as in a blister.

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TERMS OF LOCATION
Anterior (Ventral). Pertaining to the front surface of the body or part.
Caudal. Pertaining to the tail end of the body.
Cephalic. Pertaining to the head or to the head portion of the body.
Deep. Not superficial; situated far beneath the surface of the body or part.
Distal. Part farthest from the point of attachment.
Inferior. Beneath or below some part of a structure.
Lateral. At or near the side surface of the body or part.
Medial. At or toward the midline of the body or part.
Midline. Along the line extending down the middle of the body dividing the body into right and left sides.
Pelvic. Pertaining to the basin-shaped ring of bones which supports the spinal column and rests upon the lower extremities.
Proximal. Part nearest to the point of attachment.
Substernal. Situated below the breast bone.
Superficial. Pertaining to the outer surface of the body or part.
Superior. Over or above some part of a structure.

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TERMS OF MOTION
Abduction. Movement away from the midline.
Adduction. Movement toward the midline.
Eversion. Turning outward (e.g., sole of foot away from midline).
Extension. Movement that results in a straightening of an extremity.
External (lateral) rotation. To rotate from the midline; outward rotation.
Flexion. Movement that results in a bending of an extremity.
Internal (medial) rotation. To rotate from the midline; inward rotation.
Inversion. Turning inward (e.g., sole of foot towards midline).
Pronation. Refers to hand and forearm movement; results in the palm of the hand facing backward.
Supination. Refers to hand and forearm movement; results in the palm of the hand facing forward.

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The proponent of this pamphlet is the Deputy Chief of Staff for Health
Policy and Services. Users are invited to send comments and suggested improvements on DA Form 2028 (Recommended Changes to Publications and Blank Forms) to Commander, U.S. Army Medical
Command, ATTN: MCHO-CL-C, 2050 Worth Road, Suite 10, Fort Sam
Houston, TX 78234-6010.
FOR THE COMMANDER:

WILLIAM H. THRESHER
Chief of Staff
VASEAL M. LEWIS
Colonel, MS
Assistant Chief of Staff for
Information Management
DISTRIBUTION:
This publication is available in electronic media only and is intended for MEDCOM distribution As (4) 5 ea, (6) 1 ea, (10) 20 ea, (25) 5 ea, (26) 2 ea; Bs (1 and 2) 5 ea;
Cs (1 thru 11) 1 ea; Ds (1 thru 6) 10 ea, (7 thru 39) 5 ea.
SPECIAL DISTRIBUTION:
MCHC (Stockroom) (1 cy)
MCHS-AS (Forms Mgr) (1 cy)
MCHS-AS (Editor) (2 cy)

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