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The beam is then invisible as it traverses the almost protein and cell-free aqueous humor in the anterior chamber effective 200mcg levothroid thyroid gland swollen causes. The light beam is visible again as a focal reflection on the anterior lens capsule and then as a diffuse beam through the body of the normal lens due to best 100 mcg levothroid thyroid symptoms blood work normal presence of lens proteins discount levothroid 100 mcg with mastercard zapping thyroid gland. If uveitis has allowed leakage of serum proteins into the anterior chamber then these will cause a scattering of the light as it passes through the aqueous order levothroid 200mcg mastercard thyroid cancer books. Aqueous flare is therefore detected when a beam of light joining the focal reflections on the corneal surface and the anterior lens capsule is visible traversing the anterior chamber. A slit lamp provides ideal conditions for detecting flare, however the beam produced by the smallest circular aperture on the direct ophthalmoscope held as closely as possible to the cornea in a completely darkened room and viewed transversely will also provide excellent results. The slit beam on the direct ophthalmoscope is not as intense and does not provide as many "edges" of light where flare can be appreciated most easily. Assessment of flare may be easier after complete pupil dilation due to the apparent dark space created by the pupil. Long term use of miotics Ans b Allergic conjunctivitis is suggested by bilateral itchy eyes, a history of atopy, and a ‘cobblestone’ appearance of the upper palpebral conjunctiva. Typical lesion is characterized by the presence of hard, flat-topped papillae arranged in cobblestone or pavement stone fashion. Clinical findings include dense stromal and epithelial edema with corneal protrusion, possible conjunctival hyperemia and irregular epithelium secondary to microcystic edema the location and area of the involved cornea is variable 16. Its common causes are thinning of sclera following perforating injury, scleritis & absolute glaucoma. Posterior staphyloma In the posterior segment of the eye, typically diagnosed at the region of the macula, deforming the eye in a way that the eye-length is extended associated with myopia (nearsightedness). It is diagnosed by ophthalmoscopy, which shows an area of retinal excavation in the region of the staphyloma. It consists of 1 percent tetracycline or 1 percent erythromycin eye ointment 4 times a day for 6 weeks or 20 percent sulfacetamide eye drops three times a day along with 1 percent tetracycline eye ointment at bed time for 6 weeks. The continuous treatment for active trachoma should be followed by an intermittent treatment especially in endemic or hyperendemic area. Tetracycline or erythromycin 250 mg orally, four times a day for 3-4 weeks or doxycycline 100 mg orally twice daily for 3-4 weeks or single dose of 1 gm azithromycin has also been reported to be equally effective in treating trachoma. It includes: (i) 1 per cent tetracycline or erythromycin eye ointment 4 times a day for 6 weeks; and (ii) tetracycline or erythromycin 250 mg orally 4 times a day for 2 weeks. Gram positive diplobacilli Ans C Morax-Axenfeld diplobacillus or Moraxella lacunata is a rod-shaped, Gram negative, non motile bacteria, generally present as diploid pairs. Depending on the physical and chemical structure of the polymer, it is capable of absorbing from 10 to 600% water relative to the dry weight. Because of this property, it was one of the first materials to be successfully used in the manufacture of flexible contact lenses 20 By using which one of the instruments corneal thickness can be best measuredfi Modern devices use ultrasound technology, while earlier models were based on optical principles. The ultrasonic Pachymeters traditionally have been devices that provide the thickness of the human cornea in the form of a number in micrometres that is displayed to the user. Pachymetry using the corneal waveform allows the user to more accurately measure the corneal thickness, have to ability to check the reliability of the measurements that were obtained, have the ability to superimpose corneal waveform[12] to monitor the change of patients cornea over time, and ability to measure structures within the cornea such as micro bubbles created in the cornea during femto-second laser flap cu 21. Total bilirubin level 10 mg/dl Ans d Early exchange transfusion has usually been performed because of anemia (cord hemoglobin < 11 g/dL), elevated cord bilirubin level (>70 µmol/L or 4. A rapid rate of increase in the serum bilirubin level (>15-20 µmol/L /h or 1 mg/dL/h) was an indication for exchange transfusion, as was a more moderate rate of increase (>8-10 µmol/L/h or 0. Convulsions Ans D one of the following findings is also necessary for a diagnosis of severe preeclampsia: • Signs of central nervous system problems (severe headache, blurry vision, altered mental status) • Signs of liver problems (nausea and/or vomiting with abdominal pain) • At least twice the normal measurements of certain liver enzymes on blood test • Very high blood pressure (greater than 160 systolic or 110 diastolic) • Thrombocytopenia (low platelet count) • Greater than 5g of protein in a 24-hour sample • Very low urine output (less than 500mL in 24 hours) • Signs of respiratory problems (pulmonary edema, bluish tint to the skin) • Severe fetal growth restriction • Stroke 25. The serum bilirubin level that triggered an exchange transfusion in infants with hemolytic jaundice was 350 µmol/L (20 mg/dL) or a rate of increase that predicted this level or higher. Strict adherence to the level of 20 mg/dL has been jocularly referred to as vigintiphobia (fear of 20). It may also occur simply due to dehydration of the mother, maternal use of angiotensin converting enzyme inhibitors, or without a determinable cause (idiopathic). The diagnostic approach to polyhydramnios consists of (1) physical examination of the mother with an investigation for diabetes mellitus, diabetes insipidus, and Rh isoimmunization; (2) sonographic confirmation of polyhydramnios and assessment of the fetus; (3) fetal karyotyping; and (4) maternal serologic testing for syphilis. For ultrasound diagnosis of chronic polyhydramnios, the amniotic fluid index should be more than A. In the presence of known haemoglobinopathy, serum ferritin should be checked and women offered therapeutic iron replacement if the ferritin is <30 fig/l. Referral to secondary care should be considered if there are significant symptoms and/or severe anaemia (Hb<70g/l) or advanced gestation (>34 weeks) or if there is no rise in Hb at 2 weeks Parenteral iron should be considered from the 2nd trimester onwards and postpartum period in women with iron deficiency anaemia who fail to respond to or are intolerant of oral iron 29. Severe form of concealed accidental haemorrhage Ans D Couvelaire uterus (also known as uteroplacental apoplexy)[1] is a life threatening condition in which loosening of the placenta (abruptio placentae) causes bleeding that penetrates into the uterine myometrium forcing its way into the peritoneal cavity. The hemorrhage that gets into the decidua basalis ultimately splits the decidua, and the haematoma may remain within the decidua or may extravasate into the myometrium (the muscular wall of the uterus). The myometrium becomes weakened and may rupture due to the increase in intrauterine pressure associated with uterine contractions. In pregnancy which one of the following heart diseases is associated with the least maternal mortalityfi An asymptomatic young woman with a small or moderate-sized ductus and normal pulmonary arterial pressure can anticipate an uncomplicated pregnancy, apart from the risk of infective endarteritis during delivery Eisenmenger syndrome: Reported risk of maternal mortality in this disorder has ranged from 30 to 50 percen 32. Having continuous monitoring will reduce the risk of an adverse outcome to about 1 in 3,000 (0. Microscopic pathological features determine whether a surface epithelial-stromal tumor is benign, borderline, or malignant (evidence of malignancy and stromal invasion). This group consists of serous, mucinous, endometrioid, clear cell, and brenner (transitional cell) tumors, though there are a few mixed, undifferentiated and unclassified types. Human chorionic gonadotropin can be used as a tumor marker, as its fi subunit is secreted by some cancers including seminoma, choriocarcinoma, germ cell tumors, hydatidiform mole formation, teratoma with elements of choriocarcinoma, and islet cell tumor.

Diseases

  • Schmidt syndrome
  • Macrocephaly dominant type
  • Chromosome 2, trisomy 2p
  • Nanism due to growth hormone combined deficiency
  • Homocarnosinase deficiency
  • Prostate cancer, familial
  • Severe combined immunodeficiency (SCID)
  • Selenium poisoning
  • Anterograde amnesia
  • Congenital hemidysplasia with ichtyosiform erythroderma and limbs defects

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Turner 112 Noroviruses and Sapoviruses (Caliciviruses) 244 Raphael Dolin and John J 100mcg levothroid sale thyroid symptoms normal test results. Batteiger and Ming Tan 117 Psittacosis (Due to buy levothroid 50 mcg low cost thyroid gland enlarged hypothyroidism Chlamydia psittaci) 253 David Schlossberg 118 Chlamydia pneumoniae 254 Margaret R levothroid 50mcg online thyroid symptoms breastfeeding. Simberkoff 120 Genital Mycoplasmas: Mycoplasma genitalium buy generic levothroid 100mcg thyroid cancer low iodine diet, Mycoplasma hominis, and Ureaplasma Species 256 David H. Blanton 122 Rickettsia akari (Rickettsialpox) 259 Didier Raoult 123 Coxiella burnetii (Q Fever) 260 Thomas J. Marrie and Didier Raoult 124 Rickettsia prowazekii (Epidemic or Louse-Borne Typhus) 262 Lucas S. Walker 126 Orientia tsutsugamushi (Scrub Typhus) 265 Didier Raoult 127 Ehrlichia chaffeensis (Human Monocytotropic Ehrlichiosis), Anaplasma phagocytophilum (Human Granulocytotropic Anaplasmosis), and Other Anaplasmataceae 266 J. Stevens 131 Nonsuppurative Poststreptococcal Sequelae: Rheumatic Fever and Glomerulonephritis 279 Stanford T. Musher 133 Enterococcus Species, Streptococcus gallolyticus Group, and Leuconostoc Species 283 Cesar A. Baker 135 Viridans Streptococci, Nutritionally Variant Streptococci, Groups C and G Streptococci, and Other Related Organisms 287 Scott W. Reboli 139 Listeria monocytogenes 293 Bennett Lorber 140 Bacillus anthracis (Anthrax) 296 Gregory J. Friedlander 141 Bacillus Species and Related Genera Other Than Bacillus anthracis 298 Thomas Fekete 142 Erysipelothrix rhusiopathiae 299 Annette C. Reboli xxxvi 143 Whipple’s Disease 300 Thomas Marth and Thomas Schneider 144 Neisseria meningitidis 301 David S. Apicella 146 Moraxella catarrhalis, Kingella, and Other Gram-Negative Cocci 307 Timothy F. Carpenter 149 Campylobacter jejuni and Related Species 314 Ban Mishu Allos, Nicole M. Blaser 150 Helicobacter pylori and Other Gastric Helicobacter Species 315 Timothy L. Donnenberg 152 Pseudomonas aeruginosa and Other Pseudomonas Species 317 Erika D’Agata 153 Stenotrophomonas maltophilia and Burkholderia cepacia 318 Amar Safdar 154 Burkholderia pseudomallei and Burkholderia mallei: Melioidosis and Glanders 320 Bart J. Currie 155 Acinetobacter Species 323 Michael Phillips 156 Salmonella Species 324 David A. Miller 157 Bacillary Dysentery: Shigella and Enteroinvasive Escherichia coli 325 Herbert L. Halperin 164 Rat-Bite Fever: Streptobacillus moniliformis and Spirillum minus 341 Ronald G. Koehler xxxvii 168 Klebsiella granulomatis (Donovanosis, Granuloma Inguinale) 348 Ronald C. Horton 174 Lyme Disease (Lyme Borreliosis) Due to Borrelia burgdorferi 357 Allen C. Garrett 179 Bacteroides, Prevotella, Porphyromonas, and Fusobacterium Species (and Other Medically Important Anaerobic Gram-Negative Bacilli) 364 Wendy S. Hospenthal 191 Cryptococcosis (Cryptococcus neoformans and Cryptococcus gattii) 390 John R. Galgiani 195 Dermatophytosis (Ringworm) and Other Superfcial Mycoses 400 Roderick J. Hay 196 Paracoccidioidomycosis 402 Angela Restrepo, Angela Maria Tobon, and Luz Elena Cano 197 Uncommon Fungi and Related Species 404 Duane R. Wellems 203 Leishmania Species: Visceral (Kala-Azar), Cutaneous, and Mucosal Leishmaniasis 419 Alan J. Magill 204 Trypanosoma Species (American Trypanosomiasis, Chagas’ Disease): Biology of Trypanosomes 420 Louis V. Maguire xxxix 214 Tissue Nematodes (Trichinellosis, Dracunculiasis, Filariasis, Loiasis, and Onchocerciasis) 439 James W. Kazura 215 Trematodes (Schistosomes and Liver, Intestinal, and Lung Flukes) 440 James H. Fairley 217 Visceral Larva Migrans and Other Uncommon Helminth Infections 445 Theodore E. Henderson 225 Nosocomial Pneumonia 458 Michael Klompas 226 Nosocomial Urinary Tract Infections 460 Thomas M. Sepkowitz 228 Transfusion and Transplantation-Transmitted Infections 463 Matthew J. Weisdorf 231 Infections in Solid-Organ Transplant Recipients 474 Nina Singh and Ajit P. Maculopapular rashes are usually seen in viral illnesses, drug eruptions, and immune complex–mediated diseases. Difuse erythema suggests scarlet fever, toxic shock syndrome, Kawasaki disease, or Stevens-Johnson syndrome/toxic epidermal necrolysis. Bullous lesions suggest streptococcal erysipelas with necrotizing fasciitis, ecthyma gangrenosum, and Vibrio 3 4 infections. Petechial eruptions suggest gram-negative sepsis, invasive Neisseria meningitidis infection, and rickettsial infections. Clinical practice guideline for the diagnosis and manage ment of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Empirical validation of guidelines for the management of pharyngitis in children and adults. Otitis Media • Otitis media occurs at all ages, but the peak age group is children in the frst 3 years of life.

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Descriptive epidemiological study of treatment cheap levothroid 200mcg amex thyroid cancer quarantine, development of new therapeutic mol acne on scholar pupils in France during autumn 1996 discount levothroid 50mcg mastercard thyroid nodules eye problems. The familial prognosis and hence improvement in the social risk of adult acne: a comparison between first-degree dimension of treating patients purchase 100 mcg levothroid fast delivery thyroid quotes funny, and the possible relatives of affected and unaffected individuals discount levothroid 100 mcg without prescription thyroid iodine. A large number history of acne was associated with the need of tandem repeats in the polymorphic epithelial mucin for a higher number of systemic treatments gene is associated with severe acne. Finally, the « motherly » factor tor mutations causing human androgen insensitivity seems to play a predominant role compared to syndromes show a key role of residue M807 in Helix the « fatherly » factor, with a higher frequency 8-Helix 10 interactions and in receptor ligand-binding of comedones and a more marked extension domain stability. Retinoic acid receptors and topical acne therapy: establishing the link between gene expres sion and drug efficacy. Peroxisome proliferator-activated receptor and farnesoid X receptor ligands differentially regu 1. The clinical importance of neonatal acne lies Neonatal acne has been attributed both to mater mostly in the differentiation from infectious dis nal androgens and fetal androgens produced by eases, the exclusion of an underlying cause of gonads and adrenal glands [14]. On the one hand, virilization, and the suggested association with the transplacental transfer of maternal androgens, severe acne in adolescents [1, 3, 4 ]. In both male and female infants, the neonatal the pathogenesis of neonatal acne remains adrenal gland is primarily a “fetal” adrenal gland unclear (Table 38. Several mechanisms have consisting of an enlarged zona reticularis, the been proposed. During the neonatal period, there is a consider At birth, and persisting for the first 6–12 able sebum excretion rate [6, 11]. By the age of 6 weeks, the total number of • Controversial role of Malassezia species [3, 7 – 10 ] organisms is comparable to that found in adults. Malassezia spe tion related to the development or clinical stage cies are saprophytic of normal human adult and of the disease [7]. Both the age at which neo Moreover, since Malassezia has not been iso nates become infected and the route by which lated in a series of cases with acne neonatorum, it healthy neonate skin is colonized with Malassezia has been proposed that neonatal acne may be an are unclear [7 ]. It is secretion rate and quality, probably affect neona more commonly seen in boys (5:1) [23]. The lesions affect predominantly the the absence of complete correlation might be face, especially the cheeks, chin, eyelids, and explained by a better adaptation of M. Further studies venous catheter, surgery, and the use of a naso are warranted in order to discern the clinical gastric tube [16, 17, 20]. During this cutaneous infiammatory reaction may occur the neonatal period (defined as the first 4 weeks in predisposed neonates with increased sebum of life), the infant is extremely vulnerable to production, which may lead to follicular or poral bacterial, viral, and fungal infections. It is a neonatal pustular Staphylococcus aureus neonatorum eruption that presents in similar fashion to neo (bullous impetigo) Infantile acropustulosis Listeria monocytogenes Transient neonatal natal acne. Comedones are typi Pseudomonas Eosinophilic pustular cally absent [8], although a subset of patients aeruginosa folliculitis of infancy Hemophilus infiuenzae Milia may present with comedones and infiammatory Sebaceous gland lesions, and may have early-onset androgen hyperplasia driven neonatal acne. Viral Acneiform eruptions Diagnostic criteria of neonatal cephalic pus Herpes virus infections Acne venenata infantum tulosis were defined by Rapelanoro et al. Nevertheless, the causative role of Incontinentia pigment Malassezia has been questioned [7]. Parasitic the association between neonatal acne and Scabies neonatal cephalic pustulosis remains unclear. Moreover, chloracne, an acneiform observed in neonates born of a first pregnancy, at eruption sparing the centrofacial region, may term and by vaginal delivery, fed with milk pow occur due to accidental topical, inhalation, or der substitute or a mixed diet, and born in sum oral exposure to chlorinated aromatic hydrocar mer or autumn [27 ]. The lesions appear as erythematous macules as pustular eruptions during the neonatal period and evolve to red, white, or yellow papules, to a (Table 38. They are asymptomatic and evanes neonatal acne should be differentiated from seri cent and affect mainly the face, chest, trunk, and ous and life-threatening conditions that require extremities, while sparing the palms and soles. There are no consistent data a Gram’s stain of the pustular content of the about the prevalence of neonatal cephalic lesions [26]. In addition to closed pustular eruptions and open comedones, papules, pustules, nod Smears of the pustules: ules, and cystic lesions with a scarring poten Erythema toxicum eosinophils tial, may develop [1, 5] (see Childhood Acne, neonatorum Eosinophilia Chap. Infantile acropustulosis Tzanck smear: neutrophils Gram stain: neutrophils Pustular miliaria is rare in neonates. It resolves after Viral infections Cytologic smears: 3–4 days with the use of light cotton clothing in multinucleated giant cells Negative bacterial culture cool environment [33]. In neonatal acne, a careful history of the dis Infantile acropustulosis is an uncommon, self ease and a physical examination of skin lesions limited dermatosis of unknown etiology, affect are typically sufficient for the correct diagnosis. It may begin during However, when in doubt, a history of maternal the neonatal period and persist in infancy and infections during pregnancy and simple labo early childhood [31]. It presents with pruritic red ratory investigations may facilitate diagnosis papules, which evolve within 24 h into vesicles (Table 38. They are located on the hands and Tzanck smear is useful to exclude herpes sim feet, and less often on the scalp, face, and trunk. Diagnosis is based on the distribution of lesions, Gram’s stain is useful to rule out bacterial infec their recurrence in crops every 2–3 weeks and tions such as impetigo, and routine potassium stains of the pustules (Table 38. These lesions then rupture and evolve detailed evaluations for congenital adrenal hyper into hyperpigmented macules with a surrounding plasia, a virilizing tumor, or underlying endocri scale [26]. In these cases, physical buttocks, abdomen, palms, and soles are com examination for precocious puberty, bone age monly affected [32 ]. Any abnormality needs referral to a ized by lesions that are more infiamed than pediatric endocrinologist [24 ]. Clinical and therapeutic approaches to childhood ous resolution with no scarring in 4 weeks to 3 acne: an update. Colonization of neonate skin by Malassezia species relation associated with severe acne in adolescence [3, 5].

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As the casualty lies dow n on the bed cheap levothroid 50 mcg without prescription thyroid nodules greater than 4 cm, hold his dislocated arm until you have placed a sm all pillow or big pad under the affected shoulder order levothroid 100 mcg thyroid gland in animals. Then low er the arm slow ly until it is hanging straight dow n the side of the bunk and leave it to order 100 mcg levothroid with mastercard thyroid gland underactive causes hang freely proven 50mcg levothroid thyroid cancer vocal cords. The patient should rem ain in this position for about 1 hour, letting the w eight of the arm overcom e the m uscle spasm caused by the dislocation. At the end of this period, if the dislocation is reduced, the patient should roll onto his good side and then use the injured arm by bending the elbow and then touching the good shoulder w ith the fingers. Afterw ards he should be helped to sit up and the arm should be kept in a collar and cuff sling until the shoulder is fairly com fortable. When the sling is rem oved, the patient should exercise the joint slow ly and carefully. Dislocated finger Finger dislocations can usually be reduced by pulling firm ly on the finger. Pull firm ly on the finger for about one m inute w hile a helper is pulling in the opposite direction at the elbow. Keeping the ends of the bones apart by pulling, gently ease the joint back into its norm al position. After 24 hours, the strapping should be rem oved and the patient should exercise the finger slow ly and carefully. Sprains and strains these injuries are usually the result of tw isting, turning or tripping. Pain is usually felt at once, and later sw elling at the site of injury w ill occur due to bleeding. There is no sure clinical m ethod of excluding fracture associated w ith sprains and strains except by x-ray. When there is doubt, it is therefore safer to assum e the possibility of fracture and to treat accordingly. W hether the injury is seen im m ediately or later w hen m uch sw elling m ay have occurred, put the casualty in his bunk and elevate the injured part, if this is possible. Rest and elevation m ay be necessary for tw o to three days (or som etim es longer according to the severity of the injury). If an associated fracture is not present, gentle m ovem ent of the injured part should be encouraged. Sprains and strains do m uch better w ith early m ovem ent than w ith too long a period of rest. The casualty can usually judge w hen he can use the injured part for full or restricted duties. Of the m any causes of disease, General principlesFood infection by living organism s is the com m onest and an of first aid understanding of their m ode of spread is necessary if healthy Catering staff: personal living and w orking conditions are to be m aintained. They are w idely dissem inated board ship throughout nature and although m ost of them are not harm ful to m ankind certain organism s m ay invade the body Dressings, bandages,Insecticides and produce particular diseases. They gain entry to the body, Disinfectionslings and splints usually through the nose or m outh or the broken skin. Infection can take place directly from person to person or it IsolationFirst aid satchels and m ay be conveyed indirectly in air, w ater or food or by a boxes Ventilation parasite carrier (such as an insect). The viruses of influenza, that of the com m on cold and Port health clearance m uch m ore rarely Legionnaires disease are exam ples of air Severe bleeding Preventing heat illness borne infection w hich is spread w hen the sufferer coughs or Unconscious casualty sneezes. Exposure Typhoid fever is an exam ple of a w ater-borne bacterial Burns and scalds Lifting heavy w eights infection. The excreta of infected persons contam inate w ater Suffocation (asphyxia) supplies. Hence the necessity for safeguarding the w ater Exercise and boredom supply for w ashing as w ell as for drinking at all tim es. Strangulation Exam ples of tw o w ell-know n bacterial diseases brought Choking about by personal contact are syphilis and gonorrhoea. The plague Epileptic fits germ is conveyed by the bites of fleas living on the rat. M alaria and yellow fever organism s inhabit the salivary glands of the m osquito Bleeding and are injected into the blood w hen the m osquito bites. W ounds Flies, because of their behaviour, are very prone to convey disease germ s from filth to food. Fractures Ringw orm is an exam ple of a disease caused by a fungus Dislocations through contact. Head injuries Potable w ater Transportation this covers w ater used for drinking, cooking, the w ashing of cooking and eating utensils, and w ater used for general cleaning and bathing. Fresh w ater should be free from causes of infection and be bright, clear and virtually colourless. It should be aerated, that is, it should bubble w hen shaken, otherw ise it has an insipid taste. The M erchant Shipping Crew Accom m odation Regulations 1997 and M erchant Shipping Crew Accom odation (Fishing Vessels) Regulations 1975 require all fresh w ater produced on board ship to be disinfected autom atically. Fresh w ater storage tanks these w ater tanks are coated internally w ith an anti corrosive m aterial w hich w ill not contam inate the w ater. Anyone entering any potable or w ashing w ater tanks should w ear clean clothing and footw ear, and should not be suffering from skin infections, diarrhoea or any com m unicable disease. Disinfection of the fresh w ater tanks and distribution system by super chlorination It is recom m ended that the storage tanks and the w hole of the fresh w ater system should be disinfected at intervals of not m ore than tw elve m onths even if the quality of the w ater that has been used to fill them is not suspect. The chlorine com pounds that m ay be used for disinfecting are chlorinated lim e, high-test hypo-chlorite or com m ercially prepared sodium hypo-chlorite solution. Determ ine the volum e of w ater necessary to fill the tanks and distribution system com pletely and the am ount of chlorine com pound required.

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