Clinical Summary

Hard exudates are refractile, yellowish deposits with sharp margins composed of fat-laden macrophages and serum lipids. Occasionally the lipid deposits form a partial or complete ring (called a circinate ring) around the leaking area of pathology. If the lipid leakage is located near the fovea, a spoke or star-type distribution of the hard exudates may be seen. Cotton wool spots, or soft exudates, are actually microinfarctions of the retinal nerve-fiber layer, and appear white with soft or...

Otitis Externa Clinical Summary

Otitis externa (OE), or swimmer's ear, is an inflammation and infection (bacterial or fungal) of the auricle and external auditory canal (EAC). Typical symptoms include otalgia, pruritus, otorrhea, and hearing loss. Physical examination reveals EAC hyperemia and edema, otorrhea, malodorous discharge, occlusion from debris and swelling, pain with manipulation of the tragus, and periauricular lymphadenopathy. Several factors predispose the EAC to infection increased humidity and heat, water...

Anal Fissure Clinical Summary

An anal fissure is a longitudinal tear of the skin of the anal canal and extends from the dentate line to the anal verge. Fissures are thought to be caused by the passage of hard or large stools with constipation, but may also be seen with diarrhea. The fissures are typically a few millimeters wide and occur in the posterior midline, but may occur elsewhere. An anal fissure that is off the midline may have a secondary cause, such as inflammatory bowel disease or sexually transmitted infection....

Internalexternal Hemorrhoids Clinical Summary

External hemorrhoids result from the dilatation of the venules of the inferior hemorrhoidal plexus below the dentate line. They have a covering of skin, or anoderm, versus internal hemorrhoids, which have a mucosal covering. Hemorrhoids commonly present with an episode of rectal bleeding of bright red blood after defecation. This results from the passage of the fecal mass over the thin-walled venules, causing abrasions and bleeding. Symptoms from external hemorrhoids include swelling, burning,...

Prolapsed Rectum Clinical Summary

Rectal prolapse occurs when anorectal tissue slides through the anal orifice. Prolapse may be partial, involving only the mucosa (prolapse is < 2 cm), or complete, involving in full thickness extrusion of the rectal wall. Prolapse may result from laxity of the pelvic floor, weak anal sphincters, and or lack of mesorectal fixation. Patients complain of bleeding, mucous discharge, rectal pressure, or a mass. Problems with fecal incontinence, constipation, and rectal ulceration are common as...

Lead Poisoning Clinical Summary

Although the prevalence of markedly elevated lead levels in the population has been declining, acute and chronic lead poisoning still occur. Lead is well absorbed by the lungs and less well via the gastrointestinal tract. Lead paint in older homes is a continued source of lead exposure. Other possible exposures may occur from occupational exposures, retained lead bullets in synovial fluid, jewelry, lead-painted toys, fishing weights, ceramic glazes, and cosmetics. Severe lead poisoning in...

Carpal And Carpometacarpal Dislocations Clinical Summary

Lunate dislocation can occur in a palmer or dorsal position with the lunate displaced relative to the other carpal bones. The normal lunoradial relationship is disrupted. The median nerve is commonly involved and should be evaluated. If the lunoradial articulation is intact and the other carpal bones are dislocated relative to the lunate, it is termed a perilunate dislocation. Another potentially serious injury is scapholunate dissociation, often mistakenly diagnosed as a sprained wrist....

Emergency Department Treatment And Disposition

No specific treatment is offered in the emergency department. If found during evaluation for vaginal bleeding, infection and pregnancy should be treated excluded. Incidental diagnosis may be referred for ligation and histologic evaluation. SnuniE Knoop KJ, Stack LB, Sturrow AB, Thurman RJ The Adas of Emergency Medicine, 3rd Edition iittp www.a ccessmedicine.com Copyright The McGraif+Tll Companies, Inc. All lights reserved. SnuniE Knoop KJ, Stack LB, Sturrow AB, Thurman RJ The Adas of Emergency...

Abdominal Hernias Clinical Summary

A hernia is a tissue protrusion through an abnormal body cavity opening. Most abdominal wall hernias occur at the groin and umbilicus. Incarceration is defined as the inability to reduce the protruding tissue to its normal position. Strangulation occurs when the blood supply of the hernia's contents is obstructed and tissue necrosis ensues. An incisional hernia may manifest clinically as a mass or palpable defect adjacent to a surgical incision and can be reproduced by having the patient...

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Note Large images and tables on this page may necessitate printing in landscape mode. The Atlas of Emergency Medicine> Part 1. Regional Anatomy> Chapter 2. Ophthalmologic Conditions> NEONATAL CONJUNCTIVITIS (OPHTHALMIA NEONATORUM) Clinical Summary Neonatal conjunctivitis comprises a number of entities, including chemical irritation caused by antimicrobial prophylaxis (most common cause), infections acquired through direct contact between the neonate and the mother's cervix and vagina...

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Note Large images and tables on this page may necessitate printing in landscape mode. The Atlas of Emergency Medicine> Part 1. Regional Anatomy> Chapter 4. Opthalmic Trauma> Corneal abrasions present with acute onset of eye discomfort, tearing, and often a foreign-body sensation. A ciliary flush (conjunctival injection hugging the limbus) may be seen. Visual acuity may be affected by large abrasions or those in the central visual axis. Photophobia and headache from ciliary muscle spasm...

Acute Anterior Myocardial Infarction Ecg Findings

Myocardial Infarction Ecg Finding

ST segment elevation in the anterior precordial leads. Commonly-used terminology for injury location Vi -V4 Anteroseptal injury. V3 -V6 Anterolateral injury. Leads I and aVL may also be involved, especially if the circumflex artery is affected (high lateral injury). Reciprocal ST segment depressions are often present in the inferior leads (II, III, aVF). Figure 23.1A. Source Knoop KJ, Stack LB, Storrow AB, Thurman RJ The Attas of Emergency Medicine, 3rd Edition http ferow.accessmiedicine.corn...

Acute Posterior Myocardial Infarction Ecg Findings

With acute injury pattern ST segment depression in lead Vi and or V2 with acute injury pattern. With infarction pattern Small S wave and large R wave greater than 4 ms duration in lead Vi or V2 with infarction. With infarction pattern R-wave S-wave ratio greater than 1 in lead Vi or V2 with infarction. Figure 23.4A. SnurcE Knoop KJ, Stack LB. Stomrw AS, Thurman RJ The Arias of Emergency Medicine, 3rd Edition http wvwJacce5smedicine. cim Copyright The McGraw-Hill Companies, Inc. All lights...

Acute Sickle Dactylitis Handfoot Syndrome Clinical Summary

This painful condition is commonly the first clinical manifestation of sickle cell disease. It usually presents in children younger than 5 years of age. The pain and abnormalities are the result of infarction of the small bones of the hands or feet. These children present acutely ill, with fever, refusal to bear weight, and swollen hands and feet. They may have a marked leukocytosis, and the initial x-rays may be normal. It is not until 1 to 2 weeks later that subperiosteal new bone, cortical...

Anisocoria Clinical Summary

Anisocoria is a disparity of pupil size. Five to twenty percent of people have physiologic anisocoria, usually of less than 2 mm. This asymmetry is preserved in both light and dark conditions, and no other ocular abnormalities are present. If pathologic anisocoria is suspected, examine pupil size in both light and dark to determine which eye is affected anisocoria increases in the direction of action of the paretic iris muscle. A weakened iris sphincter muscle is accentuated by bright light....

Balanoposthitis Clinical Summary

Balanoposthitis is an infection and inflammation of the glans penis that also involves the overlying foreskin (prepuce). Balanitis is isolated to the glans, whereas posthitis involves only the prepuce. Pain, erythema, and edema of the affected parts of the penis are typically present. Patients may refrain from urination secondary to dysuria, or the edema may induce meatal occlusion, leading to urinary retention or obstruction. Common etiologies include overgrowth of normal bacterial flora...

Black Hairy Tongue Clinical Summary

Black hairy tongue (BHT) represents a benign reactive process characterized by hyperplasia and dark pigmentation of the tongue's filiform papillae. The elongated filiform papillae may reach up to 2 cm in length and vary in actual degree of pigmentation from light tan to black. Predisposing factors may include excessive smoking, gastroesophageal reflux, poor oral hygiene, chemotherapy, and the use of broad-spectrum oral antibiotics. Pigment from consumed food, beverages, and tobacco products...

Black Widow Spider Envenomation Clinical Summary

The black widow spider (Latrodectus mactans) is the prototype for the genus Latrodectus, several members of which cause human disease. The black widow spider is not particularly aggressive but will defend her web, which is often found in woodpiles, basements, and garages. Most envenomations occur between April and October, with bites most commonly located on the hand and forearm. The clinical presentation of severe and sustained muscle spasm is produced by a neurotoxic protein, which causes the...

Blistering Distal Dactylitis Clinical Summary

Blistering distal dactylitis is a cellulitis of the fingertip caused by Group A 3-hemolytic streptococci or Staphylococcus aureus infection in children from infancy to teenage years. The typical lesion is a fluid-filled, painful, tense blister with surrounding erythema located over the volar fat pad on the distal portion of a finger or toe. Polymorphonuclear leukocytes and gram-positive cocci can be found in the Gram stain of the purulent exudate from the lesion. The differential diagnosis...

Bluntforcepattern Injuries Clinical Summary

The most common blunt force is the contusion (Fig. 19.22). The pattern contusion is a common injury that helps identify the causative weapon. A blow from a linear object leaves a contusion that is characterized by a set of parallel lines separated by an area of central clearing. The blood underlying the striking object is forcibly displaced to the sides, which accounts for the pattern's appearance. Pattern injuries that an emergency physician should recognize include those caused by the hand...

Boutonnire And Swanneck Deformities Clinical Summary

Fine control of the fingers is achieved by a delicate balance between the extensor, flexor, and intrinsic tendons in each finger. The boutonnire deformity is a result of injury to the central slip insertion of the extensor hood on the dorsal surface of the middle phalanx. After a tear of the central slip, the flexor tendon is unopposed at the proximal interphalangeal (PIP) and the lateral bands of the extensor tendon contract. With time, these displace palmerly resulting in additional flexion...

Branchial Cleft Cyst Clinical Summary

A branchial (aka pharyngeal) cleft cyst arises from the incomplete obliteration of one the branchial clefts during embryogenesis. There are four paired branchial arches that form on the external surface of the embryo. The spaces in between these arches are the branchial clefts. The branchial arches ultimately develop into structures of the head and neck. As the obliteration of the clefts occurs, a portion of a cleft may remain forming a cystic space. The anatomic location of a branchial cleft...

Buccal Space Abscess Clinical Summary

The buccal space lies between the buccinator muscle and the overlying superficial fascia and skin. The maxillary second and third molars are the usual nidus of disease. Infection from the involved teeth erodes either superiorly through the maxillary alveolar bone, or rarely, inferiorly from the third mandibular molar through the mandibular alveolar bone into the buccal space. These patients present with unilateral facial swelling, redness, and tenderness of the cheek. Trismus is generally not...

Clenched Fist Injury Fight Bite Clinical Summary

The clenched fist injury classically occurs during a fight when the metacarpophalangeal (MCP) joint contacts human teeth, resulting in a laceration. Many patients will not divulge the true circumstances surrounding the injury therefore all wounds at the MCP joint must be considered a clenched fist injury until proven otherwise. These wounds occur most often in the dominant hand. Serious complications can result, including infection, loss of function, and amputation. Most wounds are...

Cold Panniculitis Popsicle Panniculitis Clinical Summary

Cold panniculitis represents acute cold injury to the subcutaneous fat. It manifests as erythematous, indurated plaques on exposed skin, especially the perioral areas and cheeks. Lesions appear 24 to 72 hours after exposure to cold and gradually soften and return to normal over 1 to 2 weeks usually without permanent sequelae. This phenomenon is caused by subcutaneous fat solidification and necrosis when exposed to low temperature. It is much more common in infants. It is believed to occur...

Corneal Ulcer Clinical Summary

A number of infections and inflammatory conditions can ulcerate the cornea. Common bacterial causes include Staphylococcus, Streptococcus, and Pseudomonas . Herpes simplex virus can also ulcerate the cornea, as can Acanthamoeba, a ubiquitous protozoan. Because contacts lens and contaminated solutions can permit microbial invasion, lens wear should raise clinical suspicion for a serious bacterial or protozoan infection. Fungal infections are rare but possible when either vegetable matter (such...

Dacryocystitis Clinical Summary

Dacryocystitis is inflammation of the medial lacrimal apparatus, which usually follows occlusion of the nasolacrimal duct. Age distribution is bimodal, with peaks in infancy and after 40 years. Clinical findings include, pain, erythema, and swelling over the medical lacrimal apparatus, tearing, and possibly mucopurulent discharge from the punctum. Dacryocystitis may develop in 4 to 7 of newborn infants who do not yet have a patent nasolacrimal passage, and may progress to periorbital...

Decubitus Ulcers Clinical Summary

Decubitus ulcers develop when soft tissue is compressed between a bony prominence and a hard external surface. Compression of the tissue results in decreased blood flow, which promotes tissue ischemia and cell death. Pressure, shearing forces, friction, and excessive moisture are all contributing factors to the formation of pressure ulcers. Areas commonly affected include the sacrum, heels, and posterior scalp. All patients may develop decubitus ulcers, but those at higher risk include...

Delivery of the Placenta

Following delivery, gentle traction can be placed on the cord while the opposite hand is used to massage the uterine fundus. The placenta is generally delivered within 20 minutes and should be grossly inspected for evidence of a missing segment or coty ledon. The obstetrician should be notified as retained placental fragments often warrant manual exploration of the uterus, especially in the context of persistent postpartum bleeding. Unusual placental vasculature, such as a velamentous placenta,...

Dextrocardia Ecg Findings

P, QRS, and T are downgoing in lead I, a mirror image of normal. QRS deflections in V4 to V6 are small and downgoing. Figure 23.35A. Source Knoop KJr Stack ILB, Storrow ABr Thurman RJ Tfte Adas of Emergency Medicine, 3rd Edition htCpsZ www-accessmedicine.com Copyright The McGraw-Hill Companies.- Inc. All rights reserved. Source Knoop KJr Stack ILB, Storrow ABr Thurman RJ Tfte Adas of Emergency Medicine, 3rd Edition htCpsZ www-accessmedicine.com Copyright The McGraw-Hill Companies.- Inc. All...

Diphtheria Clinical Summary

Diphtheria is a highly contagious disease caused by the exotoxin-producing bacterium Corynebacterium diphtheriae . It is transmitted either by direct contact or through respiratory aerosolization. Many adults are now susceptible to diphtheria because their vaccine-induced immunity decreases over time or owing to decreased opportunity for naturally acquired immunity. Diphtheria may involve any mucous membrane but most commonly affects the mucosa of the upper respiratory tract. It typically...

Drug Eruptions Clinical Summary

Exanthematous drug eruptions are an adverse hypersensitivity reaction. This symmetric, pruritic, morbilliform, blanching, erythematous eruption is the most frequent of cutaneous drug eruptions. The initially pruritic macules or papules usually become confluent and may progress to an exfoliative dermatitis. Acute generalized exanthematous pustulosis (AGEP), a type of drug eruption, presents 1 to 5 days after starting a new medication. Typically, a E> -lactam or a macrolide antibiotic is...

Elastic Wound Closure Strips

Elastic wound closures strips have the same advantages and indications as adhesives. Wound closure strips can be used alone or in conjunction with a tissue adhesive such as benzoin resin. This can be applied to the normal skin on either side of the wound and used as an anchor point for the strip. The edges of strip will curl up over time and can be trimmed by the patient as needed. Closure strips usually fall off completely in 2 to 3 weeks. Wound closure strips are not recommended in children...

Emergency Department Treatmentand Disposition

Treatment is largely symptomatic except for antibiotics and rehydration. Analgesics, antipyretics, and throat sprays or gargles can provide symptomatic relief. Patients with known or suspected GABHS require antibiotics primarily to prevent rheumatic fever and suppurative complications. The Centor criteria are clinical decision rules developed to help guide physicians in testing and prescribing of antibiotics. Criteria include (1) tonsillar exudates, (2) tender anterior cervical adenopathy, (3)...

Facial Nerve Palsy Clinical Summary

Cranial nerve (CN) VII innervates the facial muscles via the five branches of the motor root, the submandibular, sublingual, and lacrimal glands, and the taste organs on the anterior two-thirds of the tongue and it provides sensation to the pinna of the ear. CN VII (facial) palsy may occur as an isolated finding or as part of a constellation of symptoms. Facial palsies are either central or peripheral. Central lesions occur before or proximal to the CN VII nucleus in the pons. Lesions distal to...

Figure 1129

Storrow AB, Thurman RJ The Atlas of Emergency Medicine, 3rd Edition httpi wivw,accessmedicine.tcm Source Knoop KJr Stack LB. Storrow AB, Thurman RJ The Atlas of Emergency Medicine, 3rd Edition httpi wivw,accessmedicine.tcm Copyright The McGramHHiK Companies, Inc. All rights reserved. Copyright The McGramHHiK Companies, Inc. All rights reserved. Source Knoop KJ, Stack LB. Storrow AB. Thurman RJ The Adas of Emergency Medicine, 3rd Edition 5ittpi www,accessmed cine,com...

Figure 2210E

Storrow AB, hurmari RJ T ie Adas of Emergency Medicine, 3rd Edition http www.acce55medicine.com Copyright The McGraw-Hill Companies. Inc. All eights 'leEerved, Sduite Knoop KJr Stack LB. Storrow AB, hurmari RJ T ie Adas of Emergency Medicine, 3rd Edition http www.acce55medicine.com Copyright The McGraw-Hill Companies. Inc. All eights 'leEerved, Progressive Visualization during Laryngoscopy Vocal Cords. The vocal cords have a distinct white appearance. (Photo...

Figure 535

Intense erythema with scant exudates is seen in this early (< 24 hours) case of GABH pharyngitis. (Photo contributor Kevin J. Knoop, MD, MS.) Tonsilar Exudate. White and yellow cryptic exudates are seen in this patient with rapid strep test proven streptococcal pharyngitis. (Photo contributor Lawrence B. Stack, MD.) SnuniEi Knoop KJ, Stack Lfl. Storrow AB, Thurman RJ The Atlas of Emergency Mediane, 3rd Edition iittpi wivw,a ccesEmedicine.com Cop right The McGraw4Hil...

Fournier Gangrene Clinical Summary

Fournier gangrene most frequently occurs in a middle-aged diabetic male who presents with swelling, erythema, and severe pain of the entire scrotum, but it is also known to occur in females. In males, the scrotal contents often cannot be palpated because of the marked inflammation. The patient has constitutional symptoms with fever and frequently is in shock. There is often a history of recent urethral instrumentation, an indwelling Foley catheter, or perirectal disease. A localized area of...

Gingival Abscess Periodontal Abscess Clinical Summary

Gingival abscesses tend to involve the marginal gingiva and result from entrapment of food and plaque debris in a gingival pocket. Subsequent staphylococcal, streptococcal, anaerobic, or mixed bacterial overgrowth leads to abscess formation. Localized swelling, erythema, tenderness, and possible fluctuance in the space between the tooth and the gingiva (the so-called pocket) ensue. There may be spontaneous purulent drainage from the gingival margin, or an area of pointing (purulent material...

Graze Wounds

Graze wounds are considered atypical and result from tangential contact with a passing bullet. The direction of the bullet's path may be determined by careful wound examination. The bullet produces a trough and may cause the formation of skin tags on the lateral wound margins (Figs. 19.16 and 19.17). The base of these tags point toward the weapon and away from the direction of bullet travel. Figure 19.16. Source Knoop KJr Stack LB. Stcrrow AS, Thurman RJ The At as of Emergency Medicine, 3rd...

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Storrow AB, Thurman RJ The Adas of Emergency Medicine, 3rd Edition 5ittpi www,-a ccessmedicine.com Copyright The McGraw-Hill Gompanies, Inc. All rights reserved, Calcium Oxalate Crystals. Calcium oxalate crystals may be seen in the urine of the patient who ingested ethylene glycol and metabolized the parent compound to create oxalic acid. (Photo contributor Susan K. Strasinger. Urinalysis and Body Fluids , 3rd ed. Philadelphia Davis 1994.) 1. Provided adequate...

Hand Foot And Mouth Disease Clinical Summary

Hand, foot, and mouth disease is a seasonal (summer-fall) viral infection caused by coxsackievirus A16. Toddlers and school-age children are affected most commonly. It is characterized by a prodrome of fever, malaise, sore throat, and anorexia over 1 to 2 days, followed by the appearance of the characteristic enanthem in the posterior oropharynx and on the tonsillar pillars consisting of small, red macules evolving into small vesicles 1 to 3 mm in diameter that rapidly ulcerate. The oral...

Herpetic Gingivostomatitis Clinical Summary

Herpetic gingivostomatitis is a viral infection commonly seen in infants and children caused by herpes simplex virus (HSV). Patients usually present with fever, malaise, decreased oral intake, cervical adenopathy, and pain in the mouth and throat. Vesicular and ulcerative lesions appear throughout the oral cavity. The gingiva becomes very friable and inflamed, especially around the alveolar rim. Increased salivation with foul breath may be present. Although fever resolves in 3 to 5 days,...

Highaltitude Pulmonary Edema Clinical Summary

High-altitude pulmonary edema (HAPE) is a form of noncardiogenic pulmonary edema, generally beginning within the first 2 to 4 days after ascent above 2500 m (8202 ft). The earliest symptoms are fatigue, weakness, dyspnea on exertion, and decreased exercise performance. Symptoms of acute mountain sickness (AMS) such as headache, anorexia, and lassitude may also be present, but HAPE may develop without AMS. If untreated, a persistent dry cough develops, followed by tachycardia and tachypnea at...

Highaltitude Retinal Hemorrhage Clinical Summary

Retinal hemorrhages are common above 5200 m (17,060 ft) and are not always associated with acute mountain sickness (AMS). High-altitude retinal hemorrhages (HARH) are rarely symptomatic, but if found over the macula, these hemorrhages may cause temporary blindness. The diagnosis can be established by ophthalmoscopy. Without visualization of the lesion, the differential diagnosis of unilaterally decreased vision or blindness at high altitude includes migraine equivalent, cerebrovascular...

Hydatid Cyst Clinical Summary

Hydatid cysts are parasitic infections caused by the larval stage of Echinococcus granulosis tapeworms. The life-cycle is maintained between canines and various farm animals (usually sheep or cattle). Adult worms inhabit the small intestine of canines and eggs are passed in the stool. Farm animals become infected when they feed upon stool-contaminated material. The lifecycle is completed when dogs or other canines ingest the larval cysts that form in infected farm animals. Humans can be...

Hymenoptera Envenomation Clinical Summary

The order Hymenoptera includes wasps, hornets, yellow jackets, bees, and ants. Envenomation usually results in local pain, mild erythema, swelling, and pruritus. Severe systemic or toxic reactions may occur from one or multiple stings, manifesting as gastrointestinal symptoms, headache, pyrexia, muscle spasms, or seizures. Anaphylaxis may occur within minutes from a single sting, and may cause death from airway obstruction and or cardiovascular collapse. A serum sickness-type reaction may occur...

Hypertrophic Pyloric Stenosis Clinical Summary

Hypertrophic pyloric stenosis (HPS) is characterized by progressive postprandial, nonbilious vomiting that steadily increases in frequency and amount due to hypertrophy of the pyloric musculature and edema of the pyloric canal, producing gastric outlet obstruction. It is usually diagnosed in infants from birth to 5 months, most commonly at 2 to 8 weeks of life. The vomiting may become forceful and is then described as projectile (although this pattern is not always present). There is a familial...

Hypokalemia Ecg Findings

Flattened or inverted T waves Conduction disturbances Figure 23.44A. Source Knoop KJr Stack LB, Storrow ABr Thurman RJ The Atlas of Emergency Mediane, 3rd Edition http www.accessrnedicine.com Copyright The McGraw-Hill Companies, Inc. All rights reserved. Source Knoop KJr Stack LB, Storrow ABr Thurman RJ The Atlas of Emergency Mediane, 3rd Edition http www.accessrnedicine.com Copyright The McGraw-Hill Companies, Inc. All rights reserved. Hypokalemia (ECG contributor R. Jason Thurman, MD.)...

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Inflicted Burns Clinical Summary

Burns in children are frequently the result of child abuse. The most common types of pediatric burns from abuse are immersion burns and contact burns. Certain clues may assist the physician in differentiating accidental burns from inflicted burns, but often considerable doubt remains even after a careful evaluation. In an immersion burn, a child is held firmly and deliberately immersed and will have burn margins that are sharp and distinct. If the child has little opportunity to struggle, few...

Intrauterine Fetal Demise Clinical Summary

The timing of intrauterine fetal demise (IUFD) is important for the emergency department physician to appreciate for both consoling and advising the parents, as well as to know the likelihood of successful resuscitation after delivery. This tragic event may occur immediately before or during the birthing or in the prior weeks before delivery. The appearance of the fetus at delivery can be used to estimate that antepartum fetal demise has occurred and that resuscitative efforts are fruitless....

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Stomow AB, Thurman RJi The Atlas of Emergency Medicine, 3rd Edition )ittpi www .a ccessmedicine.com Copyright The McGraw-Hil Companies, Inc. All rights -reserved. Calcium Oxalate Crystals. Calcium oxalate crystals come in two shapes. The classically described octahedral, or envelope-shaped, crystals are made of calcium oxalate dihydrate. Calcium oxalate monohydrate crystals are needle-shaped. They are seen in acid or neutral urine. They may be found in the urine of...

Jaundice Clinical Summary

Jaundice presents as light yellowing of the skin, mucous membranes, and sclera it is generally detectable when bilirubin levels are about 3.0 mg dL. Many patients may not be aware of the faint yellowing of their skin and present with seemingly unrelated symptoms. Be aware that up to 50 of patients with jaundice will have pruritus. The most important diagnoses to rule out are hemolytic anemias, viral hepatitis, chronic alcohol abuse, autoimmune hepatitis, medications, primary biliary cirrhosis,...

Jugulovenous Distension Clinical Summary

Central venous (right atrial) pressure is reflected by distention of the internal or external jugular veins. Normal pressure is less than 3 cm of distention above the sternal angle of Louis. Distention greater than 4 cm should be considered abnormal. Evaluation begins by raising the head of the supine patient 30 to 60. The highest point of venous pulsation at the end of normal expiration is measured from the sternal angle of Louis. The presence of jugulovenous distention (JVD) should prompt an...

Laryngoscopic Orotracheal Intubation Patient Preparation

The optimal position to maximize laryngoscopy visualization of the larynx is 3. The base of the ear aligned with the sternal notch (see Fig. 22.1) 4. The facial plane horizontal, parallel to the ceiling This position most closely replicates in a supine posture that which the patient would assume sitting up. For very large individuals or those with significant morbid obesity, this may require creation of a textile ramp of blankets, sheets, or towels to raise the head and shoulders to proper...

Left Bundle Branch Block Ecg Findings

Wide QRS complex, at least 120 ms (three small blocks). T wave appears on the opposite side of the baseline from the QRS complex. The QRS precordial axis is normal or deviated to the left. QRS complex deflection is predominately downward in lead Vi and upward in lead V6 . Figure 23.20A. Snurca Knoop KJ, Stock LB, Storrow AS. Thurman fU The Atlas of Emergency Mediane, 3rd Edition htLpi wwvi.ai e & medicrne.- cni Copyright The McGraw-Hill Compini , nc. All rights rtl ferrod. Snurca Knoop KJ,...

Left Ventricular Hypertrophy Ecg Findings

Large S waves in anterior precordial leads Large R waves in lateral precordial leads R wave in aVL + S wave in V3 greater than 28 mm in males, greater than 20 mm in females S wave in Vi + R wave in V5 or V6 greater than 35 mm if age over 40, greater than 40 mm if age 30 to 40, greater than 60 mm if age 16 to 30 R wave in aVL greater than 11 mm T waves deflected opposite to QRS complex (strain pattern) Figure 23.36A. Source Knoop KJr Stack LB, Storrow AB, Thurman RJs Tfie Adas of Emergency...

Lymphogranuloma Venereum Clinical Summary

Lymphogranuloma venereum (LGV) is caused by a serotype of Chlamydia trachomatis and is primarily a disease of lymphatic tissue. Initially, LGV causes a painless genital ulceration that is not noticed by the patient more than 90 of the time. Patients usually present with painful, nonfluctuant inguinal adenopathy, which is often but not always unilateral. Lymphadenopathy may lie above and below the inguinal ligament, causing the groove sign suggestive of this diagnosis. The enlarged lymph nodes...

Melanoma Clinical Summary

Melanoma is a potentially fatal cutaneous tumor derived from epidermal melanocytes. Any age can be affected but the peak incidence is 20- to 45-year old patients (much younger than basal cell or squamous cell carcinomas). The most significant risk factor is a primary relative with melanoma. Evaluation of any pigmented lesion should include the ABCDE rule (A for asymmetry, B for irregular borders, C for color variegation, D for diameter greater than 6 mm, and E for elevation or thickening). Any...

Nasal Cellulitis Clinical Summary

Nasal cellulitis is an infection of the skin and subcutaneous tissues and does not include nasal cartilage. It is most common at the extremes of age. Bacterial invasion due to disruption of the skin is the usual cause. Streptococcus pyogenes and Streptococcus aureus cause most infections. Risk factors include nasal surgery, instrumentation, diabetes, immunocompromise, and nasal piercing. Clinical features include pain, redness, swelling of the nasal tissues. Headache, fever, and malaise suggest...

Neonatal Jaundice Clinical Summary

Neonatal jaundice occurs when total serum bilirubin is sufficiently elevated to cause yellowing of the skin, sclerae, and or mucous membranes. This correlates with a total bilirubin concentration in excess of 5 mg dL and progresses in a head-to-toe fashion as bilirubin levels increase. Most cases of physiologic (< 12 mg dL) jaundice are self-limited, without sequelae, appear on the second or third day of life, and peak between the third and fifth day (preterm infants peak later). Causal...

Neonatal Mastitis Clinical Summary

Neonatal mastitis is an infection of the breast tissue that occurs in full-term neonates with a peak incidence in the third week of life. Females are affected more often than males in a 2 1 distribution. Clinically it manifests as swelling, induration, erythema, warmth, and tenderness of the affected breast. In some cases purulent discharge may be expressed from the nipple. Fever may be present in 25 to 40 of affected patients. Bacteremia is rare. Staphylococcus aureus is the most common...

Neonatal Milk Production Witchs Milk Clinical Summary

Neonatal galactorrhea occurs in up to 6 of term newborns and is usually secondary to transplacental transfer of maternal estrogen. These hormonal effects (maternal estrogens and possibly endogenous prolactin) lead to palpable breast buds in approximately one-third of all term newborns. Males and females are equally affected. In most cases, the breast enlargement and galactorrhea begin to subside after the second week of life and have almost always resolved by 2 months of age. In an occasional...

Nursing Bottle Caries Clinical Summary

The etiology of dental caries is multifactorial with an interplay between microflora (plaque colonized with Streptococcus mutans), substrate (fermentable carbohydrates from breast milk, formula, or juice), and host (saliva and teeth). Nursing or milk bottle caries results from prolonged and frequent night time breastfeeding or sleeping with a bottle containing milk or sugar-containing juices. The sugars are fermented by the bacteria in plaque, lowering the pH in the mouth and resulting in...

Open Cricothyrotomy Technique

Identify the thyroid cartilage and the cricothyroid membrane directly caudally. 2. Cleanse skin surface with appropriate antibacterial medication. 3. Anesthetize skin surface with 1 lidocaine. 4. While stabilizing the trachea with the gloved nondominant hand, make a vertical incision through the skin overlying the cricothyroid membrane. 5. Dissect the tissues over the cricothyroid membrane in a horizontal direction, until the cricothyroid membrane is exposed. 6. Incise the cricothyroid membrane...

Orbital And Periorbital Preseptal Cellulitis Clinical Summary

Orbital (postseptal) cellulitis is a serious bacterial infection characterized by fever, painful purple-red eyelid swelling, restriction of eye movement, proptosis, and variable decreased visual acuity. It may begin with eye pain and low-grade temperature. In general, it is caused by Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and Staphylococcus aureus. It usually arises as a complication of ethmoid or maxillary sinusitis. If not treated promptly, it can lead to...

Pearl

The patient's vision may improve somewhat after a period of sitting or standing as the blood layers out. Patients often complain of monocular, decreased visual function and may describe a shadow or curtain descending over the eye. Other complaints include cloudy or smoky vision, floaters, or momentary flashes of light. Monocular visual filed defects may be noted, and central visual acuity is diminished with macular involvement. Fundal examination may reveal a billowing or tentlike elevation of...

Pearls

Maintain a high index of suspicion for this disease, especially in travelers, military personnel, or immigrants. 2. Leishmanial organisms are abundant in skin lesions, and can be demonstrated by stained smears of ulcer scrapings. Advice for treatment is also available through the CDC's Division of Parasitic Diseases. HERPES ZOSTER IN HIV PATIENTS Clinical Summary Following primary infection with varicella zoster virus, the virus migrates to the dorsal root sensory ganglia where it becomes...

Pediculosis Clinical Summary

Pediculosis can be caused by either the body louse or the crab louse. Body lice are not sexually transmitted and tend to cluster around the waist, shoulders, axillae, neck, and head. They are extremely itchy patients may present with excoriations and intense pruritus. The lice are very small and may not be easily seen. The larval form of the louse, the nit, may be mistaken for dandruff in the hair. Unlike dandruff, however, the nits are extremely adherent to the hair shaft and cannot be brushed...

Pelvic Fracture Clinical Summary

Pelvic fractures are often the result of motor vehicle crashes or falls and are fraught with associated complications. The pelvis should be regarded as a ring identification of one fracture or dislocation should prompt surveillance for another. The purpose of the pelvis is to bear weight and to protect the visceral organs consequently, a fracture of the pelvis will often compromise these functions. Pain is the most common complaint however, patients with pelvic fractures may present unconscious...

Perianalperirectal Abscesses Clinical Summary

The perianal abscess is the most common anorectal abscess. Symptoms include pain in the anal area worsened by bowel movements, straining, coughing, or palpation. Examination findings include a fluctuant and possibly erythematous mass found at the perianal region. Perianal abscesses are usually fairly superficial and easy to drain with local anesthesia. The patient may notice swelling or a pressure sensation. Perirectal abscesses tend to be more complex and are named according to the involved...

Periapical Abscess Clinical Summary

Acute pain, swelling, and mild tooth elevation is characteristic of a periapical or dentoalveolar abscess. Exquisite sensitivity to percussion or chewing on the involved tooth is a common sign. The involved tooth may have had dental caries, a filling, or a root canal treatment. Periapical abscesses can enlarge over time and point, either internally on the lingual or buccal mucosal surfaces or extraorally with swelling and redness of the overlying skin. Occasionally these lesions may track up to...

Pilonidal Abscess Clinical Summary

Pilonidal abscesses are typically seen at or just superior to the gluteal fold and are more common in teenage and young adult males. Patients complain of localized pain, swelling, and drainage but usually do not have systemic symptoms. The abscess begins with the formation of a small opening in the skin that develops into a cystic structure involving surrounding hairs. This opening is occluded by hair or keratin, creating a closed space that does not allow drainage. The acute abscess contains...

Pinworm Infection Enterobiasis Clinical Summary

Enterobius vermicularis is a threadlike white worm that infects the colon and causes intense pruritus of the perianal region, where the gravid adult female migrates to deposit eggs at night. Female worms measure 8 to 13 mm in length and can be observed moving about the perianal area at night. On rare occasions this nematode can lead to vulvovaginitis. The diagnosis can be made by direct visualization of the nematode by the parents or by using a piece of transparent adhesive tape and touching it...

Pneumocystis Clinical Summary

Pneumocystisjirovecii (formerly carinii) pneumonia (PCP) is the most common opportunistic infection in HIV-infected patients. Clinical suspicion for PCP pneumonia in any HIV patient presenting with complaints of dyspnea and nonproductive cough should remain high. Presentations can be indolent, acute, or subacute, with associated symptoms including fever, fatigue, anorexia, weight loss, and chest pain. The CBC is usually normal except for lymphopenia, while serum LDH is often elevated. Arterial...

Postpartum Perineal Lacerations Clinical Summary

Lacerations to the perineum occur commonly following a rapid, uncontrolled expulsion of the fetal head. Postpartum perineal lacerations range from minor to severe. Perineal lacerations due to birth trauma are categorized into four groups. First-degree lacerations are limited to the mucosa, skin, and superficial subcutaneous and submucosal tissues. Second-degree lacerations penetrate deeper into the superficial fascia and transverse perineal musculature. In addition to these structures, a...

Raynaud Disease Clinical Summary

Raynaud disease refers to reversible ischemia of peripheral arterioles, usually in response to exposure to cold or emotional stress. The phenomenon is manifested by sharply demarcated color changes of the skin primarily of the digits. In general, it is more prevalent in women and most often affects the hand, although the toes may be involved as well. Cutaneous vasospasm may also affect other areas, including face, ears nose, and nipples. A typical episode usually starts suddenly with the onset...

Right Bundle Branch Block Ecg Findings

Wide QRS complex, at least 120 ms (three small blocks). QRS complex has sR' or rsR' in leads Vi and V2 . Slurred S wave V6 and I. Figure 23.19A. SnurcE Knoop KJ, Stack LB, Storrow AB, Thurman fU TiieAtias of Emergency Medicine, 3rd Edition httpi wwwJacce5& madicfne.ccm Copyright The lcGi avi Hili Companies, Inc. All l ights reserved. SnurcE Knoop KJ, Stack LB, Storrow AB, Thurman fU TiieAtias of Emergency Medicine, 3rd Edition httpi wwwJacce5& madicfne.ccm Copyright The lcGi avi Hili...

Roseola Infantum Exanthem Subitum Clinical Summary

The typical presentation of roseola infantum involves a prodrome characterized by a 3- to 5-day history of high fever in a child 6 months to 3 years of age. Fussiness may be present, but the child is often otherwise well-appearing. This is followed by defervescence and the appearance of the typical exanthem which is composed of erythematous macules and papules on the trunk, neck, proximal extremities, and occasionally the face. The rash fades in a few days. The causative agent in most cases is...

Scleritis Clinical Summary

Scleritis is an uncommon, but serious inflammatory condition involving the sclera. It is most often associated with systemic inflammatory conditions such as rheumatoid arthritis, and most commonly affects women. The onset is gradual and includes severe, deep eye pain, which may radiate over the distribution of the trigeminal nerve, as well as tearing and photophobia. There may be sectorial or diffuse involvement, with intense redness of the affected area. Bilateral involvement occurs in over...

Secondary Syphilis Clinical Summary

The rash of secondary syphilis occurs 2 to 10 weeks after resolution of the primary lesions. It begins as a nonpruritic macular rash that evolves into a papulosquamous rash involving primarily the trunk, palms, and soles. The rash is often annular in shape. Diffuse, painless lymphadenopathy is also seen at this stage. Mucous patches represent mucous membrane involvement of the tongue and buccal mucosa. Condyloma lata can be seen during this stage, as can patchy alopecia. The manifestations of...

Septal Hematoma Clinical Summary

Septal hematoma is an uncommon complication of direct nasal trauma, often associated with fracture of the nasal septum with or without concomitant nasal bone fracture. Other etiologies include septal surgery or rhinoplasty. Bleeding from submucosal blood vessels leads to an accumulation of blood between the mucoperichondrium and the septal cartilage, which may lead to ischemic avascular necrosis of the underlying cartilage, destruction of the cartilage and saddle deformity (see Figure 1.11b,...

Sharpforcepattern Injuries Clinical Summary

There are two types of sharp-force injuries incised and stabbed. The incised wound is longer than it is deep. The stab wound is defined as a puncture wound that is deeper than it is wide. The wound margins of sharp-force injuries are clean and lack the abraded edges of injuries from blunt forces. Forensic information can be gathered during the examination of a stab wound. Some characteristics of a knife blade, single- or double-edged, can be determined by visual inspection. Characteristics such...

Shoulder Dislocation Clinical Summary

Anterior shoulder dislocations are the most common dislocations seen in the emergency department. They are most frequently caused by falling with the arm externally rotated and abducted. Acutely, patients present with the affected extremity held in adduction and internal rotation. Often, the patient complains of shoulder pain, refuses to move the affected arm, and may support the dislocated shoulder with the other arm. The acromion becomes prominent and there is a loss of the rounded contour of...

Simple Wound Closures Clinical Summary

The majority of wounds seen in the emergency department (ED) are uncomplicated lacerations which can be repaired primarily. Complications of wound closure (dehiscence, infection, improper healing) can be minimized by proper suturing techniques. It is important for the emergency physician to stress to the patient, or patient's caretakers, that scar formation is certain to occur with any wound closure. Proper suturing technique approximates the wound edges and decreases wound tension. Wound edge...

Stoma Prolapse Clinical Summary

When a stoma prolapses, bowel telescopes out on itself, lengthening the stoma. A stoma of the ileum may prolapse in 3 to 11 of patients over a lifetime. Causes of stomal prolapse include stomal construction difficulties, abdominal wall abnormalities such as obesity, increased intra-abdominal pressure, and weak abdominal musculature. Clinical findings of stomal prolapse include increase in size and length of the stoma edema of the mucosa bleeding, and if ischemic may be dusky, cyanotic, or...

Strawberry Hemangioma Clinical Summary

Hemangiomas are benign vascular tumors characterized by a rapid proliferative phase followed by a spontaneous involutional phase. They are the most common soft tissue tumors of infancy. The appearance of hemangiomas is determined by the lesion's depth, location, and stage of evolution. A strawberry hemangioma lies in the upper dermis and often originates as an erythematous macular patch, a pale macule, or a localized telangiectasia with a pale halo. The lesion grows and becomes vascularized...

Superior Vena Cava Syndrome Clinical Summary

This symptom complex develops from obstruction of venous drainage from the upper body, resulting in increased venous pressure, which leads to dilation of the collateral circulation. Superior vena cava (SVC) syndrome is most commonly caused by malignant mediastinal tumors. Dyspnea swelling of the face, upper extremities, and trunk chest pain, cough, or headache may be present. Physical findings include dilation of collateral veins of the trunk and upper extremities, facial edema and erythema...

Sweet Syndrome Clinical Summary

Sweet syndrome, also known as acute febrile neutrophilic dermatosis, is characterized by fever, peripheral neutrophilia, and a nonvasculitic neutrophilic cutaneous eruption. The lesions are tender, well-demarcated violaceous to erythematous plaques that may have a central yellowish discoloration and can occur anywhere on the body, but most frequently on the upper extremities, neck, and face. The plaques generally cause a burning pain and are nonpruritic. While the cause of Sweet syndrome is...

Technique

The LMA is inserted into the mouth and held against the hard palate while being advanced into the hypopharynx. The LMA is advanced until resistance is met, and the cuff is then inflated with 20 to 40 mL of air to affect a seal. The mask should be lubricated prior to insertion. Because the LMA aligns with the glottic opening, it is possible to intubate the trachea through the LMA with minimal interruption of ventilation. The distal grate prevents anything larger than a 6.0 ID ET tube through a 3...

Temporal Mandibular Joint Dislocation Clinical Summary

Temporal mandibular joint (TMJ) dislocation generally occurs in predisposed individuals after a vigorous yawn or seizure, or less commonly from direct trauma to the chin while the mouth is open. Acute dislocation occurs when the mandibular condyles displace forward and become locked anterior to the articular eminence. Masseter muscle spasm contributes to prevention of spontaneous relocation. Weakness of the temporomandibular ligament, an overstretched joint capsule, and a shallow articular...

Thirdtrimester Blunt Abdominal Trauma Clinical Summary

Trauma is a major cause of maternal and fetal mortality. In addition to the common injuries to a solid organ and or hollow viscus associated with blunt abdominal trauma, special consideration should be given to the possibility of preterm labor, fetal-maternal hemorrhage, uterine rupture, and, most importantly, abruptio placentae. Abruptio placentae is defined as the premature separation of the placenta from the site of uterine implantation. It is found in up to 50 of major blunt trauma patients...

Tooth Subluxation Clinical Summary

Tooth subluxation refers to the loosening of a tooth in its alveolar socket. Traumatic oral injury is the most common etiology however, infection and periodontal disease may also produce loosening of teeth. Gingival lacerations and alveolar fractures are commonly associated with dental subluxations. Subluxated teeth are diagnosed by applying gentle pressure to the teeth with a tongue blade or fingertip. Movement, mild displacement, or blood along the crevice of the gingiva are signs of...

Torsades De Pointes Ecg Findings

Wide-complex tachycardia with QRS polymorphism. QRS morphology changes gradually throughout the tracing, appearing to rotate around the baseline to the opposite direction. Source Knoop KJr Stack LB, Stjorrmv AB, Thurman RJ TJie Arias of Emergency Medicine, 3rd Edition Jittpi www,acce5& med ici ne.com Copyright The McGraw-Hill Companies, Inc. All rights reserved. Source Knoop KJr Stack LB, Stjorrmv AB, Thurman RJ TJie Arias of Emergency Medicine, 3rd Edition Jittpi www,acce5& med ici...

Trachoma Clinical Summary

Trachoma is the leading cause of infectious blindness in the world. It is endemic in areas of Africa, Asia, Latin America, the Middle East, and aboriginal communities in Australia. Trachoma is a chronic follicular conjunctivitis caused by Chlamydia trachomatis and is prevalent in populations with limited access to adequate sanitation and clean water. It is spread from person to person through ocular and respiratory secretions with flies constituting a major means of transmission. Although...

Umbilical Hernia Clinical Summary

The umbilicus is a common site of abdominal hernias. Predisposing conditions in adults most commonly include ascites and prior abdominal surgery. The size of the defect determines the symptomatology and incidence of incarceration, with smaller defects resulting in more pronounced symptoms and an increased incidence of incarceration. Pain is located in the area of the fascial defect. Contents of the hernia may be palpable and tender. Symptoms of obstruction (nausea, vomiting, and abdominal...

1

Source Knoop KJ, Stack LB, Storrow AB. Thurman RJ The Atlas of Emergency Medicine, 3rd Edition http www.accessmedicine.com Copyright The McGraw-HN Companies, Inc. All rights reserved. Cocaine Body-Packing. Cocaine-filled balloon packets from the stool of a cocaine body-packer (penny used for scale). Radiopaque packets are often visible on KUB radiograph in the left upper quadrant. Severe toxicity may result in the event of a ruptured packet. (Photo contributor Alan B. Storrow, MD.) Source Knoop...

Cellulitis Clinical Summary

Cellulitis, an infection of the skin or subcutaneous tissues, is common. The characteristic findings are erythema with poorly defined borders, edema, warmth, pain, and limitation of movement. Fever and constitutional symptoms may be present and are commonly associated with bacteremia. Predisposing factors include trauma, lymphatic or venous stasis, immunodeficiency (including diabetes mellitus), and foreign bodies. Common etiologic organisms include group A 13-hemolytic Streptococcus and...