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

Simple incision and drainage followed by sitz baths provide the most effective and expeditious relief on an emergency basis. Reocclusion and reaccumulation of cystic swelling are common. SaurcE Knoop KJr Stack LB. Stumiw AB. Thurman RJi The Adas of Emergency Medicine, 3rd Edition http www ,a ccesEmedicine.com Copyright The McGraw+l l Companies, Inc, All rights - Ben ed. SaurcE Knoop KJr Stack LB. Stumiw AB. Thurman RJi The Adas of Emergency Medicine, 3rd Edition http www ,a ccesEmedicine.com...

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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We have a passion for improving patient care. Our journey with The Atlas of Emergency Medicine began with an aggressive goal of producing the most comprehensive source of highquality emergency department images available. The emergency department is, perhaps, the most diverse melting pot of patient conditions in the hospital. Diagnostic accuracy and prognostic prediction often rely heavily on visual clues. Our efforts are directed toward maximizing this skill. We also strongly believe the...

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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...

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Note Large images and tables on this page may necessitate printing in landscape mode. The Atlas of Emergency Medicine > Part 2. Specialty Areas > Chapter 21. Tropical Medicine > FREE-LIVING AMEBA INFECTION Clinical Summary Free-living ameba, usually harmless residents of soil and water, can occasionally cause devastating illness in humans. There are three distinct human illnesses caused by these protozoa. Primary amebic meningoencephalitis (PAM) is a disease of previously healthy...

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 Inferior Myocardial Infarction Ecg Findings

ST segment elevation in inferior leads (II, III, aVF) Reciprocal ST segment depressions in the anterior leads (Vi -V3 ) and possibly high lateral leads (I, aVL) Figure 23.2A. Source Knoop KJr Stack ILB, Storrow AB, Thurman (Us The Attas of Emergency Mediane, 3rd Edition http www,acces5mecflci ne.com Copyright The McGraw-Hill Companies, Inc. All rights reserved. Source Knoop KJr Stack ILB, Storrow AB, Thurman (Us The Attas of Emergency Mediane, 3rd Edition http www,acces5mecflci ne.com...

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....

Atrial Fibrillation Ecg Findings

Electrical activity in the atria is chaotic. The ECG baseline, representing the ongoing chaotic atrial activity, is unorganized. The resulting rumbling baseline may have large or indiscernibly small amplitude. The AV node has a refractory period, and therefore does not conduct every signal it receives from the atria. Since the signals are received unpredictably, the AV node signals are sent to the ventricles in an irregularly irregular pattern creating varying R-R intervals. SnurcE Knoop KJ,...

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...

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...

Cerebral T Waves Ecg Findings

Inverted, wide T waves are most notable in precordial leads (can be seen in any lead). QT interval prolongation. Figure 23.10A. Snunca Knoop KJ, Stock LB, Storrow AS, Thurman RJ TTie fias of Emergency Medicine, 3rd Edition httpi www.acce & medicme.ccm Copy rig hi The VIcGraw+lili Compjniei, Inc. All l ights -eserved. Snunca Knoop KJ, Stock LB, Storrow AS, Thurman RJ TTie fias of Emergency Medicine, 3rd Edition httpi www.acce & medicme.ccm Copy rig hi The VIcGraw+lili Compjniei, Inc. All...

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...

Corner Stitch

A corner stitch is used to close triangular wounds or flaps. A simple interrupted suture cannot be placed to approximate the point of the flap. If this is done the wound will not approximate correctly and the chances of dehiscence are higher due to the already tenuous blood supply to the flap. The technique is effectively a half-buried horizontal mattress suture, where the needle is initially introduced through the skin in the noncorner area of the wound. The needle is brought out through the...

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...

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...

Digoxin Effect Toxicity Ecg Findings

ST segment shortening and depression leading to a scooped appearance Premature ventricular complexes are the most common dysrhythmia Bradydysrhythmias, various heart blocks, especially with findings consistent with increased automaticity (atrial tachycardia with block, atrial fibrillation with slow ventricular response, accelerated junctional rhythms) Bidirectional ventricular tachycardia may rarely be seen (see Figure 17.67). Figure 23.49A. Source Knoop KJr Stack LB, Storrow ABr Thurman RJ...

Early Repolarization Ecg Findings

ST elevation, usually in the anterior leads. J-point elevation, but usually less than one-third the total height of the T wave. ST segment is concave upward, or holds water, or is smiling at you. J-point notch strongly suggests early repolarization, but is not always present. Figure 23.11A. Snurce Knoop KJ, Stank LB, Stjorrow AB, Thurmao RJ The Atlas of Emergency Medicine, 3rd Edition httpiZ ww accestmed cine.com Copy rig hi The McGraw-Hil) Companies, inc. All rights reserved. Snurce Knoop KJ,...

Ecg Findings Dependent On Which Leads Are Reversed

Reversal of the left arm (LA) and right arm (RA), most common P, QRS, and T predominantly downgoing in lead I P, QRS, T upgoing in lead aVR Precordial leads unaffected Reversal of the leg leads (left leg LL and right leg RL ) Does not commonly produce EKG changes because RL is used as a grounding electrode Transposition of leads I and II and leads aVF and aVL with reversal of lead III Transposition of aVR and aVL and inversion of lead II Incorrect precordial lead placement Isolated reversal of...

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Stcrnow AB. Thurman RJ T ie Atlas of Emergency Medicine, 3rd Edition nttpi wwwjaccessmed icine, cim Copyright The McGraw-Hil Companies, Inc. All rights -reserved, Tympanogram of Otitis Media. The compliance tracing of an ear with otitis media. The line is flat (arrow). (Photo contributor Lawrence B. Stack, MD.)

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)...

Figure 111B

Storraw AB, Thurman FUi The Atlas of Emergency Mediane, 3rd Edition littp www,accB55med cine, com Copyright The McGraw-Hil Companies, Inc. All rights lesenied. Saddle Nose Deformity. Nasal septal necrosis resulting in saddle nose deformity is seen here. (Photo contributor David Effron, MD.) SnuncEi Knoop KJr Stack LB. Stcirow AB., Thurman RJ The Atias of Emergency Medicine, 3rd Edition Jittp www.a cceEEmedicine.com Copyright The McGraw il Companies, Inc. AlE rights...

Figure 155

Cigarette burns are circular injuries with a diameter of about 8 mm. Children who accidentally run into a lit cigarette often have burns to the face or distal extremities. Accidental burns may be less distinct or deep compared with inflicted burns. (Photo contributor Kathi L. Makoroff, MD.) Impetigo. These circular lesions of impetigo resemble healing cigarette burns. (Photo contributor Michael J. Nowicki, MD.)

Figure 2210A

Storruw AB, Thurman RJ TTie Atlas of Emergency Medicine, 3rd Edition iittp www.acDessmed cine.com Copyright The McGrav Hilt Companies. Inc. All rights reserved, Source Knoop KJr Stack LB. Storruw AB, Thurman RJ TTie Atlas of Emergency Medicine, 3rd Edition iittp www.acDessmed cine.com Copyright The McGrav Hilt Companies. Inc. All rights reserved, Progressive Visualization Uvula. The uvula and posterior pharynx are the first structures visualized during correct...

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 2343A

Source Knoop KG, Stack LB, Storrow AB, Thurman RJ The Adas of Emergency Medicine, 3rd Edition. http www.accessmedlcine.com Copyright ig The McGraw-Hill Companies, Inc. All rights reserved. Source Knoop KG, Stack LB, Storrow AB, Thurman RJ The Adas of Emergency Medicine, 3rd Edition. http www.accessmedlcine.com Copyright ig The McGraw-Hill Companies, Inc. All rights reserved. Hypothermia with Osborne Waves (J Waves) Present. (ECG contributor Michael L. Juliano, MD.) Source Knoop KJr Stack LB....

Figure 2345A

Of Emergency Medicine, 3rd Edition http i www-accessmed1ci ne.com Copyright The McGraw-Hill Companies, Inc. All rights reserved. of Emergency Medicine, 3rd Edition http i www-accessmed1ci ne.com Copyright The McGraw-Hill Companies, Inc. All rights reserved. Hyperkalemia (K 7.1). (ECG contributor R. Jason Thurman, MD.) of Emergency Medicine, 3rd Edition ittpj www.-a ce5 medii ine.icm Copyright The McGraw-H li Companies, inc. All rights -reserved. of Emergency Medicine, 3rd Edition ittpj www.-a...

Figure 420A and B

Storrow AB, Thurman RJ The Adas of Emergency Medicine, 3rd Edition ittp wiwj a ccessmedicine.com Copyright The McGraw-HN Companies, inc. All l ights -reserved, Source Knocp KJr Stack LB. Storrow AB, Thurman RJ The Adas of Emergency Medicine, 3rd Edition ittp wiwj a ccessmedicine.com Copyright The McGraw-HN Companies, inc. All l ights -reserved, Penetrating Globe. (A ) This penetrating injury shows an eight-ball hyphema. (B ) Bedside ultrasound shows both intraocular...

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...

Forearm Fractures Clinical Summary

Fractures of the wrist and elbow usually involve a fall onto the outstretched arm, while fractures of the ulnar shaft are more commonly the result of a direct blow. Anteroposterior (AP) and lateral views of the wrist, forearm, and elbow are required when a forearm fracture is suspected. Functional deficits in the hand are important clues to identification of occult injury to forearm nerve and vascular structures that could require immediate surgical intervention. Monteggia fracture-dislocation...

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 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...

Hypertrophic Cardiomyopathy Ecg Findings

High-voltage QRS suggesting left ventricular hypertrophy Prominent Q waves, especially in the lateral precordial leads Deep S waves in anterior precordial leads Poor R wave progression across precordium Lateral T wave inversions Figure 23.40A. Source Knoop KJ, Stack LB, Storrow ABr Thurman RJs The Atlas of Emergency Medicine, 3rd Edition http ww w. accessmed ici ne.com Copyright The McGraw-Hill Companies, Inc. All rights reserved. Source Knoop KJ, Stack LB, Storrow ABr Thurman RJs The Atlas of...

Hypertrophic Cardiomyopathy with underlying Atrial Flutter with 21 Block ECG contributor James V Ritchie MD

Stcmow AB, Thurman RJ The Atlas of Emergency Medicine, 3rd Edition nttpi ywivw.accessmed cine, com Copyright The McGratiHHil Companies, Inc. All rights -Teserved, Source Knoop KJ, Stack LB. Stcmow AB, Thurman RJ The Atlas of Emergency Medicine, 3rd Edition nttpi ywivw.accessmed cine, com Copyright The McGratiHHil Companies, Inc. All rights -Teserved, Deep S-wave voltage (28 mm S in V2 , large arrow), and narrow Q waves in V5 and V (arrowheads). This patient also has...

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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LIVING CAROLINA BIOLOGICAL SUPPLY CO CULTURES iJURLIN TON, N. C. & GLADSTONE, QREGUN LIVING CAROLINA BIOLOGICAL SUPPLY CO CULTURES iJURLIN TON, N. C. & GLADSTONE, QREGUN SourcE Knoop KJr Stack Lfi. Storrow A& , Thurman RJ The Atlas of Emergency Medicine, 3rd Edition nttp wivw,-3ccessmedicine.icm Copyright The flcGranH-lil Companies, Inc. Ali rights reserved. SourcE Knoop KJr Stack Lfi. Storrow A& , Thurman RJ The Atlas of Emergency Medicine, 3rd Edition nttp wivw,-3ccessmedicine.icm...

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Storraw AB. Thurman RJ The Atlas of Emergency Medicine, 3rd Edition iittpi www.accesEmediicine.tjom Copyright ThE McGraw H Companies, Inc. All rights oesen ed, Apical Lung Mass. This 68-year-old male cigarette smoker complained of cough and weight loss. A chest radiograph shows a left apical tumor. There is erosion of the tumor into the chest wall, with an indurated supraclavicular and infraclavicular mass. Moderate JVD is apparent, suggesting venous outflow...

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....

Iron Ingestion Clinical Summary

Iron is a commonly used pharmaceutical agent and supplement found in prenatal and multivitamins. Although the incidence has declined, acute iron poisoning remains a significant cause of pediatric morbidity and mortality. The toxic dose depends upon the quantity of elemental iron in the preparation, which in turn depends upon the iron formulation. While the minimum toxic dose remains controversial, ingestion of more than 40 mg kg elemental iron may result in toxicity, while ingestion of more...

J V

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...

Junctional Rhythm Ecg Findings

The QRS complex is narrow, with a rate typically between 40 and 60 beats per minute. P waves are absent, retrograde, very slow, or unrelated to the QRS complex. Source Knoop KJ, Stack LB, Storrow ABr Thurman RJs The Adas of Emergency Medicine, 3rd Edition http www.accessmed ici ne.com Copyright The McGraw-Hill Companies Inc. All rights reserved. Source Knoop KJ, Stack LB, Storrow ABr Thurman RJs The Adas of Emergency Medicine, 3rd Edition http www.accessmed ici ne.com Copyright The McGraw-Hill...

L U vU Jr

Source Knoop KJr Stack LB, Storrow AB, Thurman RJ The Adas of Emergency Medicine, 3rd Edition http www. accessrnedicine.com Copyright The McGraw-Hill Companies, Inc. All rights reserved, Right Atrial Hypertrophy. (ECG contributor James V. Ritchie, MD.) Source Knoop KJ, Stack LB. Stomow Afl. Thurman RJ The AtSas of Emergency Medicine, 3rd Edition 'ittp wiwj,a ccessmedlicine.com Copyright The McGravv-J-lill Companies, Inc. All rights Me& eniei. The P wave in lead II (an inferior lead) is...

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...

Lee E Edstrom MD

Surgeon in Chief Division of Plastic Surgery Rhode Island Hospital Assistant Professor of Surgery Brown University Providence, Rhode Island Department of Emergency Medicine Metro Health Medical Center Cleveland, Ohio Staff Physician Naval Hospital Jacksonville, Florida Chief, Preventive Medicine Department US Army Medical Research Institute of Infectious Diseases Staff Hemopathologist St. Thomas Hospital Nashville, Tennessee Attending Surgeon Division of Trauma Department of Surgery Cook County...

Left Anterior Fascicular Block Ecg Findings

QRS complex widening, usually 90 to 120 ms Left axis deviation beyond minus 45 degrees with no other cause (such as inferior myocardial infarction) Small R wave and large S wave in the inferior leads Slurred S wave in V5 and V6 Figure 23.21A. Copyright The McGraw-Hill Companies, Inc. All rights reserved. Left Anterior Fascicular Block. (ECG contributor James V. Ritchie, MD.) Copyright The McGraw-Hill Companies, Inc. All rights reserved. Left Anterior Fascicular Block. (ECG contributor James V....

Left Atrial Hypertrophy Ecg Findings

Increased duration (width) of the P wave without affecting its upward amplitude (as commonly seen with right atrial abnormalities) Negative P wave deflection in lead Vi , with width and depth greater than 0.04 seconds (one small box) Notched P wave in II, III, or aVF with duration greater than or equal to 0.12 seconds (also known as P-mitrale) Source Knoop KJr Stack LB, Stomsw AB, Thurman RJ The Atlas of Emergency Medicine, 3rd Edition httpsZ www. accessmedicine.com Copyright The McGraw-Hill...

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 Posterior Fascicular Block Ecg Findings

QRS complex widening to 90 to 120 ms. Right axis deviation must be beyond 100 degrees and must have no other cause (such as lateral myocardial infarction). Small R wave and large S wave in the high lateral leads, I and aVL. Slurred S wave in V5 and V6 . This example also contains unrelated ST changes. Figure 23.22A. Copyright The McGi aw-Hili Companies, Inc. All rights reserved. Left Posterior Fascicular Block. (ECG contributor James V. Ritchie, MD.) Copyright The McGi aw-Hili Companies, Inc....

Left Ventricular Aneurysm Ecg Findings

ST elevation in anterior contiguous leads Deep pathologic Q waves in anterior leads Figure 23.12A. Source Knoop KJ, Stack LB, Storrow Afl, Thurmaji RJ T ie Arias of Emergency Medicine, 3rd Edition httpi www.3cce5& med cine.com Copyright The McGraw-Hill Companies, Inc. All rights reserved. Source Knoop KJ, Stack LB, Storrow Afl, Thurmaji RJ T ie Arias of Emergency Medicine, 3rd Edition httpi www.3cce5& med cine.com Copyright The McGraw-Hill Companies, Inc. All rights reserved. Left...

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...

Multifocal Atrial Tachycardia Ecg Findings

Multiple P-wave morphologies with heart rate greater than 100 bpm Varying PR intervals Figure 23.29A. Multifocal Atrial Tachycardia. (ECG contributor James V. Ritchie, MD.) Multifocal Atrial Tachycardia. (ECG contributor James V. Ritchie, MD.) Multiple P morphologies (arrowheads), varying PR intervals (lower double arrows), and varying R-R intervals (upper double arrows) with heart rate greater than 100 bpm.

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...

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...

Paced Rhythm Ecg Findings

Very narrow signal of no discernable width, immediately followed by a P wave (if an atrial lead) or a QRS complex (if a ventricular lead). The narrow pacer spike amplitude varies, and can be larger than the QRS or may be indiscernible. A QRS complex initiated by a pacer spike will be wide, with morphology similar to a PVC or idioventricular rhythm. The axis is unlike typical bundle branch blocks, because the signal usually originates low in the right ventricle. Copyright The McGraw-Hill...

Papilledema Clinical Summary

Papilledema involves swelling of the optic nerve head, usually in association with elevated intracranial pressure. The optic disks are hyperemic with blurred disk margins the venules are dilated and tortuous. The optic cup may be obscured by the swollen disk. There may be flame hemorrhages and infarctions (white, indistinct cotton wool spots) in the nerve fiber layer and edema in the surrounding retina. Ocular inflammation (eg, papillitis), tumors or trauma, central retinal artery or vein...

Pearl

A rectocele is the herniation of the rectovaginal wall and is usually due to childbirth. So Jicei Knoc KJr Stack UB. Stcmow AB, Thunnari RJi The Adas of Emergency Medicine, 3rd Edition Jittpj www.a ccessmedicrne.com Copyright The McGraw-Hl Companies, Inc. Alt rights reserved. So Jicei Knoc KJr Stack UB. Stcmow AB, Thunnari RJi The Adas of Emergency Medicine, 3rd Edition Jittpj www.a ccessmedicrne.com Copyright The McGraw-Hl Companies, Inc. Alt rights reserved. Rectocele. This is characterized...

Pearls

Branchial cleft anomalies are second only to thyroglossal duct cysts in frequency of congenital head and neck lesions in children. 2. Malformations of the second branchial cleft represent approximately 95 of branchial cleft anomalies and give rise to cysts in the region of the sternocleidomastoid muscle. 3. These lesions may be intimately involved with major vessels and nerves. Excision by a specialist familiar with the underlying anatomy is recommended.

Pectus Excavatum Clinical Summary

Pectus excavatum is a common developmental deformity of the anterior chest wall present in 0.25 of births. The cause is not well understood and may be related to intrauterine growth effects or muscle and connective tissue abnormalities within the thorax. In many cases there is a family history of the condition. SnurcEi Knoop KJ, Stack LB. Storrcnv Afl, Thurman RJ iTie Atlas of Emergency Medicine, 3rd Edition ittp www,accessmedinne.aom Copyright The McGraw HN' Companies, Inc. AlE rights...

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...

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...

Pericarditis Ecg Findings

Diffuse ST elevation in noncontiguous leads T wave flattening or inversion SnurcE Knoop KJ, Stack LB, Storrow AB, Thurman fU The Atlas of Emergency Medicine, 3rd Edition htt wtv, jJacceE& medicrna.iom Copyright Tha McGraw-Hilk Companies, Inc. All rights Earned. Acute Pericarditis. (ECG contributor James V. Ritchie, MD.) Source Knoop KJr Stack LB. Stiomow AB, Thurman RJ The Atlas of Emergency Medicine, 3rd Edition nttpi www,a ccessmedicine.com Copyright The McGramHHili Companies, Inc. All...

Physeal Fractures Salterharris Classification Clinical Summary

There are several fracture patterns that are unique to children. Physeal fractures, torus (buckle) fractures, greenstick fractures, and bowing fractures or deformities all occur secondary to the physiologic differences between immature and mature bone. Physis (growth plate) fractures are common because of the relative weakness of the growth plate compared to the cortical lamellar bone. This weakness is related to the relatively large ratio of cells to matrix in the physis. The Salter-Harris...

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...

Prominent S in Lead I Figure 2350A

Source Knoop KJr Stack LB, Storraw ABr Thurman FUi The Atlas of Emergency Mediane, 3rd Edition fattps www.accessmed1ci ne.com Copyright The McGraw-Hill Companies, Inc. All rights reserved. Source Knoop KJr Stack LB, Storraw ABr Thurman FUi The Atlas of Emergency Mediane, 3rd Edition fattps www.accessmed1ci ne.com Copyright The McGraw-Hill Companies, Inc. All rights reserved. Tricyclic Antidepressant Toxicity. (ECG contributor Saralyn R. Williams, MD.) SnurcE Knoop KJ, Stalk LB, Storrow AB,...

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 Ventricular Hypertrophy Ecg Findings

S wave amplitude increases in lateral leads (V5 , V6 , I, aVL). R wave amplitude increases in aVR, Vi , V2 , and may exceed the S-wave amplitude (especially in lead V1 ). Right axis deviation (> +90 degrees). T wave inversions in relation to QRS complex. Copyright The McGraw-Hill Companies, Inc. All rights reserved. Right Ventricular Hypertrophy. (ECG contributor James V. Ritchie, MD.) Copyright The McGraw-Hill Companies, Inc. All rights reserved. Right Ventricular Hypertrophy. (ECG...