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Thyroid and Adrenal Disorders

Key Concepts Hyperthyroidism Hyperthyroidism induces a hypermetabolic state and increases β-adrenergic activity. The resulting clinical manifestations range from vague constitutional symptoms to more organ-specific symptoms (see Box 117.1 ). BOX 117.1 Symptoms of Thyrotoxicosis Constitutional: Weight loss despite hyperphagia, fatigue, generalized weakness Hypermetabolic: Heat intolerance, cold preference, excessive perspiration Cardiorespiratory: Palpitations, dyspnea, dyspnea on exertion, chest pains, poor exercise tolerance Gastrointestinal: Nausea, vomiting, diarrhea, dysphagia Neuropsychiatric:…

Rhabdomyolysis

Key ConceptS Rhabdomyolysis is a process wherein striated muscle cells break down, resulting in the release of creatine kinase, potassium, calcium, phosphate, and uric acid. Rhabdomyolysis is associated with a variety of causes including overexertion, extreme body temperature changes, ischemia, infection, immobility, drugs, toxins, endocrine disease, autoimmune reactions, trauma, and genetic conditions. The classic presentation of rhabdomyolysis is myalgia, weakness, and dark-colored urine. However, the absence…

Diabetes Mellitus and Disorders of Glucose Homeostasis

Key Concepts The diagnosis of diabetes can be determined by one or more of four methods—random plasma glucose level above 200 mg/dL, fasting plasma glucose concentration above 126 mg/dL, 2-hour, 75-g post-load oral glucose tolerance test (OGTT) > 200 mg/dL, or HbA 1c value above 6.5%. Diabetic ketoacidosis (DKA) is diagnosed by the presence of hyperglycemia, anion gap metabolic acidosis, and elevated ketoacid levels. The essential…

Electrolyte Disorders

Key Concepts Electrolyte abnormalities are common in emergency medicine and can vary greatly in importance, severity, and symptoms. Asymptomatic electrolyte abnormalities can be gradually corrected, whereas those causing alterations in consciousness or life-threatening dysrhythmias require immediate therapy to avoid permanent sequelae or death. In some cases, therapy for life-threatening electrolyte disorders may precede laboratory confirmation. Asymptomatic electrolyte abnormalities can usually be corrected slowly, but those that…

Acid-Base Disorders

Key Concepts Metabolic acidoses are classified into wide anion gap and normal anion gap acidoses, based on basic metabolic panel (BMP) values. A wide anion gap metabolic acidosis is present when the gap exceeds 15 mmol Common causes of a wide anion gap metabolic acidosis are summarized with the mnemonic MUDPILES (Methanol, Uremia, DKA, Paraldehyde, Polyethylene glycol, or Paracetamol (Acetaminophen), Iron, Lactate, Ethylene Glycol, Salicylates). When…

Oncologic Emergencies

Foundations As improved therapies prolong the lives of cancer patients, the prevalence of oncologic emergencies continues to increase. However, nonspecific clinical features misattributed to the underlying cancer complicate their diagnosis. In this chapter, we review febrile neutropenia, metastatic spinal cord compression (MSCC), malignant pericardial disease, hypercalcemia of malignancy, tumor lysis syndrome (TLS), leukostasis, superior vena cava (SVC) syndrome, and complications of cancer immunotherapies including monoclonal antibodies,…

Disorders of Hemostasis

Key Concepts Although hemostatic disorders are confirmed through laboratory testing, a careful history and thorough physical examination may provide clues to the diagnosis. The use of antithrombotic agents remains widespread, whereas diseases such as hemophilia or disseminated intravascular coagulation (DIC) are encountered infrequently in the emergency department (ED) setting. Critical thrombocytopenia increases the risk of bleeding, particularly with trauma or invasive procedures. Platelet dysfunction may occur…

White Blood Cell Disorders

Key Concepts Chronic lymphocytic leukemia (CLL) is the most common leukemia in the elderly, and acute lymphocytic leukemia (ALL) is the most common leukemia in children. Splenomegaly is a common finding in leukemias. Leukostasis is usually not accompanied by clinical sequelae until the white blood cell (WBC) count is more than 500,000. Neutropenia plus a fever should be treated as a potentially life-threatening infection until proven…

Anemia and Polycythemia

Key Concepts Anemia is caused by three basic mechanisms: loss of red blood cells (RBCs) through bleeding, destruction of RBCs, or decrease in production of RBCs. RBC indices along with a peripheral blood smear can help determine the mechanism of anemia. Anemia in the elderly often occurs as an exacerbation of pre-existing comorbid diseases. Anemia of uncertain etiology should be thoroughly evaluated. If the patient has…

Blood and Blood Components

Key Concepts Red blood cell transfusion is indicated only to increase oxygen delivery at the tissue level. One unit of packed red blood cells (PRBCs) can be expected to raise an adult’s hemoglobin level by 1 g A similar increase is expected in children following the transfusion of 10 mL/kg of PRBCs. Controlled trials have supported newer, restrictive, red cell transfusion strategies. Pending further trials, a…

Dermatologic Presentations

Key Concepts Accurate descriptions of dermatologic lesions are essential for diagnosis and management. Primary and secondary lesions are described in Tables 107.1 and 107.2 . TABLE 107.1 Primary Lesions Lesion Description Size Macule Flat circumscribed pigmented area <0.5 cm in diameter Patch Flat circumscribed pigmented area >0.5 cm in diameter Papule Elevated, solid, palpable lesion, variable color <0.5 cm in diameter Plaque Elevated, solid, palpable lesion,…

Allergy, Anaphylaxis, and Angioedema

Key Concepts Anaphylaxis is a life-threatening systemic allergic (or nonallergic) reaction of acute onset and multiorgan involvement in which timely recognition and treatment remain essential. A history of sudden urticarial rash accompanied by respiratory difficulty, abdominal pain, or hypotension, strongly favors the diagnosis of anaphylaxis. The recommended treatment algorithm for anaphylaxis is shown in Box 106.7 . BOX 106.7 Treatment Algorithm for Anaphylaxis D 5 W,…

Systemic Lupus Erythematosus and the Vasculitides

Systemic Lupus Erythematosus Key Concepts Systemic lupus erythematosus (SLE) is a chronic autoimmune disorder that can affect any organ system. A general approach to determine whether SLE is the cause of a nonspecific or single-organ symptom is to search for evidence of other organ involvement or systemic inflammation, which is expected in SLE-mediated presentations. Patients with SLE are at significantly higher risk of coronary artery or…

Musculoskeletal Back Pain

Key Concepts Most patients presenting to the emergency department (ED) with back pain have uncomplicated musculoskeletal pain that is self-resolving with conservative therapy and does not require imaging. Indications for emergent imaging include “red flags” such as an acute neurologic deficit, bowel or bladder dysfunction, or saddle anesthesia. Risk factors for compressive myelopathy include immunocompromised patients with a history of malignancy, injection drug use, fever, chronic…

Tendinopathy and Bursitis

Tendinopathy Foundations Background and Importance Tendons are collagenous, dynamic structures that connect muscle to bone. They transmit forces originating in muscles to bone by stiffening, thereby enabling joint motion. Key Concepts Tendinopathy Mechanical overload and repetitive microtrauma are key underlying mechanisms in the development of tendinopathy. Patients most often present with a history of progressively worsening localized pain after repetitive work- or sports-related activities. Tendinopathy may…

Arthritis

Key Concepts 1. Arthritis can be considered in three broad classes: degenerative, infectious, and inflammatory. The number of joints involved, time course, and presence of other systemic symptoms can help in classification. 2. Septic (acute infectious) arthritis should be considered in any patient presenting with acute monoarticular arthritis. 3. No singular physical examination finding, serum test, or synovial fluid test in isolation can diagnose or exclude…

Suicidal Behavior

Key Concepts Many suicidal individuals see a physician shortly before their death. An ED visit for suicidal thoughts or behaviors represents an opportunity for a critical intervention that may prevent a subsequent suicide. Suicidal thoughts or behaviors are often triggered by short-term crisis, and most survivors are grateful to be alive. An empathetic, patient-centered, collaborative approach that incorporates information from collateral sources (e.g., family) can optimize…

Factitious Disorders and Malingering

Key Concepts Patients who have consciously synthesized symptoms and signs may be divided into two broad diagnostic categories: (1) those with obvious secondary gain (malingering), who control their actions, and (2) those with a motivation of achieving the sick role (factitious disorders), who cannot control their actions. The initial management of patients suspected of fabricating disease should include a caring, nonjudgmental attitude and a search for…

Somatic Symptoms and Related Disorders

Key Concepts Several conditions previously classified in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) as somatoform disorders are now classified under DSM-V as Somatic Symptom and Related Disorders (SSRD). These include somatic symptom disorder (SSD), illness anxiety disorder (IAD), and conversion disorder. They share a common feature of patients’ maladaptive and inappropriate psychological response to somatic (bodily) symptoms. SSRD patients…

Anxiety Disorders

Key Concepts Patients who present with predominant symptoms of anxiety may be suffering from medical disorders, medication effects, or substance abuse or withdrawal. Anxiety may accompany the onset of serious medical disease, cause significant metabolic demands, and stress a marginally compensated organ system. Anxiety caused by non-psychiatric illness is usually suggested by the patient’s physical examination findings but may require testing to further delineate the cause.…