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Mood Disorders

Key Concepts Patients with apparent mood disorders should be evaluated for medical disorders, medication effects, or substance abuse or withdrawal because these conditions can mimic both depression and mania. Mood disorders should be suspected in patients with multiple, vague, nonspecific complaints and in patients who are frequent, heavy users of medical care. Patients with mood disorders should be assessed for their suicide potential. Pharmacologic treatment and…

Thought Disorders

Key Concepts Thought disorder symptoms can be precipitated by psychiatric, underlying medical, and toxicologic etiologies. Diagnostic testing should be patient specific and based on the particular medical processes that the clinician feels may be causing or exacerbating the thought disorder, rather than panels of routine tests. Consider nonphysical interventions first when appropriate, but chemical sedation or physical restraints may become immediately necessary for patients who demonstrate…

Central Nervous System Infections

Key Concepts CNS infection should be considered in all patients with headache, nuchal rigidity, fever, altered sensorium, or diffuse or focal neurologic findings. Patients with suspected CNS infection should be asked about history focused on risk factors for CNS disease and infection and receive a full neurologic examination. CSF testing is the most reliable method of assessing the presence of meningitis and should be obtained in…

Neuromuscular Disorders

Key Concepts In patients presenting with acute neuromuscular weakness, complaints of difficulty in breathing or swallowing are signs of bulbar nerve or respiratory muscle compromise with potential airway or ventilatory failure. In such patients, forced vital capacity (FVC) of less than 15 mL/kg or maximal negative inspiratory force of less than 15 mm H 2 O is a potential indication for mechanical support, either by intubation…

Peripheral Nerve Disorders

Key Concepts The diagnosis of a specific peripheral neuropathy generally requires confirmatory ancillary testing; approach in the ED should focus on identifying one of seven categorical patterns. Diagnostic approach to peripheral neuropathies involves combining three clinical features: (1) right-left symmetry or asymmetry, (2) proximal-distal location, and (3) sensorimotor modalities affected. Any patient with symmetrical weakness, distributed both proximally and distally, with loss or diminution of deep…

Spinal Cord Disorders

Key Concepts Nontraumatic spinal cord disorders can be intrinsic or extrinsic, some of which require prompt diagnosis, advanced imaging, and specialist intervention to prevent or limit permanent neurologic dysfunction. The bulbocavernosus reflex is cord-mediated. Return of this reflex following a spinal injury marks the termination of spinal shock. Anterior cord syndrome is marked by symmetrical motor loss but intact proprioception and vibration sense. In patients with…

Brain and Cranial Nerve Disorders

Key Concepts Multiple Sclerosis The clinical picture of multiple sclerosis (MS); is one of marked heterogeneity. The classic clinical syndrome consists of recurring episodes of neurologic symptoms that rapidly evolve over days and slowly resolve over weeks. Magnetic resonance imaging (MRI) is a high-yield diagnostic test for MS. When the emergency department (ED) MRI is an option, it should be considered as it may expedite follow…

Delirium and Dementia

Key Concepts Delirium is an acute condition characterized by an altered level of attention and awareness. It develops during a short time, and symptoms tend to fluctuate throughout the day. Delirium is commonly caused by medications, drug intoxication or withdrawal, infections, metabolic disorders, CNS and cardiovascular events, and autonomic nervous system disturbances. Dementia is a chronic condition characterized by cognitive impairment. It is slow in onset…

Headache Disorders

Headache is divided into primary and secondary disorders. Key Concepts The goals of headache evaluation in the ED are (1) to distinguish between benign primary headache disorders and potentially life-threatening secondary causes of headache and (2) to treat the headache pain effectively and rapidly without causing undue side effects. Patients with the following headache presentations are at risk for serious underlying disease: sudden explosive headache; new-onset…

Seizure

Key Concepts Epilepsy is a neurologic condition associated with an intrinsically lower seizure threshold and a higher risk of recurrent seizures without a clear trigger. The characterization of seizure semiology, duration, and etiology is important for accurate classification of seizures and status epilepticus; these impact definitive treatment choices. There is no single test to confirm that a patient seized, and several seizure mimics, including convulsive syncope,…

Stroke

Key Concepts Anterior circulation strokes result in contralateral hemiparesis of the face and body. Vertebrobasilar strokes result in ipsilateral cranial nerve (CN) deficits and contralateral hemiparesis. Posterior cerebral artery stroke causes ipsilateral CN III palsy and contralateral homonymous hemianopsia. Wallenberg syndrome (lateral medullary syndrome) causes vertigo, Horner syndrome, ipsilateral facial numbness, loss of corneal reflex, along with contralateral loss of pain and temperature. Cervical artery dissection…

Gynecologic Disorders

Key Concepts Adnexal torsion is easily missed on initial presentation and should be considered in any patient with known risk factors, even if symptoms are subtle or atypical. Doppler ultrasound is the preferred initial imaging study for suspected adnexal torsion. An ultrasound examination may distinguish among the various types of ovarian cysts and identify associated complications, such as torsion, hemorrhage, and malignancy. Most ovarian cysts are…

Urologic Disorders

Key Concepts Urinary obstruction should be considered in patients with a urinary tract infection (UTI) with risk factors for obstruction. Urinary obstruction should be ruled out in patients presenting in septic shock. Patients presenting with acute ureteral obstruction require a urinalysis to rule out the presence of a superimposed UTI. Acute, uncomplicated UTIs should be treated with fosfomycin, nitrofurantoin, or trimethoprim-sulfamethoxazole. Fluoroquinolones are not recommended as…

Sexually Transmitted Infections

Key ConceptS The emergency department (ED) diagnosis of sexually transmitted infections (STIs) is often based on clinical findings. Empirical antibiotic treatment is warranted to cover the most likely infecting organisms based upon history and physical examination findings. Rapidly available diagnostic tests (Gram stain, darkfield microscopy, wet mount microscopy, and other point-of-care tests) increase diagnostic sensitivity and specificity. Confirmatory diagnostic studies (PCR, culture, serology, and others) should…

Renal Failure

Key Concepts The causes of acute kidney injury (AKI) can be classified as prerenal, postrenal, and intrinsic renal disorders. Abrupt cessation of glomerular filtration typically results in a rise of the serum creatinine level of 1 to 2 mg/dL per day. Management of AKI is directed first at potentially lethal complications such as hyperkalemia or volume overload and then at reversal of the underlying cause of…

Anorectum

Key Concepts Anorectal conditions can be approached using an algorithm that addresses the presence or absence of pain, bleeding, swelling, and pruritus, in combination with an assessment of the patient’s overall health (see Fig. 82.2 ). Patients who seek treatment for nonspecific anorectal complaints should be evaluated for the presence of underlying systemic disease (e.g., cancer, diabetes mellitus, immunodeficiency) because disorders of the anorectum may be…

Large Intestine

Key Concepts Irritable Bowel Syndrome Irritable bowel syndrome (IBS) is a chronic disorder that includes both abdominal pain and bloating and is either diarrhea-predominant, constipation-predominant, or a mixed picture. Treatment of IBS is challenging and commonly involves a combination of diet, pharmacological, and behavioral therapy, along with reassurance. Diverticular Disease Diverticular disease can consist of diverticulosis, which can cause bleeding but is often asymptomatic, or inflammation…

Gastroenteritis

Key Concepts Gastroenteritis is usually self-limited and requires supportive care only. Routine laboratory testing or stool cultures are not indicated for most patients. Patients with gastroenteritis associated with fever, dysentery, bloody stools, severe dehydration, sepsis, a suspicion for Clostridium difficile, or an immunocompromised state should generally have a complete blood count, electrolytes, and stool cultures evaluated. Caution should be used in the care of the very…

Acute Appendicitis

Key Concept Appendicitis is a progressive illness caused by appendiceal luminal distention followed by appendiceal wall ischemia, transmural inflammation, and eventual perforation, with resulting peritonitis. Clinical history, physical examination, and laboratory findings need to be combined to formulate a comprehensive assessment. No one finding can definitively diagnose or exclude appendicitis. The most useful historical features in evaluating appendicitis are right lower quadrant (RLQ) pain, pain preceding…

Small Intestine

Small Bowel Obstruction Key Concepts Small bowel obstruction (SBO) is a common clinical condition accounting for 2% of patients presenting to the emergency department with abdominal pain, leading to an estimated 300,000 hospitalizations annually in the United States. The most common cause of SBO is adhesions from prior abdominal surgery, which are found in approximately 60% of cases. Tumors and abdominal hernias account for another 20%…