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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.…

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…