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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%…

Pancreas

Key Concepts Acute pancreatitis represents a wide spectrum of disease, ranging from mild to severe life-threatening disease with a mortality rate as high as 30%. The most common causes of acute pancreatitis are gallstones and chronic alcohol consumption. Acute pancreatitis is diagnosed by the presence two of three criteria—characteristic abdominal pain, serum lipase or amylase levels greater than three times the upper limit of normal, and…

Liver and Biliary Tract Disorders

Key Concepts Viral Hepatitis The clinical presentation of viral hepatitis is highly variable, and many cases may be asymptomatic, particularly in children. Hepatitis A is transmitted through oral fecal spread, whereas hepatitis B and C are spread through parenteral or intimate contact. Highly effective immunizations exist against hepatitis A and B viruses. Postexposure, passive immunization exists for hepatitis A and B viruses, though its use is…

Esophagus, Stomach, and Duodenum

Key Concepts Dysphagia Dysphagia can be caused by obstructive lesions (e.g., esophageal neoplasm), motility disorders (e.g., achalasia), or neuromuscular disorders that can be vascular (e.g., cerebral vascular accident), immunologic (e.g., myasthenia gravis, multiple sclerosis [MS]), infectious (e.g., botulism), or metabolic in nature. The incidence of achalasia increases with age, presenting insidiously with equal frequency for solids or liquids. Dysphasia can be the initial presentation of myasthenia…

Pulmonary Embolism and Deep Vein Thrombosis

Key Concepts Hallmarks of deep venous thrombosis (DVT) include unilateral limb pain and swelling, though these findings can be subtle and nonspecific. Patients with low pretest probability (PTP) can have DVT ruled out in the ED with a negative D-dimer or venous ultrasound (US), patients with high PTP can have DVT ruled out in the ED with a negative D-dimer and venous US. Three-point US evaluates…

Peripheral Arteriovascular Disease

Key Concepts Acute arterial occlusion is a limb-threatening emergency requiring early anticoagulation and Fogarty catheter embolectomy. The clinical diagnosis is based on some variant of the five Ps: pain, pallor, pulselessness, paresthesias, and paralysis. Confirmatory tests are unnecessary and increase the limb’s ischemic time. Atheroembolism (blue toe syndrome) is associated with cool, painful cyanotic toes in the presence of palpable distal pulses. A proximal source should…

Abdominal Aortic Aneurysm

Key Concepts A ruptured abdominal aortic aneurysm (AAA) should be considered in any patient with otherwise unexplained abdominal or back pain. The complete triad of pain, hypotension, and a pulsatile mass may not be present. In a patient with an AAA and acute symptoms such as severe abdominal or back pain or hypotension, rupture is imminent or has already occurred. A patient with a ruptured AAA…

Aortic Dissection

Key Concepts Aortic dissection most commonly presents as abrupt, sharp, severe pain maximally intense at onset in the chest or back. There may be various seemingly unconnected associated symptoms due to altered blood pressure or insufficiency of disparate vascular beds. Definitive diagnosis is most commonly made with an imaging study such as computed tomography of the aorta with intravenous contrast. A combination of standardized clinical assessment,…

Hypertension

Key Concepts Elevated blood pressure with or without associated symptoms is exceedingly common in the emergency department (ED). A true hypertensive emergency is defined by the presence of acute target organ damage (TOD) and is distinct from other clinical presentations. Commonly encountered hypertensive emergencies include ischemic and hemorrhagic stroke, myocardial infarction, acute heart failure, aortic dissection, and pre-eclampsia. Management strategies regarding target blood pressure reduction, rate…