Presentation Patients with bug or insect bites seek medical help because of itching, secondary infection, or anxiety about secondary effects such as communicable diseases or infestation. Skin lesions generally consist of single or multiple pruritic wheals or papules, which may include excoriations from scratching ( Fig. 164.1 ). Mosquito bites most often occur on skin-exposed areas in the summer in mosquito-infested environments ( Fig. 164.2 ).…

Presentation Occasionally patients will come in with a dead or captured spider after having rolled over it in bed or finding it in their clothing while dressing. They may have felt a minor pinprick sensation or no discomfort at all. Early presentations may show only mild erythema at the suspected bite site. Burning pain, pruritus, and swelling may develop within a few hours of the bite.…

Presentation Patients present with a very pruritic, eczematous-like rash at sites of skin exposure to allergens. Lesions may consist of small papules, vesicles, or bullae that may be confluent. Inflammation may exist with erythema, edema, oozing, or crusting. Dermatitis may remain localized at contact sites or, in severe cases, can spread to involve distant body areas. Sites with thin skin (e.g., eyelids [ Fig. 162.1 ],…

Presentation Usually a child (or parent) has dressed (the child) too quickly and, possibly not wearing underpants, has accidentally pulled penile skin into his zipper ( Fig. 161.1 ). The skin becomes entrapped and crushed between the teeth and the actuator (slide) of the zipper, thereby painfully attaching the article of clothing to the body part involved (most often the penis, or less often the area…

Presentation The patient has fallen onto a coarse surface, such as a blacktop or macadam road. Most frequently, the skin of the face, forehead, chin, hands, and knees is abraded. When pigmented foreign particles are impregnated within the dermis, tattooing will occur. An explosive form of tattooing can also be seen with the use of firecrackers, firearms, and homemade bombs. You’re Reading a Preview Become a…

Presentation A patient comes to the emergency department or clinic with an earlobe torn by a sudden pull on an earring. Contributing factors might include previous lengthening of the earlobe hole because of long-term use of relatively heavy or dangling ear jewelry, or the original earring hole may have been placed in an excessively low position. Patients with this type of injury require lobuloplasty to maximize…

Presentation A patient is brought in by police officers after being subdued with a Taser. A Taser is a type of conducted electrical weapon (CEW) that fires two barbed darts using a compressed nitrogen charge. The darts penetrate light clothing and embed in the skin. Electricity is conducted through fine insulated copper wires, resulting in neuromuscular incapacitation. You’re Reading a Preview Become a Clinical Tree membership…

Presentation A patient may present with focal tenderness, a palpable cord, and mild erythema over the course of a superficial vein. The risk factors for the development of a superficial venous thrombosis (superficial thrombophlebitis [ST]) are similar to those of deep venous thrombosis (DVT) and include smoking, estrogen, prolonged immobility, malignancy, clotting disorders, pregnancy, and recent surgery Varicose veins are likely the most significant risk factor,…

Presentation After blunt trauma to the distal phalanx of any digit, a patient can develop a subungual hematoma. The hematoma is contained between the nail plate and the sterile matrix of the nail bed, which is highly vascularized. Unless artificial nails are present, the collecting blood is easily visualized as a dark blue-black discoloration under the nail ( Fig. 156.1 ). The bleeding into the potential…

Presentation The patient had a mild to moderate crushing injury to a fingernail, such as being caught in a closing drawer or being struck by a heavy object. The pain was initially intense but rapidly subsided over the first few minutes to 0.5 hour. Usually, by the time the patient is examined, there is only mild pain and tenderness. There is a light brown or blue-brown…

Presentation Small, moderate-velocity metal fragments can be released when a hammer strikes a second piece of metal, such as a chisel. The patient has noticed a stinging sensation and a small puncture wound or bleeding site and is worried that there might be something inside. A BB projectile will produce a more obvious but very similar problem. Another mechanism for producing hard radiopaque foreign bodies is…

Presentation The patient is caught on a sharp splinter (usually wooden) and either cannot grasp it, has broken it trying to remove it, or has found that it is too large and painful to remove. The history may be somewhat obscure. On examination, a puncture wound should be found with a tightly embedded sliver that may or may not be palpable over its entire length (…

Presentation Removal of rings from fingers or toes may be required due a variety of conditions that predispose to digital swelling, such as trauma, infection, burns, peripheral edema, or arthropod assault. Sometimes chronic tight-fitting rings begin to obstruct lymphatic drainage, causing swelling and further constriction ( Fig. 152.1 ). Rings often have sentimental and monetary value to the patient. Thus providers should be familiar with a…

Presentation Puncture wounds are common injuries, especially in children during the summer months when protective footwear may not be worn. The risk of a puncture wound is disproportional to its size, as irrigation is difficult and the tract of the wound is prone to creating an anaerobic environment. As such, patients either present early after the injury or delayed due to the development of infection. You’re…

Presentation A patient presents with pain and redness around the piercing site. Upon inspection, there is erythema and some purulence coming from the piercing. The patient is afebrile and denies any other symptoms. Piercing complications typically fall into two categories: infection or inability to remove. As infections lead to swelling, the edematous surrounding tissue may encase the piercing. The more usual sites of piercing include ears,…

Presentation The patient presents after being stabbed or stuck with a sharp pencil point. The patient may voice concerns regarding lead poisoning due to retained pencil lead. A small puncture wound lined with graphite tattooing will be present ( Fig. 149.1 ). The pencil tip may or may not be present, visible, or palpable. With palpation of the puncture wound, an underlying pencil point may give…

Presentation The patient presents with finger or toe pain that has developed rapidly, either over the past several hours or over a few days. This pain is accompanied by a very red, tender swelling of the nail fold ( Fig. 148.1A ), or this swelling may be less red and tender or has developed granulation tissue and appears chronic in nature (see Fig. 148.1B ). Paronychia…

Presentation An employee presents for evaluation and treatment after an accidental needle stick injury to the hand obtained in the process of providing patient care. The employee requests postexposure prophylaxis (PEP). This chapter will discuss the risk of transmission and appropriate PEP of three bloodborne pathogens after accidental occupational needle stick injuries: hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV). What…

Presentation Although a needle could be embedded under any skin surface, most commonly a patient will have stepped on one while walking without shoes on a carpeted floor. In general, the patient will experience a sharp pain initially and complain of a foreign-body sensation with weight bearing. Patients with peripheral neuropathy may seek care with delay. A very small puncture wound may be found at the…

Presentation The patient has caught a finger in a car door or dropped a heavy object on an exposed toe, causing a painful deformity. The base of the nail will be found resting above (on top of) the eponychium instead of in its normal anatomic position beneath. The cuticular line that had joined the eponychium at the nail fold will remain attached to the nail at…