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…

Presentation The patient has either cut into the nail with a sharp edge or crushed a finger (commonly in a door). With shearing forces, the nail may be avulsed from the nail bed to varying degrees, and there may be an underlying bony injury. The nail bed is prone to lacerations in these types of injuries. You’re Reading a Preview Become a Clinical Tree membership for…

Presentation After coming into contact with marine life, the patient may seek medical attention because of local pain, swelling, or skin discoloration. While more common in coastal areas, envenomation can also occur from handling animals kept in saltwater aquaria. Marine animal envenomations can be divided into two major categories: macropenetration and micropenetration. Macropenetration occurs after contact with spiny fish or mollusks and is due to stingers…

Presentation Histories of animal bites are usually volunteered, but the history of a human bite, such as one obtained over the knuckle during a fight, is more likely to be denied or explained only after direct questioning. Dog bites make up about 60% to 80% of all bite injuries, followed by cats (20–30%). Urban medical centers may see human bites more frequently (up to 20%). In…

Presentation A patient presents with swelling of the lower extremity. It may be mildly painful, but there has been no trauma. The patient denies any fever, chest pain, difficulty breathing, or other systemic symptoms. Peripheral edema can be categorized in two different ways: unilateral versus bilateral and pitting versus non-pitting. The list of differential diagnoses varies; a comprehensive history, physical exam, and target laboratory testing are…

Presentation Lacerations arise from either a cut with a sharp object or direct blunt trauma that exceeds the tensile strength of the skin. Consequently, lacerations may be linear ( Fig. 140.1 ) or stellate/complex with various amounts of tissue loss. The elderly and patients on chronic steroid therapy may present with “wet tissue paper” skin tears following relatively minor trauma. What to Do A history should…

Presentation A sharp metal object, such as a needle, heavy wire, or nail, is driven into the soft tissue. The patient may arrive with an additional large object attached (e.g., a child who has stepped on a nail going through a board) ( Fig. 139.1 ). Any of these skin-piercing foreign objects, such as impaled Taser darts, can be quite dramatic and can be the cause…

Presentation The patient complains of a paint chip or wooden sliver under the nail. Due to high sensory nerve density, these injuries are often quite painful. Most subungual foreign bodies are completely visible and are lodged under the distal portion of the nail. Occasionally, a wooden sliver will be large and deeply embedded over the proximal germinal matrix. Often the patient has unsuccessfully attempted to remove…