Presentation A toddler who is between 1 and 4 years of age presents with upper extremity pain and reluctance to use that extremity following a sudden jerk on the arm. Circumstances surrounding the injury may be obvious (such as a parent pulling the child up by the arm to avoid stepping into a puddle, pulling a child back by the arm who is trying to run…

Presentation Most patients with ankle sprains describe an inversion injury; eversion injuries are less common. Inversion injuries constitute 85% of ankle sprains. Patients may report having stepped off a curb or into a hole. Sports-related injuries often occur after jumping and landing on another player’s foot, which causes an inversion or supination of the ankle. There may be a sensation of a “pop” or “snap” at…

Presentation After a direct blow to or a fall onto the lateral shoulder with the arm adducted, the patient complains of shoulder pain increased by motion of the arm ( Fig. 95.1A ). An indirect mechanism of injury commonly involves a fall onto an outstretched arm or falling back onto an elbow ( Fig. 95.1B ). Patients are generally able to localize their pain to the…

Presentation A patient presents for evaluation of vaginal discharge, possibly with itching and/or irritation of the labia and vagina. Odor, dysuria, vague low abdominal discomfort, or dyspareunia may be present. Abdominal examination is benign, but examination of the introitus may reveal erythema of the vulva and edema of the labia, often with pustulopapular peripheral lesions (especially with Candida organisms). Speculum examination may disclose a diffusely red,…

Presentation A worried menstruating female presents with greater-than-usual bleeding, which is either off of her usual schedule (metrorrhagia), lasts longer than a typical period, or is heavier than usual (menorrhagia), perhaps with crampy pains and passage of clots. Bleeding is considered prolonged when lasting longer than 7 days. Profuse bleeding is generally defined as soaking a large sanitary pad or tampon every 1 to 2 hours…

Presentation A female patient presents for evaluation after sexual contact. There was no barrier to prevent sexually transmitted infections (STIs) or pregnancy, or the barrier method being used was suspected to have failed (e.g., a condom broke or contraceptive pills were used imperfectly). Sexual contact may be described as consensual or nonconsensual, such as the result of a sexual assault or sexual abuse. Patients may present…

Presentation A sexually active female, possibly with a new sex partner or multiple sex partners, presents with lower abdominal pain beginning with or soon after her last menstrual period. There may be associated vaginal discharge, malodor, dysuria, dyspareunia, menorrhagia, or intermenstrual bleeding. In patients with more severe infections, systemic symptoms such as fever, chills, malaise, nausea, and vomiting may also be present. Women with severe pelvic…

Presentation Vaginal foreign bodies occur in both children and adults. The patient presents for care with a foul-smelling, bloody or brown purulent discharge, or pain. Children may insert a foreign body and not tell their parents or may be the victims of child abuse. Vaginal foreign bodies in the adult may be a result of a psychiatric disorder or sexual practices. Frequently, patients are reluctant to…

Presentation A young female presents with crampy, laborlike pains that began shortly before or at the onset of the visible bleeding of her menstrual period. The pain is focused in the lower abdomen, low back, suprapubic area, or thighs and may be associated with nausea, vomiting, increased defecation, headache, muscular cramps, or passage of clots. The pain is most severe on the first day of the…

Presentation A patient presents for evaluation of severe vulvar itching that may be accompanied by edematous swelling. Occasionally there will be tenderness, pain, burning, and dysuria severe enough to cause urinary retention. The vulvovaginal area is variably inflamed, erythematous, and edematous. In more severe cases there may be a microvesicular papular eruption with excoriations. In cases where there is chronic contact dermatitis, there may be an…

Presentation Patients may complain of perineal itching, burning, pain, and tenderness, although they are commonly asymptomatic, especially with cervical and vaginal involvement. Distinctive fleshy warts can be found on the external genitalia or anus ( Figs. 87.1 and 87.2 ). Lesions are pedunculated or broad-based with pink to gray soft excrescences, with multiple papillae arising from a single base. They occur in clusters or individually and…

Presentation A female of reproductive age presents for evaluation of vulvar pain and swelling that has developed over the past 2 to 3 days. Pain is increased when walking and sitting. On physical examination in the lithotomy position, there is a unilateral (occasionally bilateral), tender, fluctuant, mildly erythematous swelling at the 4-o’clock or 8-o’clock position within the posterior labium minora ( Fig. 86.1 ). You’re Reading…

Presentation The patient (usually female) complains of urinary frequency and urgency, internal dysuria, and suprapubic pain or discomfort. The onset of symptoms is generally abrupt, often causing her to seek care within 24 hours. There may have been some antecedent trauma (sexual intercourse) to inoculate the bladder, and there may be blood in the urine (hemorrhagic cystitis). Usually, there is no labial irritation, external dysuria, or…

Presentation Urinary retention is a common problem encountered in the emergency department. Acute urinary retention (AUR) presents as a sudden inability to voluntarily void. The patient, usually male, may complain of increasing dull, low abdominal discomfort or pain and the urge to urinate, without having been able to urinate for many hours. Lower abdominal pain may become severe. Urinary hesitancy, sensation of incomplete voiding, an interrupted…

Presentation A man complains of dysuria, a burning discomfort along the urethra, pruritus of the urethral meatus, and/or a urethral discharge. A copious, thick yellow-green discharge that stains underwear is characteristic of gonorrhea, whereas a thinner mucopurulent or white scant discharge with milder symptoms is characteristic of Chlamydia. These symptoms may be transient. Urethritis in a woman may be asymptomatic or indistinguishable from cystitis or vaginitis.…

Presentation A man complains of acute onset of malaise, fever, chills, and perineal, rectal, or low back pain. He also may have dysuria, urinary urgency and frequency, and signs of obstruction to urinary flow, ranging from a weak stream to urinary retention. There may be painful ejaculation and hematospermia. On gentle examination, the prostate is swollen, hot, and exquisitely tender. The infection may spread from or…

Presentation Phimosis is the inability to retract the foreskin over the glans and is usually the result of a contracted preputial opening ( Fig. 81.1 ). Patients with phimosis may seek acute medical care when they develop signs and symptoms of infection, such as pain and swelling of the foreskin and a purulent discharge. Pediatric patients with acute phimosis are either fussy or complain of penile…

Presentation The patient may be distraught with severe genital pain, with subsequent outbreak of painful vesicles on the external genitalia that may ulcerate or erode. Alternatively, the patient may just be concerned about paresthesias and subtle genital lesions, may want pain relief during a recurrence, or may be suffering complications such as superinfection or urinary retention. Often, with primary infection, there are associated systemic symptoms such…

Presentation A male child, adolescent, or adult complains of dull to moderately severe unilateral scrotal pain developing gradually over a period of hours to days and possibly radiating to the ipsilateral lower abdomen or flank. In adult or adolescent males, there may be a history of recent urinary tract infection, urethritis, prostatitis, or prostatectomy (allowing ingress of bacteria), strain from lifting a heavy object, or sexual…

Presentation Patients may complain of or be frightened about the color of their urine. Color may be one component of some urinary complaint, or the color may be noted incidentally on urinalysis. You’re Reading a Preview Become a Clinical Tree membership for Full access and enjoy Unlimited articles Become membership If you are a member. Log in here