Presentation Patients may present with a complaint of acute monocular floaters or flashes of light. Floaters can be described as gray or dark “blobs” or “worms” in the visual field and are caused by the interference of light moving through the vitreous ( Fig. 17.1 ). “Flashes” are flashes of white light caused by traction on the retina from the shrinking of vitreous jelly. The most…

Presentation The patient may complain of eye pain or a sensation of the presence of a foreign body after direct ocular trauma. The patient may have abraded the cornea while inserting or removing a contact lens. Removal of a corneal foreign body produces some corneal abrasion, but corneal abrasion can occur without any identifiable trauma. There is often excessive tearing, blurred vision, and photophobia. Often the…

Presentation A patient who wears hard, impermeable, or rigid gas-permeable contact lenses comes to the emergency department in the early morning complaining of severe eye pain after they have left their lenses in for longer than the recommended time period. Extended-wear soft contact lenses can cause a similar syndrome when worn for days or weeks and have become contaminated with bacteria and/or irritants. The patient may…

Presentation Conjunctivitis is the most common diagnosis in patients with a red eye and discharge, but not all red eyes are the result of conjunctivitis. With bacterial conjunctivitis the patient complains of a red, irritated eye and perhaps a gritty or foreign-body sensation; a thick, purulent discharge that continues throughout the day; and crusting or matting of the eyelids on awakening ( Fig. 14.1 ). It…

Presentation An older patient, complaining of isolated “weakness” or an inability to perform the usual activities or care for oneself, comes to an acute care clinic or emergency department (ED), often brought in by family members. 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

Presentation The patient presents with a complaint of dizziness, which may be abrupt or gradual in onset. The symptoms may be reported in many different ways, such as lightheadedness, disequilibrium, room-spinning vertigo, imbalance, wooziness, or incoordination. The patient may have persistent symptoms associated with severely debilitating nausea and hence be reluctant to engage in an examination or provocative maneuvers. However, differentiating benign from dangerous causes of…

Presentation The patient experiences a brief loss of consciousness, preceded by a feeling of lightheadedness, a sense of warmth and nausea, and the awareness of passing out. This may or may not be accompanied by weakness and diaphoresis. In addition, the patient may or may not experience ringing in the ears or a sensation of tunnel vision. First, there is a period of sympathetic tone, with…

Presentation A patient presents after a fall from standing with a head strike. There was no loss of consciousness, but a small laceration is noted on the occiput with surrounding swelling, described by bystanders as a “goose egg.”The patient complains of a dull headache and transient nausea and drowsiness. There was no seizure, vomiting, amnesia, or alteration in mental status and the patient exhibits no focal…

Presentation The patient complains of a dull, steady (nonpulsating) pain, described as a pressing, tightening, squeezing, or constricting band, located bilaterally anywhere from the eyes to the occiput, perhaps including the neck or shoulders. Often the headache is a bilateral tightness or sensation of pressure around the temples. Most commonly, the headache develops near the end of the day or after some particularly stressful event. The…

Presentation Frightened parents bring in their young child who has just had a first-ever generalized seizure with jerking tonic-clonic movements and loss of consciousness (LOC), followed by a period of postictal obtundation that gradually resolves within 30 minutes. The patient has completely recovered by the time the child is brought to your attention. The parents describe their child becoming cyanotic with breathing difficulty, unresponsiveness, and jerking…

Presentation The patient with seizure may present in full tonic-clonic seizure or may have experienced a seizure witnessed by others. Seizure may be preceded by an aura or have sudden onset without warning. Most patients presenting with seizure have a preexisting seizure disorder, and the most common etiology of seizure is noncompliance with medication. Two of the most telling physical exam findings of a patient who…

Presentation Migraine headache is one of the most disabling neurologic disorders, with a lifetime prevalence of 33% in women and 13% in men worldwide. In a third of cases, patients will have an aura, which can manifest with visual phenomena or paresthesias, typically in the hand or oral area. The headache is typically moderate to severe and can be associated with other symptoms such as photophobia,…

Presentation The patient with Bell palsy can present with any of the following signs or symptoms: sudden onset of facial numbness; a feeling of fullness or swelling; periauricular pain; muscular facial asymmetry; an irritated, dry, or tearing eye; drooling; or changes in hearing or taste. Symptoms can develop over several hours or days. Often there will have been a viral illness 1 to 3 weeks earlier,…

Presentation The patient with psychogenic nonepileptic attack (PNEA), also known as psychogenic nonepileptic seizure (PNES), typically presents with the appearance of having tonic-clonic seizure activity or can develop this during a visit. There may be a history of sexual abuse, eating disorders, depression, substance abuse, anxiety disorders, or personality disorders, and the episode may be preceded by a stressful event. The terminology “pseudoseizure” or “hysterical seizure”…

Presentation The patient presenting with hyperventilation syndrome typically appears anxious and exhibits shortness of breath with an inability to fill the lungs adequately. The patient also may have palpitations, dizziness, intense anxiety, fear, chest or abdominal pain, tingling or numbness around the mouth and fingers, and possibly even flexor spasm of the hands and feet (carpopedal spasm) ( Fig. 3.1 ). The patient’s respiratory volume is…

Presentation Heat illnesses comprise a spectrum of illnesses resulting from failure of the body’s normal thermoregulatory mechanisms after exposure to excessive heat. Most heat-related illness is mild; however, severe hyperthermia associated with heat stroke, neuroleptic malignant syndrome, or serotonin syndrome is a severe, life-threatening condition and should not be overlooked. The milder forms of heat-related illness include heat syncope (or presyncope), or heat cramps. These illnesses…

Presentation The patient with a dystonic reaction to a neuroleptic or other agent typically presents to the emergency department (ED) or urgent care center with posturing, facial grimacing and involuntary muscle movements, and/or difficulty speaking. Pain is minimal, if at all. The jaw, tongue, lip, throat, and neck muscles are frequently involved. Hyperextension and lateral deviation of the neck along with upward gaze is a classic…