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Do's and dont's of er.
 

Do's and dont's of er.

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what to do and what not to do in emergency set up .This booklet is very helpful for young doctors and internee

what to do and what not to do in emergency set up .This booklet is very helpful for young doctors and internee

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    Do's and dont's of er. Do's and dont's of er. Document Transcript

    •      BY      DR  SHAHID  BASHIR  CHADHARY  ED  SPECIALIST          March  2012       1  
    •                                                                                  I  N  D  E  X  NO                            TOPIC   PAGE  NO.  1   Abscess   1  2   Anal  Fissure   2  3   Ankle  Sprain   3  4   Black  Eye   4  5   Bites   5  6   Bleeding  after  Dental  Surgery   8  7   Blunt  Scrotal  Trauma   9  8   Broken  Toe   10  9   Rib  Fracture   11  10   Bruises   13  11   Cellulitis   14  12   Collar  Bone  Fracture   16  13   Carpal  Tunnel   17  14   Cystitis   18  15   Digital  Block   19  16   Epididymitis   21  17   Finger  Dislocation   22  18   Finger  tip  Dressing   23  19   Finger  Tip  Avulsion   24  20   Fish  Hook  Removal   25  21   Foreign  Body  Beneath  Nail   26  22   Ganglion  Cyst   27  23   Minor  Implant  Injuries   28  24   Impetigo   29  25   Jaw  Dislocation   30  26   Low  Back  Pain   31  27   Minor  Head  Trauma   33  28   Muscle  Strain  and  Tears   35  29   Nail  Root  Dislocation   35  30   Nail  Bed  Laceration   37  31   Neck  Strain   38  32   Needle  in  Foot   39  33   Paronychia   41     2  
    • 33   Pencil  Point  Puncture   43  34   Periorbital  and  Conjuctival  edema   44  35   Pelvic  Inflammatory  Disease   45  36   Pinworm  or  Threadworm   46  37   Plantaris  Tendon  Rupture   47  38   Polymyalgia  Rheumatica   48  39   Rhus  contact  Dermatitis  (Poison  IVY,Oak,Sumac)   49  40   Prostitis   50  41   Pulpitis   51  42   Puncture  wound   52  43   Pyelonephritis  (Upper  urinary  Tract  Infection)   53  44   Rabies  Prophylaxis   55  45   Rectal  Foreign  Body   56  46   Removal  of  Dislocated  Contact  lens   58  47   Ring  Removal   60  48   Ruptured  Ear  Drum     61  49   Saturday  night  Palsy   62  50   Scabies   63  51   Seizure   65  52   Serous  otitis  Media   67  53   Shingles  (Herpes  Zoster)   69  54   Shoulder  Dislocation   70  55   Shoulder  Separationn  (Acromio-­‐Clavicular  Joint)   72  56   Sinusitis   73  57   Sore  Throat   76  58   Split  Ear  Lobes   79  59   Streakhouse  Syndrome   79  60   Subconjuctival  Hemorrhage   82  61   Subcutaneous  Foreign  Body   83  62   Subungeal  Ecchymosis   85  63   Subungeal  Hematoma   85  64   Subburn   87  65   Swallowed  Foreign  Body   88  66   Tailbone  Fracture  (Coccyx  Fracture)   89  67   Tear  Gas  Expoure   90  68   Tension  Headache   91  69   Tetanus  Prophylaxis   93     3  
    • 70   Thrush   94  71   Tinea   95  72   Tempromandibular  Joint   96  73   Tooth  Trauma   97  74   Upper  Respiratory  Tract  Infection   98  75   Urinary  Retention   100  76   Vaginal  Bleeding   101  77   Vaginitis   105  78   Vasovagal  Syncope   106  79   Vertigo   107  80   Weakness   109  81   Wry  Neck  (Torticollis)   111  82   Zipper  Caught  on  Penis  or  Chin   113    This   booklet   is   very   helpful   for   new   ED   Physicians   while  treating  the  patients,  and  can  avoid  those  steps  that  can  involve  them  in  medicolegal  problems.  The   material   in   this   booklet   is   taken   from   different  surgical  manuals  and  reference   books,  also  included  my  practical   experience   of   work   in   the   emergency  department  in  tertiary  referral  hospital.  I  need  your  opinion  and  suggestions.  DR  SHAHID  BASHIR  CHAUDHARY  MBBS  DTCD,FCCS     4  
    • ABSCESS:    WHAT  TO  DO:   1. Simply  snip  open  the  cutaneous  roof  with  fine  scissor  or  an  inverted  #11   blade.   2. When  the  location  of  an  abscess  cavity  is  uncertain,  attempt  to  aspirate  it   with  a  #18  gauge  needle  after  preparing  the  area  with  Povidine  –iodine.   3. Anesthetize   the   area   with   regional   field   block   and   give   additional   anesthesia  like  I/V  paracetamol  1  gm.   4. Make  the  incision  at  the  most  dependent  area.   5. In   large   abscesses   insert   a   hemostat   in   to   the   cavity   to   break   up   any   loculated   collection   of   pus   and   irrigate   with   normal   saline,   put   packing   and    do  dressing,   6. The  patient  should  be  instructed  to  use  intermittent  warm  water  soaks.   7. Ask  for  dressing  after  two  days.   8. Discharge  the  patient  with  antibiotic  cover.  WHAT  NOT  TO  DO:   a. Do  not  incise  an  abscess  that  lies  close  to  major  vessel,  such  as  in   axilla,  groin  or  anticubital  space.   b. Do   not   treat   deep   infections   of   the   hands   as   simple   cutaneous   abscesses.   c. Routine  culture  is  not  indicated.         5  
    • ANAL  FISSURE  Patient   complains   of   painful   rectal   bleeding   and   sometimes   constipation,   the  pain   occurs   with   and   immediately   after   defecation,   the   patient   is   relatively  comfortable   between   bowel   movements.   bleeding   with   defecation   is   usually  slight,   only   staining   the   toilet   tissue.   Mucus   discharge   may   increase   perineal  moisture  and  cause  itching.  Examination  of  anus  reveals  a  radial  tear  or  ulceration  of  the  posterior  midline  95%of  the  time.  WHAT  TO  DO:   1. Provide  topical  anesthesia  with  lidocain.   2. Advise   the   patient   to   take   soft   diet   and   use   a   glycerin   suppository   twice   daily  to  maintain  lubrication  of  the  anal  canal.   3. Instruct   the   patient   to   use   warm,   soothing   sitz   baths   after   each   painful   bowel  movement.   4. Prescribe  analgesia  if  needed.   5. Inform   the   patient   that   an   acute   superficial   fissure   will   take   about   one   month  to  heal   6. He  /she  should  follow  up  in  OPD.  WHAT  NOT  TO  DO:       a. Do   not   assume   that   a   lesion   located   outside   the   anterior-­‐posterior   midline      saggital  plane  of  anus  is  an  anal  fissure     b. Do  not  confuse  a  sentinel  pile  with  a  heamorrhoidal  vein.     6  
    • ANKLE  SPRAIN:  The  patient  inverted  the  foot  and  either  came      immediately  or  a  day  later  with  pain,   swelling   and   inability   to   walk,   there   is   tenderness   to   palpation   of   the  anterior  talofibularr  ligament.  WHAT  TO  DO:   1. Elevate   the   foot   and   apply   ice   for   15   minutes/hr   to   treat   the   reactive   inflammation   2. Palpate   the   prominence   on   the   lateral   foot   to   check   the   avulsion   of   peroneus  brevious   3. Palpate  the  fibula  on  the  lateral  leg  up  to  the  knee,  where  spiral  fracture   can  propagate   4. If   there   is   tenderness   and   patient   cannot   take   four   steps   in   the   ED,   obtain   x-­‐rays  to  rule  out  a  fracture.   5. Immobilize  the  ankle  in  a  stirrup.   6. Anti-­‐inflammatory  analgesics.   7. Follow  up  to  ortho  OPD/ED.  WHAT  NOT  TO  DO:   a. Don’t  rule  a  fracture  based  on  a  negative  x-­‐rays.   b. Don’t   overlook   fractures   of   the   tarsal   navicular,   talus   or   os   trigonum,  all  visible  on  the  ankle  view.         7  
    • BLACK  EYE  The   patient   has   received   blunt   trauma   to   the   eye,   most   often   from   a   fist,   a   fall,   or  a   car   accident   Family   and   friends   are   more   concerned   than   the   patient   about   the  appearance  of  the  eye.  There   may   be   associated   subconjuctival   hemorrhage,   but   the   remainder   of   the  eye  examination  should  be  negative.    WHAT  TO  DO:   1. Clarify  as  well  as  possible  the  specific  mechanism  of  injury.   2. Perform   a   complete   eye   exam   to   rule   out   a   retinal   detachment   or   dislocated  lens.   3. Fluorescein  stain  to  rule  out  corneal  abrasion.   4. Test  extra  ocular  eye  movements;  look  especially  for  diplopia  on  upward   gaze.   5. Check  sensations  over  the  infra  orbital  nerve  distribution.   6. Symmetrically  palpate  the  supra  and  infra  orbital  rims  as  well  as  zygoma.   7. If   there   is   any   suspicion   of   any   underlying   fracture,   obtain   x-­‐rays   of   the   orbit.   8. If  significant  injury  is  discovered,  then  consult  with  an  ophthalmologist.   9. CT   scan   is   more   sensitive   and   can   visualize   subtle   fractures   of   the   orbit   and  small  amount  of  air.   10. When   there   is   significant   injury   ,   reassure   the   patient   that   the   swelling   will  subside  with  in  12-­‐24  hrs     8  
    • 11. Give  inj.  paracetamol  1gm  i/v.  or  oral  paracetamol  1  gm.   12. Instruct  the  patient  to  follow  up  in  ophthalmology  clinic  WHAT  NOT  TO  DO:   a. Don’t  get  unnecessary  radiograph.   b. Minor   injuries   with   normal   eye   exams   and   no   palpable   deformities  do  not  require  X-­‐rays.   c. Do   not   brush   off   bilateral   deep   peri   orbital   ecchymosis   (raccoon   eye),   especially   if   caused   by   head   trauma   remote   to   the  eye.    BITES  A  single  bite  may  contain  various  types  of  injury,  including  underlying  fractures  and  tendon  and  nerve  injuries,  not  all  of  which  are  immediately  WHAT  TO  DO:   1. Obtain  a  complete  history  including,  the  type  of  animal  that  bit,  whether   or   not   the   attack   was   provoked,   what   time   the   injury   occurred,   the   current   health   status   and   vaccination   record   of   the   animal   has   been   captured   and   is   being   held   for   observation,   report   the   bite   to   police   or   appropriate  local  authorizes.   2. Assess   the   wound   for   any   damage   to   deep   structures,   any   need   for   surgical  consultation  and  risk  of  infection.   3. Look  for  bone  and  joint  involvement  and  if  present.     9  
    • 4. Obtain   appropriate   imaging   studies   (dog   bites   have   caused   open   depressed  fractures  in  small  children).   5. Examine   for   nerve   and   tendon   injury   and   be   aware   that   crush   and   puncture   wounds   as   well   as   bites   on   the   hands,   wrist,   and   feet,   are   at   higher   risk   for   development   of   infection   and   significant   complications   such  as  tenosynovitis,  septic  joints,  osteomylitis  and  sepsis.   6. If  tissue  damage  is  higher  then  take  opinion  of  surgery  and  orthopedic.   7. For   crush   wounds   and   contusions,   elevate   above   the   heart   and   apply   cold   packs.   8. If  the  wound  requires  debridement,  or  will  be  painful  to  clean  or  irrigate,   then  anesthetize  the  area.   9. If  there  is  already  sign  of  infection,  obtain  aerobic  and  anaerobic  cultures   of  pus.   10. Irrigate  the  wound  with  antiseptic  (10%povidine-­‐iodine  solution,  dilated   1:10   in   normal   saline)   and   sharply   debride   any   debris   and   non   –viable   tissue.   11. Irrigate   the   wound,   using   a   20ml   syringe,   a   19   gauge   needle   or   an   irrigation  shield,  and  at  least  200ml  of  sterile  saline.   12. For   animal   bite   wounds   that   are   clean,   uninfected   lacerations   located   anywhere  other  than  the  hand  or  foot.  You  may  suture.   13. If  the  wound  is  infected  when  first  seen  .plan  either  a  delayed  repair  after   three  to  five  days  of  saline  dressings  or  secondary  wound  healing  with  out   closure.   14. Prescribe  antibiotics  for  seven  days.   15. Severe  infection  requires  hospitalization.     10  
    • 16. With   human   bites,   animal   bites   that   are   punctured   or   located   on   he   hand,   wrist   or   foot,   or   bite   more   than   12   hours   old   ,in   most   cases,   you   should   leave  the  wounds  open  and  apply  a  light  dressing  .   17. Wounds   should   also   be   left   open   on   debilitated   and   patients   with   diabetes,   alcoholism,   chronic   steroid   use,   organ   transplants,   vascular   insufficiency,   spleenectomy,   HIV   or   other   immnunocompromised   conditions,   18. Start  prophylactic  antibiotics  in  the  ED  on  these  wounds  and  in  patients   with  artificial  or  damaged  heart  valves  and  implanted  prosthetic  devices,   19. If   the   patient   has   had   no   tetanus   toxoid   in   the   past   5-­‐10   years,   provide   prophylaxis.   20. Start  rapid  rabies  vaccination:     i. first  day  (0)   ii. third  day(3)   iii. seventh  day(7)   iv. Fourteenth  (14)   v. Twenty-­‐eighth  (28)   21. Provide   hepatitis   prophylaxis   for   patients   who   have   been   bitten   by   known   carriers   of   hepatitis   B.   Administer   hepatitis   B   immunoglobulin   0.06ML/kg   i/m   at   the   time   of   injury   and   schedule   a   second   dose   in   30   days.   22. Follow  standard  guidelines  applicable  to  contaminated  needle  sticks.   23. Minimize  edema  of  hand  wound  by  splitting  and  elevation.     11  
    • 24. Have  patient  returns  for  a  wound  check  in  two  days  or  sooner  if  there  is   any  sign  of  infections.   25. Explain   the   potential   for   serious   complication   such   as   septic   arthritis,   swollen   immobile,   tender   along   the   flexor   surface   painful   on   passive   extension  that  will  require  specially  consultation.  WHAT  NOT  TO  DO:   a. Do  not  overlook  a  puncture  wound.   b. Do   not   suture   debris,   non   –viable   tissue   or   a   bacteria   inoculation  into  a  wound.   c. Do   not   use   buried   absorbable   suture,   which   act   as   foreign   body   and   cause   a   reactive   inflammation   for   about   a   month   and   increase  the  risk  of  infection.   d. Do  not  routinely  suture  human  bites.    BLEEDING  AFTER  DENTAL  SURGRY  The   patient   had   an   extraction   or   other   dental   surgery   performed   earlier   in   the  day,  now  ha  excessive  bleeding  at  the  site  and  can  not  reach  his/her  dentist.  WHAT  TO  DO:   1. Ask  what  procedure  was  done     2. Inquire  about  antiplatelet  drugs,  like  aspirin.   3. H/O  previous  experience  of  bleeding     12  
    • 4. Use   suction   and   saline   irrigation,   clear   any   packing   and   clot   from   the   bleeding  site.   5. Roll  a  2x2”  gauze  pad,  insert  it  over  the  bleeding  site.   6. If  the  site  is  still  bleeding  after  20  minutes  of  gauze  pressure  ,inject  local   anesthetic,   7. If  this  does  not  stop  the  bleeding.  Pack  the  bleeding  site  with  Gel  foam.   8. An  arterial  bleeding  requires  ligation  with  figure  eight  stitch.   9. When  the  bleeding  stops,  remove  the  overlying  gauze.   10. Arrange  the  follow  up  for  dentist   WHAT  DO  NOT  DO:   a. Don’t  do  routine  lab  tests.   b. Don’t  use  tea  bags  as  a  gauze    BLUNT  SCROTAL  TRAUMA  Blunt   injuries   to   the   scrotum   usually   occur   in   patients   less   than   50   yrs.   Of   age   as  a   result   of   an   athletic   injury,   a   straddle   injury,   an   automobile   or   industrial  accident,   or   as   an   assault.   Patient   presents   with   various   degrees   of   pain,  ecchymosis  and  swelling.  WHAT  TO  DO:   1. Get  a  clear  history  of  the  exact  mechanism  of  the  trauma  and  the  point  of   maximum  impact.   2. Determine  if  there  was  any  bloody  penile  discharge  or  hematuria.b     13  
    • 3. Gently  examine  the  external  genitalia  and  give  analgesia  according  to  pain   scale.   4. If   scrotal   swelling   is   not   too   severe,   try   to   palpate   and   assess   the   intrascrotal  anatomy.   5. Obtain  urinalysis   6. Do  digital  examination  of  the  prostate  and  obtain  urologic  consultation.   7. When   urologic   intervention   is   not   required,   provide   analgesia,   bed   rest,   scrotal  support,  a  cold  pack  and  urologic  follow  up.  WHAT  NOT  TO  DO:   a. Don’t   miss   testicular   torsion   which   can   be   associated   with   blunt   trauma.   b. Don’t  miss  the  rare  traumatic  testicular  dislocation  that  results  in   an  “empty  scrotum”.      BROKEN  TOE  The   patient   has   stubbed,   hyper   flexed,   hyper   extended,   hyper   abducted   or  dropped   a   weight   upon   a   toe.   Patients   present   with   a   pain,   ecchymosis,   and  decreased   range   of   motion   and   point   tenderness   and   there   may   or   may   not   be  any  deformity.  WHAT  TO  DO:   1. Examine  the  toe,  particularly  for  lacerations.   2. Relieve  the  pain  by  anti-­‐inflammatory  analgesics.   3. Take  x-­‐rays  to  look  fracture  entering  the  joint  space.     14  
    • 4. Displaced   or   angulated   phalangeal   fracture   must   be   reduced   with   linear   traction  after  digital  block.   5. Splint   the   broken   toe   by   tapping   it   to   an   adjacent   non   effected   toe   ,   padding  between  toes  with  gauze  and  using  half  inch  sticking  plaster.   6. Advise   the   patient   to   be   immobilized   by   using   clutches   or   wearing   hard   sole  shoe  and  elevate  the  toe  at  sleeping  time  and  put  ice  bar  on  the  pad.   7. Inform   the   patient   that   he/she   must   keep   the   padding   dry   between   toe   while  they  are  tapped  together  otherwise  skin  will  mace  and  break  down.   8. If  the  fracture  is  not  of  phalanx,  but  of  the  metatarsal,  construct  a  pad  for   the  sole  with  space  cut  to  the  foot.   9. Arrange  a  follow  up  for  the  orthopedic  OPD  with  in  one  week  WHAT  NOT  TO  DO:   a. Do   not   tape   together   with   out   keeping   pad   between   toes   wetness  and  Friction  will  maceration  will     b. Do   not   let   the   patient   overdo   the   ice,   which   should   not   be   applied  directly.   c. Don’t   overlook   the   possibility   of   acute   gouty   arthritis,   which   sometimes  follow  minor  trauma.    RIIB  RFACTURE:  It  is  due  falling  down  on  the  side  of  the  chest,  initial  chest  pain  may  subside  but  over  the  few  hours  or  days  pain  increases  and  patient  visits  the  ED  for  chest  pain,     15  
    • there   is   point   tenderness   at   the   site   of   injury   and   occasionally   bony   crepitance  can  be  felt.  WHAT  TO  DO:   1. Examine  the  patient  for  possible  associated  injuries     2. Relieve   the   pain   and   compress   the   rib   medially   if   anterior   or   posterior   fracture  is  suspected,   3. Compress  the  rib  anterior  /posterior  if  the  fracture  is  suspected  laterally.   4. When   the   pain   occurs   at   the   suspected   fracture   site   with   indirect   stress,   this  is  clinical  evidence  of  fracture  and  document.   5. Obtain  a  history  of  chronic  pulmonary  problems  or  heavy  smoking.   6. Send   the   patient   for   PA/LAT   view   of   x-­‐rays   chest   to   rule   out   pneumothorax,  hemothorax  or  evidence  of  pulmonary  contusion.   7. If   there   is   no   evidence   of   underlying   injury   and   there   is   clinical   and   radiological   evidence   of   rib   fracture,   call   surgical   team   or   arrange   appointment  for  Surgical  OPD  with  in  48  hours  and  discharge  the  patient   by  advising  potent  oral  analgesics.   8. Instruct   the   patient   on   the   intermittent   use   of   an   elastic   rib   belt   if   it   reduces  pain.   9. Ask  the  patient  about  the  importance  of  deep  breathing  and  coughing  to   help  prevent  pneumonia.   10. Advise  the  patient  rest  for  one  week  according  the  organization  policy.   11.  If  the  patient  is  compromised  and  have  cardiac  or  associated  respiratory   disease  and  the  patient  is  old  then  hospitalization  is  required.       16  
    • WHAT  NOT  TO  DO:   a. Don’t  confuse  simple  rib  fracture  with  massive  blunt  trauma  to   the  chest.   b. Do  not  tape  ribs  or  use  continuous  strapping.   c. Do  not  assume  that  there  is  no  fracture  because  the  x-­‐rays  are   negative,   Rib   fractures   is   often   not   apparent   on   x-­‐rays,   especially  when  they  occur  on  cartilaginous  portion  of  the  rib.    BRUISES  The  patient  has  fallen  on  or  thrown  against  the  object  has  been  struck  at  a  site  with  the  point  of  tenderness  and  swelling.  Pain,  ecchymosis  and  hematoma.  On  Physical   examination   there   is   no   loss   of   function   of   muscles   and   tendons,   no  instability   of   bones   and   ligaments   and   no   crepitus   or   tenderness   produced   by  remote  stress.  WHAT  TO  DO:   1. Take   a   thorough   history   to   ascertain   the   mechanism   of   injury   and   perform   a   complete   examination   to   document   structural   integrity   and   bony  injury   2. Do   x-­‐rays   if   you   suspect   possibility   of   bony   injury   or   foreign   body,   fractures  are  uncommon  after  a  direct  blow.   3. Explain   the   patient   that   swelling   will   be   at   peak   in   one   day   and   then   resolve  gradually.     17  
    • 4. Giving   anti-­‐inflammatory   drugs   and   prescribing   rest   of   effected   part,   immobilization,  elevation  and  ice  padding  reduce  the  swelling.   5. Explain  the  patient  late  migration  and  color  changes  of  ecchymosis.   6. A   large   intramuscular   hematoma       may   require   drainage   ororthopeadic   consultation.   7. Arrange   for   follow   up   in   surgical   OPD,   if   the   patient   returns   ED   with   increased  discomfort.  WHAT  NOT  TO  DO:   a. Do   not   apply   a   elastic   bandage   to   the   middle   of   limb   where   it   may  act  as  a  tourniquet.   b. Do   not   confuse   patient   with   instructions   for   application   of   heat   and   exercise   to   prevent   stiffness   and   atrophy,   concentrate  on  the  here  –and  –  now  therapy.  CELLULITIS  The  cardinal  sign  of  infection  (pain,  redness,  warmth,  and  swelling)  are  present.  Erysipelas   is   very   superficial   and   bright   red   with   indurate,   sharply   demarcated  borders.  Cellulitis   is   deeper,   involves   the   subcutaneous   connective   tissue   and   has  indistinctive  advancing  borders.  These  infections  are  preceded  by  minor  trauma  of  the  presence  of  foreign  body  and   are   most   common   in   those   patients   who   have   predisposing   factor   like  diabetes   mellitus,   DVT   and   lymphatic   drainage   obstruction,   they   may   be     18  
    • associated   with   an   abscess   or   they   may   have   no   clear   –cut   origin.   The   patient  may  have  tender  lymphadenopathy  proximal  to  the  site  of  infection  and  may  or  may  not  have  signs  of  systemic  toxicity  (fever,  rigor  and  listlessness).  WHAT  TO  DO:   1. Look  for  possible  source  of  infection  and  remove  it.   2. Deride   and   cleans   any   wound,   remove   any   foreign   body   or   drain   any   abscess.   3. When   the   patient   is   very   sick   and   there   is   discoloration   of   the   limb,   get   medical  consultation  and  take  all  basic  investigation  (CBC,  BIO.  Culture),   and  X-­‐rays  chest  and  limb.   4. Hospitalize  the  patient  through  surgical  team,   5. If  there  is  low  grade  fever  or  none  at  all  then  prescribe  third  generation   antibiotics  and  anti-­‐inflammatory  analgesics.   6. Instruct  the  patient  to  keep  the  infected  part  at  rest  and  elevated  and  to   use  intermittent  warm  moist  compression.   7. Advise  the  patient  to  follow  up  in  ED  with  in  24-­‐48  hour  WHAT  NOT  TO  DO:   a. Do   not   send   the   patient   home   if   there   is   suspicion   of   deep   facial   cellulites      or  the  patient  has  deep  infection  of  the  handed  even   the  patient  is  a  febrile         19  
    •  COLLAR  BONE  FRACTURE  (CLAVICLE)  The  patient  has  fallen  into  his  shoulder  or  out  stretched  arm  or  more  commonly  has  received  a  direct  blow  to  the  clavicle  and  now  present  with  the  pain  to  direct  palpation   over   the   clavicle   or   with   movement   of   arm   or   neck,   there   may   be  deformity  of  the  bone  with  the  swelling  and  ecchymosis.  An   infant   or   small   child   might   present   after   a   fall,   not   moving   arm   with   above  findings.  WHAT  TO  DO:   1. After   completing   the   musculoskeletal   examination,   evaluate   the   neurovascular  status  of  the  arm.   2. Fit  a  sling  or  clavicle  strap  that  comfortably  immobilizes  the  arm.   3. Prescribe  analgesics  like  ibuprofen  or  naproxen.   4. Obtain  x-­‐rays  to  rule  out  other  injuries  and  document  the  fracture.   5. Arrange  for  orthopedic  follow  up  in  a  week  to  evaluate  heeling  and  begin   pendulum  exercise  of  the  shoulder  by  physiotherapy  or  advise  patient  by   you.  WHAT  NOT  TO  DO:   b. Do  not  apply  figure  of  eight  dressing  or  clavicle  strap  if  this  form   of  splitting  increases  patient’s  discomfort.   c. Do   not   leave   arm   immobilized   in   a   sling   for   more   than   week   ,   this   can   result   in   loss   of   range   of   motion   or   frozen   shoulder,   therefore  instruct  patient  before  sending  home.     20  
    •  CARPAL  TUNNEL  Patient  complains  of  pain  or  “pins  and  needle”  sensation  in  the  hand.  Onset  may  have  been  abrupt  or  gradual  but  the  problem  is  most  noticeable  upon  awaking  or  after  extended  use  of  the  hand.  The  sensations  may  be  bilateral,  may  include  pain  in   the   wrist   or   forearm   and   is   usually   ascribed   to   the   entire   hand   until   specific  physical   examination   localized   it   to   the   median   nerve   distribution.   More  established   cases   might   include   weakness   of   the   thumb   and   atrophy   of   the  thenaar  eminence.  Physical   examination   localizes   paresthesia   and   decreased   sensation   to   the  median  distribution  and  motor  weakness.  WHAT  TO  DO:   1. Perform   and   document   complete   examination,   sketching   the   area   of   decreased  sensation  and  grading  the  strength  of  the  hand.   2. Hold   the   wrist   flexed   at   90-­‐degree   angle   for   60   seconds,   to   see   if   it   reproduces   symptoms,   this   is   known   as   PAHALEN’S   TEST   and   is   more   sensitive  and  more  specific.   3. Explain  the  nerve  –compression  etiology  to  the  patient   4. Call  surgical  team  or  arrange  evaluation  and  follow  up  referral.   5. Borderline  diagnosis  is  established  with  electromyography(EMG)     6. Early  surgical  intervention  is  indicated  when  there  is  pain  and  weakness.     21  
    • 7. Anti-­‐inflammatory   medication,   elevation   of   the   affected   hand,   ice,   immobilization   with   a   volar   splint   and   rest   may   all   help   to   reduce   symptoms.  WHAT  NOT  TO  DO:   a. Do   not   rule   out   thumb   weakness   just   because   the   thumb   can   touch  the  little  finger.   b. Do  not  diagnose  carpel  tunnel  syndrome  solely  on  the  basis  of  a   positive  Tinley’s  sign.    CYSTITIS  The   patient   complains   of   urinary   frequency   and   urgency,   internal   dysuria   and  supra  pubic  pain,  they  may  sometime  have  antecedent  trauma  in  females  (sexual  intercourse)  to  inoculate  the  bladder  and  there  may  be  blood  in  the  urine.    WHAT  TO  DO:   1. Take  urine  for  white  cells  and  if  possible  for  Gram  stain.   2. If   the   clinical   picture   is   clearly   that   of   an   uncomplicated   lower   UTI,   give   Ciprofloxacin  and  analgesics.  For  7days.   3. Instruct  the  patient  to  drink  plenty  of  water     4. If   there   is   external   dysuria,   vaginal   discharge,   odor,   itching   and   no   frequency  or  urgency  then  evaluate  for  vaginitis.     22  
    • 5. If   the   dysuria   is   severe   then   prescribe   Phenazopyradine   (Pyridium)   200mg   tid   for   two   days   only   to   act   as   surface   anesthetic   in   the   bladder.   warn  the  patient  that  urine  will  stain  orange.   6. Arrange  follow  up  in  urology  department.  WHAT  NOT  TO  DO:   a. Do   not   undertake   urine   culture   for   every   lower   UTI   or   recent   onset  in  non  pregnant  ,   b. Do   not   follow   the   single   dose   or   3   day   regimen   for   possible   upper  UTI.   c. Do  not  rely  upon  gross  inspection  of  urine  sample;  crystals  and   odor  usually  cause  cloudiness  usually  from  diet  or  medication.   d. Do   not   require   follow   up   visit   or   culture   therapy   unless   symptoms  persist  or  reoccur.    DIGITAL  BLOCK  It   is   necessary   to   provide   complete   anesthesia   when   treating   most   fingertip  injuries,   many   techniques   for   performing   nerve   block   have   been   described,   as  the   following   is   the   one   that   is   both   effective   and   rapid   in   onset.   This   type   of  digital  block  will  only  provide  anesthesia  distal  to  the  inter  phalangeal  joint,  but  this  is  most  often  the  site  that  demands  a  nerve  block.  WHAT  TO  DO:     23  
    • 1. Cleans   the   finger   and   paint   the   area   with   Povidine-­‐   iodine   (Betadine)   solution.   2. Using   a   27-­‐gauge   needle,   slowly   inject   1%lidocain   midway   between   the   dorsal   and   palmer   surface   of   the   finger   at   the   mid   point   of   the   middle   phalanx.   3. Inject   straight   in   along   the   side   of   the   periosteum,   then   pull   with   out   removing  the  needle  from  the  skin  and  fan  the  needle  dorsally.   4. Advance  the  needle  dorsally  and  inject  again     5. Advance   the   needle   and   inject   the   lidocain   in   the   vicinity   of   the   digital   neurovascular  bundle.   6. With   each   injection,   instill   enough   lidocain   to   produce   visible   soft   tissue   swelling.   7. Repeat  this  procedure  on  the  opposite  side  of  the  finger   8. With  painful  crush  injury  or  when  the  pain  will  be  prolonged,  substitute   bupivicain  for  lidocain.    WHAT  NOT  TO  DO:   a. Do  not  use  lidocain  with  epinephrine,  The  digital  arteries  that   can   spasm   and   provide   prolonged   anesthesia,   ischemia   of   the   fingertip  and  potentially  necrosis.         24  
    • EPIDIDYMITIS.  An  adult  male  complains  of  dull  to  severe  scrotal  pain  developing  over  a  period  of   hours   to   day   and   radiating   to   the   ipsilateral   lower   abdomen   or   flank,   there  may   be   history   of   recent   urethritis,   prostitis   or   prostectomy,   straining   with  lifting  heavy  object  or  sexual  activity  with  full  bladder.  There  may  be  fever,  nausea  or  urinary  urgency  or  frequency  .The  epididymitis,  is  tender   swollen,   warm   and   difficult   to   separate   from   the   firm,   non   tender  testicles.  Increasing  inflammation  can  extend  up  to  the  spermatic  cord  and  fill  the  entire  scrotum,  making  examination  more  difficult  as  well  as  produces  frank  prostatitis  or  cystitis.  The  rectal  exam  therefore  may  reveal  a  very  tender,  boggy  prostitis.  WHAT  TO  DO:   1. Ascertain  that  testicles  are  normal  in  position  and  perfusion.     2. Doppler   ultrasound   may   help   pick   up   a   drop   off   in   arterial   flow   from   splenic  cord  to  testicle.   3. Palpate  and  auscultate  the  scrotum  to  rule  out  hernia.   4. Prescribe   antibiotics   and   call   surgical   tem   if   the   patient   is   having   sever   pain   5. Give  strong  analgesics     6. Advise   2-­‐3   days   strict   bed   rest,   with   the   scrotum   elevated   and   urologic   follow  up.  WHAT  NOT  TO  DO:   a) Do  not  miss  testicular  torsion     25  
    • b) Don’t  wait  more  than  4  hours  other  wise  chance  of  developing   ischemia  is  present,    FINGER  DISLOCATION  The   patient   has   jammed   his   finger,   causing   hyperextension   injury   that   forces   the  middle   phalanx   dorsally   and   proximally   out   of   articulation   with   the   distal   end   of  the  proximal  phalanx.  An   obvious   deformity   will   be   seen;   there   should   be   no   sensory   or   vascular  compromise.  WHAT  TO  DO:   1. X-­‐Rays  shaft  of  finger.   2. If   the   patient   is   having   considerable   delay   and   the   orthopedic   team   is   busy  then  give  digital  block.   3. To  reduce  the  joint,  do  not  pull  on  the  fingertip,  instead,  push  the  base  of   the  middle  phalanx  distally,  using  your  thumb  until  it  slides  smoothly  into   its  natural  anatomical  position.   4. Test   the   finger   by   extending   his   finger   at   the   proximal   inter   phalangeal   joint.   5. Post   reduction   x-­‐rays   should   be   taken   “chip   fracture”   may   represent   tendon  or  ligament  avulsions.   6. Splint  in  extension  for  3-­‐4  days.   7. Inform   the   patient   that   joint   swelling   and   stiffness   may   be   present   for   months  after  the  initial  injury.     26  
    • 8. Remind  the  patient  to  keep  the  injured  finger  elevated.   9. Recommend  the  ice  application  for  next  24  hours,  and  analgesics    FINGER  TIP  DRESSING  To  provide  a  complete  non-­‐adherent  compression  dressing  for  an  injured  finger  tip,   a   first   cut   out   an   L   –shaped   segment   from   a   tip   of   polyurethane   or   oil-­‐emulsion   (Adaptec)   gauze.   Cover   the   gauze   with   antibiotic   ointment   to   provide  occlusion  and  prevent  adhesion.  WHAT  TO  DO:   1. Place  the  tip  of  the  finger  over  the  short  leg  of  the  gauze  and  then  fold  it   over  the  top  of  the  finger     2. Take  the  long  leg  of  the  gauze  and  wrap  it  around  the  tip  of  the  finger.   3. For   absorption   and   compression,   a   fluff   cotton   gauze   pad   and   apply   it   over  the  end  of  the  finger.   4. Cover  with  roller  or  tube  gauze  and  secure  with  adhesive  tape.  WHAT  NOT  TO  DO:   • Do   not   place   tight   circumferential   wraps   of   the   tape   around   the   finger,                                         27  
    • FINGER  TIP  AVULSION  Mechanism   of   injury   can   be   knife,   a   meat   slicer,   closing   door   or   spinning   fan  blades  or  turning  gears.  Depending  upon  the  angle  of  amputation,  varying  degree  of  tissue  loss  will  occur  from  the  volar  pad,  or  finger  tip.  WHAT  TO  DO:   1. X-­‐ray  of  the  crush  injury  caused  by  high  speed  mechanical  instrument.   2. Consider  tetanus  prophylaxis.   3. Perform  a  digital  block  to  obtain  complete  anesthesia.   4. Thoroughly  debride  and  irrigate  the  wound.   5. When   active   bleeding   is   present   ,   provide   a   bloodless   field   by   wrapping   the  finger  from  the  tip  proximally.   6. On   a   less   than   one   square   centimeter   full   thickness   tissue   loss   ,   apply   a   simple  non  adherent  dressing  with  gentle  compression.   7. Where  there  is  greater  than  one  square  centimeter  of  full  thickness  skin   loss  there  are  three  options  that  may  be  followed.   i. Simply   apply   the   same   non   adherent   dressing   used   for   smaller    wound   ii. Call   the   surgical   team,   if   the   avulsed   piece   of   tissue   is   available  to  convert  it  into  modified  full  thickness  graft  and   suture  it  in  place.   iii. With   the   large   area   of   tissue   loss   that   has   thoughrly   cleaned,  debrided  and  where  the  avulsed  portion  has  been   lost  or  destroyed,  consider  a  thin  split  –thickness  skin  graft   on  the  site.     28  
    • 8. In  infants  and  young  children,  finger  tip  amputation  can  be  sutured  back   on  in  their  place  as  a  composite  graft,   9. When   the   loss   of   soft   tissue   has   been   sufficient   to   expose   bone,   simple   grafting   will   be   unsuccessful;   therefore   plastic   surgery   consultation   is   required.   10. Apply  a  protective  four-­‐prong  splint  for  comfort.   11. Advise  a  course  of  antibiotics  for  3-­‐5  days  and  analgesics.    WHAT  NOT  TO  DO:   a) Do   not   apply   a   graft   directly   over   the   bone   or   over   a   devitalized  or  contaminated  bed.   b) Do  not  attempt  to  stop  wound  bleeding  by  cautery  or  ligature.    FISH  HOOK  REMOVAL  The   patient   has   been   snagged   with   a   fishhook   and   arrives   with   it   embedded   in  his  skin.  WHAT  TO  DO:   1. Cleanse  the  hook  and  puncture  wound   2. Provide  tetanus  prophylaxis   3. Give  1%  local  anesthesia.   4. For   hooks   lodged   superficially,   first   try   the   simple   “retrograde   “   technique.   Push   the   back   along   the   entrance   pathway   while   applying     29  
    • gentle  downward  pressure  in  the  shank.  if  the  hook  does  not  come  out  ,   an  18  gauge  needle  may  be  inserted  in  to  puncture  hole  and  use  miniature   scalpel  blade  .Manipulate  the  hook  in  to  position  so  you  can  cut  bands  of   connective  tissue  barb  and  release  it   5. For  more  deep  imbedded  hooks  .call  the  surgical  team    WHAT  NOT  TO  DO:   a) Do  not  try  to  remove  multiple  hooks  or  fishing  lur  .   b) Do   not   attempt   to   use   the   :string”   technique   if   the   hook   is   near   the   patient’s  eye.    FOREIGN  BODY  BENEATH  NAIL  The   patient   complains   of   paint   chip   or   silver   under   the   nail.   Often   he   has  unsuccessfully   attempted   to   remove   the   foreign   body,   which   will   be   visible  beneath  the  nail.  WHAT  TO  DO  :(Paint  Chip)   1. With   out   anesthesia,   remove   the   overlying   nail   by   shaving   it   off   with   a   #15  scalpel  blade.   2. Cleanse   remaining   debris   with   normal   saline   and   trim   the   nail   edges   smooth  with  scissors.   3. Provide   tetanus   prophylaxis   if   necessary   and   then   dress   the   area   with   antibiotics  ointment.   4. Do  the  bandage.     30  
    • WHAT  TO  DO  (SILVER)   1. If   the   patient   is   cooperative   and   can   tolerate   some   discomfort,   crave   through  the  nail  down  to  the  perimeter  of  silver  with  #11  blade  until  the   overlying  nails  falls  away.   2. For   a   more   extensive   excision   of   nail   wedge,   you   will   need   to   perform   a   digital  block.   3. Slide   small   Mayo   or   iris   scissors   between   the   nail   and   nail   bed   on   both   sides  of  the  silver  and  cut  out  the  overlying  wedge  of  nail.   4. Cleans   any   remaining   debris   with   normal   saline   and   trim   the   fingernail   until  the  corners  are  smooth.   5. Give  inj  Tetanus  toxoid.   6. Dress  with  antibiotic  ointment  and  bandage   7. Advise  to  redress  after  2  –  3  days.  WHAT  NOT  TO  DO:   a) Do   not   run   tip   of   the   scissors   into   the   nail   bed   while   sliding   it   under   the  fingernail.    GANGLION  CYST  The  patient  is  concerned  about  the  rubbery,  rounded  swelling  emerging  from  the  general   are   of   a   tendon   sheath   or   the   wrist   and   hand   .It   may   have   appeared  abruptly,   been   present   for   years,   or   fluctuated,   suddenly   resolving   and   gradually  and  returning  in  pretty  much  the  same  place,  There  is  usually  little  tenderness,  inflammation  or  interference  with  function.     31  
    • WHAT  TO  DO:   1. Under   take   a   thorough   history   and   physical   exam   of   the   hand   to   ascertain   that  everything  else  is  normal.   2. X-­‐rays  are  of  no  value  unless  there  is  some  question  of  bony  pathology.   3. Explain   the   patient   that   this   is   a   fluid   filled   cyst.   Spontaneously   arising   from  bursa  or  tendon  sheath  and  posing  no  particular  danger.   4. Treatment  option  include   i. Draining  the  contents  of  the  cyst  with  an  18gauge  needle  to  reduce   its  size   ii. Injecting  corticosteroid  i/m   5. Follow  the  wishes  of  the  patient.   6. Recurrence  chances  are  present  even  with  surgical  excision    MINOR  IMPLEMENT  INJURIES  A  sharp  metal  object  such  as  a  needle,  heavy  wire,  nail  or  fork  is  driven  into  or  through  a  patient  ‘s  extremity.  In  some  instances,  the  patient  may  arrive  with  a  large  object  attached.  WHAT  TO  DO:   1. If  implant  is  acting  like  a  lever    and  causing  pain  with  movement  ,  either   immediately   pull   the   extremity   off   the   sharp   object     or   quickly     cut   through  it    to  release  the  patient,  it  can  be  cut  with  orthopedic  cutter.     32  
    • 2. Obtain   x-­‐rays   when   pain   and   further   damage   from   a   leveraged   object   is   not  a  problem.   3. Examine  the  extremity  for  possible  neurovascular  or  tendon  injury.   4. If   surgical   debridement   is   anticipated   after   removal   of   the   object   ,   then   infiltration  of  an  anesthetic  should  be  provided  prior  to  removal.   5. Objects  with  small  barbs    such  as  crochet  needle  and  fish  spines  ,  can  be   removed   by   first   anesthetizing   the   area   and   the   applying   firm   traction   until  the  barb  is  revealed  through  puncture  wound.   6. After   removal   of   the   impaled   object   ,te   wound   should   be   appropriately     debrided  and  irrigated   7. Tetanus  toxoid  is  given     WHAT  NOT  TO  DO:   b) Do   not   send   a   patient   to   x-­‐rays   with   a   leveraged   impaled.   This   creates   further  pain  and  possible  injury  with  movement.   c) Do  not  try  to  hand  –saw  off  a  board  to  an  impaled  object.    IMPETIGO  Streptococcal   lesion   consists   of   irregular   or   somewhat   circular   red,   oozing,  erosions,   often   covered   with   a   yellow   =brown   crust.   Smaller   erythmatous  macular  or  vesicopustular  areas  may  surround  these.  Streptococcal   lesion   present   as   bullae   that   are   quickly   replaced   by   a   thin   shiny  crust  over  a  erythmatous  base.     33  
    • WHAT  TO  DO:   1. Prescribe  mupiricin  2%ointment  (Bactoban)  to  rash  TID  .for  three  days.   2. Tell  parents  of  small  children  to  clean  crust  with  warm  soapy  compresses   before  applying  the  antibiotic  ointment.   3. For  repeatedly  visiting  cases  to  ED  add  a  10  days  coarse  of  Erythromycin   or   penicillin   VK   (250mg   qid)   or   intramuscular   injection   of   benzathine   penicillin   (600,000   units   i/m   for   children   and   younger,   1.2   million   units   for  children  over  7  years).   4. For   suspected   staphylococcus   infection   use   dicloxacillin   250mg   qid   in   place  of  penicillin  or  prescribe  erythromycin  or  cefadroxil.  WHAT  NOT  TO  DO:   a) Do  not  routinely  culture  these  lesions.    JAW  DISLOCATION  The  patient’s  jaw  is  “out”  and  will  not  close,  usually  following  a  yawn  ,  or  perhaps  after  laughing  ,  a  dental  extraction  ,  jaw  trauma    or  a  dystonic  drug  reaction  .  The  patient   has   difficulty   speaking   and   may   have   severe   pain   anterior   to   the   ear.   A  depression   can   be   seen   or   felt   in   the   particular   area   and   the   jaw   may   appear  prominent.    WHAT  TO  DO:   1. If  there  was  a  no  trauma  (and  especially  if  the  patient  is  chronic     dislocator)  proceed  directly  to  attempt  reduction.     34  
    • 2. If  there  is  any  possibility  of  associated  fracture  then  take  x-­‐rays.   3. Have   the   patient   sit   on   a   low   stool,   his   back   and   head   braced   against   something   firm   –   either   against   the   wall,   facing   you,   or   with   the   back   of   his  head  braced  against  your  body,  facing  away  from  you.   4. With  gloved  hands,  wrap  your  thumbs  in  gauze,  seat  them  upon  the  lower   molars,  grasp  both  sides  of  the  mandible,  lock  your  elbows,  and  bending   from   the   waist.   Exert   slow   steady   pressure   down   and   posterior.   The   mandible  should  be  at  or  below  the  level  of  your  forearm.   5. In  bilateral  dislocation,  attempt  to  reduce  one  side  at  a  time.   6. Reassess  with  x-­‐rays.   7. After  reducing  apply  soft  collar.   8. Prescribe  analgesics   9. If   reduction   cannot   be   obtained   using   above   technique,   then   consider   admission  for  reduction  under  GA.  WHAT  NOT  TO  DO:   b) Try   not   to   get   your   thumb   bitten   when   the   jaw   snaps   back   in   to   position.   c) Do  not  put  pressure  on  oral  prosthesis  that  could  cause  them  to  break.   d) Do  not  try  to  force  the  patient’s  jaw.    LOW  BACK  PAIN  Suddenly   or   gradually   after   lifting,   bending,   or   other   movement   the   patient  develops  a  steady  pain  in  one  r  both  sides  of  the  lower  back.  At  times  this  pain     35  
    • can   be   severe   and   incapacitating.   It   usually   better   on   lying   down   ,   worse   with  movement,  and  perhaps  radiates  around  the  abdomen    or  down  the  thigh  ,  but  no  farther.  WHAT  TO  DO:   1. Perform   a   complete   history   and   physical   examination   of   the   abdomen,   back,  and  legs.  looking    for  alternative  causes  for  the  back  pain,   2. Consider  plain  x-­‐rays  of  the  lumbosacral  spine  of  those  who  have  suffered   from  severe  pain  and  difficulty  in  bending.   3. Order   and   ESR   on   patients   with   history   of   cancer   or   I/V   drug   abuse   or   sign  and  symptoms  of  underlying  disease.   4. For  point  tenderness  over  a  sacroiliac  joint  with  no  neurologic  findings  to   suggest  nerve  root  compression,  refer  to  neurosurgery  team.   5. Advise   injection   Voltran50   mg   +Injection   Dexamethasone   8   mg   both   together  IM.   6. If  there  is  acute  trauma  with  in  one  hour,  advise  inj.  Methylprednisolone.   7. Prescribe      ice  to  the  acutely  injured  area,  20  minutes  /hour  for  first  day.   8. Arrange  appointment  for  neurosurgery  OPD.   9. Teach   them   to   avoid   twisting   and   bending   when   lifting   and   show   them   how   to   lift   with   back   vertical,   using   thigh   muscles   and   holding   heavy   objects  close  to  the  chest  to  avoid  re-­‐  injury.  WHAT  NOT  TO  DO:   a) Don’t  be  eager  to  use  narcotics  pain  medications.   b) Do  not  apply  lumber  traction.     36  
    • MINOR  HEAD  TRAUMA  A  patient  is  brought  in  the  emergency  department      after  suffering  a  blow  to  the  head,  there  may  or  may  nor  be  laceration,  scalp  hematoma,  headache,  transient  sleeplessness  and  or  nausea  but  there  was  no  loss  of  consciousness  or  amnesia  for   the   injury   or   preceding   events,   seizure.   Neurological   changes   or  disorientation.  WHAT  TO  DO:   1. Take  the  history  and  ascertain  why  the  patient  was  injured.   2. Perform   and   record   physical   examination   of   the   head,   looking   for   signs   of   skull  fracture.   3. Perform  and  record  a  neurological  examination  with  special  attention  to   mental  status,  cranial  nerves  and  deep  tendon  reflex  to  all  four  limbs.   4. If  the  history  or  physical  examination  suggests  there  is  clinical  evidence  of   intracranial  injury  ,  then  call  surgical/neuro  team.   5. Criteria  for  obtaining  CT  Scan  includes   i. Documented  loss  of  consciousness   ii. Amnesia   iii. CSF  leakage  from  nose  or  ear   iv. Blood   behind   the   tympanic   membrane   or   over   the   mastoid  (Battle’s  sign)   v. Stupor   vi. Coma   vii. Any  focal  neurological  sign.     37  
    • 6. If  there  is  no  clinical  indication  for  CT  Scan  or  skull  x-­‐rays,  explain  to  the   patient   and   concerned   family   and   friends.   Many   patients   expect   x-­‐rays,   but  gladly  forego  them  once  you  explain  they  are  of  little  value.   7. Make  sure  that  family  understood  and  are  given  written  instructions  that     i. Any  abnormal  behavior   ii. Increasing  drowsiness   iii. Difficulty  in  arousing  the  patient   iv. Headache   v. Neck  stiffness.   vi. Vomiting     vii. visual  problem   viii. Weakness   ix. Seizures  are  signals  to  return  to  the  ED.  WHAT  NOT  TO  DO:   a) Do  not  skip  on  the  neurological  examination  or  its  documentation.   b) Do  not  be  reassured  by  negative  skull  films,  which  do  not  rule  out   intracranial  bleeding  or  edema.             38  
    • MUSCLE  STRAINS  AND  TEARS.  Strains  occur  during  or  after  a  vigorous  over  stretching  of  a  muscle  bundle  that  leads   to   an   insidious   development   of   pain   and   tightness   that   is   worse   with   use  and  better  with  rest.  Tear   of   the   muscle   belly   tend   to   be   partial,   with   sudden   onset   pain   and   partial  loss  of  function.  Often  a  tear  occurs  with  considerable  bleeding  that  can  lead  to  remarkable   hematomas   causing   swelling   at   the   site   and   dissecting   along   tissue  planes  to  create  e  ecchymosis  at  a  distant.  Complete  tears  are  more  likely  in  the  tendinous  part  of  the  muscle,  WHAT  TO  DO:   1. Obtain  a  history  of  mechanism  of  injury.   2. A  complete  tear  of  a  muscle  merits  orthopedic  consultation.   3. For  muscle  strain,  provide  soft  splint,  analgesics  and  instruct  the  patient   to  apply  warm  moist  compresses  for  comfort.   4. For   muscle   tear,   construct   a   loose   splint   to   immobilize   the   injured   part   and  instruct  the  patient  in  rest,  elevation  and  ice.    NAIL  ROOT  DISLOCATION.  The   patient   has   caught   his/her   finger   in   the   car   door,   or   dropped   a   heavy   object,  like   a   cane   of   vegetable   on   a   bare   toe,   with   the   edge   of   the   cane   striking   the   base  of  the  toenail  and  causing  a  painful  deformity.  The  base  of  the  nail  will  be  found  resting  above  the  eponychium  instead  of  its  normal  anatomical  position  beneath.     39  
    • WHAT  TO  DO:   1. Take  an  x-­‐rays  to  rule  out  an  underlying  fracture   2. Anesthetize  the  area  using  digital  block.   3. Lift   the   base   of   the   nail   off   the   eponychium   and   thoroughly   cleanse   and   inspect  the  nail  bed.   4. Minimally  debride  loose  cuticular  tissue  and  test  for  a  possible  avulsion  of   the  extensor  tendon.     5. If   bleeding   is   the   problem,   then   establish   a   bloodless   field   using   a   tourniquet     6. Repair  any  nailed  laceration  with  a  fine  absorbable  suture  like  a  7-­‐0  or     6-­‐0  Vicryl.   7. Reinsert  the  root  of  the  nail  under  the  eponychium.   8. Reduce  any  underlying  fracture.   9. If  the  nail  tends  to  drift  out  from  under  the  eponychium.  it  can  be  sutured   in  place  with  two    4-­‐0  nylon.   10. Any  non  absorbable  sutures  should  be  removed  after  one  week.   11. Provide  Tetanus  Prophylaxis   12. Follow  up  should  be  provided  in  3-­‐5  days  either  in  surgical  OPD  or  ED.   13. Advise  analgesics  and  antibiotics   WHAT  NOT  TO  DO:   a) Do   not   ignore   the   nail   root   dislocation   and   simply   provide   a   fingertip  dressing.   b) Do  not  debride  any  position  of  the  nail  bed,  sterile  matrix  or   germinal  matrix.     40  
    • NAILBED  LACERATION  The   patient   has   either   cut   into   his   nail   bed   with   a   sharp   edge   or   crushed   his  finger.  With  shearing  forces,  the  nail  may  be  avulsed  from  the  nail  bed  to  varying  degrees  and  there  may  be  an  underlying  bony  deformity.  WHAT  TO  DO:   1. Provide  appropriate  tetanus  prophylaxis.   2. Obtain  x-­‐rays  of  any  crush  injury  or  any  injury  caused  machinery.   3. Perform  digital  block.   4. Remove   the   nail   surrounding   the   laceration   to   allow   for   suturing     the   laceration  closed   i. Use  straight  hemostat  to  separate  the  nail  from  the  nail  bed.   ii. Use   the   scissors   to   cut   away   the   surrounding   nail   or   remove   the   entire  nail  intact  for  re-­‐insertion.  After  the  nail  bed  is  repaired.   iii. Cleanse   the   wound   with   saline   and   suture   accurately   with   a   fine   absorbable  sutuer6-­‐0  or  7-­‐0.   iv. Apply  a  non-­‐adherent  dressing  and  antibiotics  antiseptic  ointment   and  plan  to  change  the  dressing  after  the  24  hours.   5. When   a   crush   injury   results   in   open   hemorrhage   from   under   the   fingernail;   ,   the   nail   must   be   completely   elevated     to   allow   proper   inspection  of  the  damage  to  the  nail  bed.   6. Apply  a  fingertip  dressing.  WHAT  NOT  TO  DO:   a) Do  not  use  non  absorbable  suture     41  
    • b) Neither   does   nor   attempts   to   suture   a   nail   bed   laceration  through  the  nail.   c) Do  not  do  any  more  than  minimal  debridement  of  the   nail  bed  and  its  surrounding  structures.    NECK  (CERVICAL)  STRAIN.  The  patient  may  arrive  directly  from  a  car  accident,  arrives  the  following  day  or  long  after.  The  injury  occurs  when  the  neck  is  subjected  to  sudden  extension  and  flexion,   possibly   injuring   inter   vertebral   joints   and   ligaments,   cervical   muscles,  or  even  nerve  roots,  as  with  other  strain  and  sprains,  the  stiffness  and  pain  may  tend  to  peak  on  the  day  following  the  injury.  WHAT  TO  DO:   1. Obtain   a   detailed   history   to   determine   the   mechanism   and   severity   of   the   injury.   2. Examine   the   patient   for   involuntary   splinting,   point   tenderness   over   the   spinous   processes   of   the   cervical   vertebrae,   cervical   muscle   spasm   or   tenderness  and  for  strength,  sensation  and  reflexes  in  the  arm.   3. Take   the   x-­‐rays   lateral   view   of   cervical   spine.   If   necessary   then   AP   view   and  open  mouth  view  of  odontoid  can  also  be  obtained.   4. To  evaluate  the  head  trauma  ask  the  history  of  loss  of  consciousness.   5. If   there   is   no   evidence   e   of   injury   then   explain   the   Patient   that   stiffness   and  pain  will  relieve  with  in  24  hours  to  3-­‐4  days.     42  
    • 6. Treat  with  one  or  two  days  of  immobilization  (a  soft  collar),  topical  ice  for   the  first  day,  then  heat  for  the  later  spasm   7. Anti  inflammatory  analgesics  (aspirin,  ibuprofen.  naproxen)   8. Arrange  follow  up.  WHAT  NOT  TO  DO:   a) D  o  not  forgot  to  tell  the  patient  his  symptoms  may  well  be  worse  a   day  after  the  injury.   b) D  o  not  skip  recording  the  history  and  physical  exam.   c) D  o  not  x-­‐rays  every  sore  neck.    NEEDLE  (FOREIGN  BODY)  IN  FOOT.  Although   a   needle   could   be   embedded   under   any   skin   surface,   most   commonly   a  patient  will  have  stepped  on  one  while  running  or  sliding  bare  foot  on  carpeted  floor.  WHAT  TO  DO:   1. Tape   a   partially   opened   clip   as   a   skin   marker   to   the   planter   surface   of   the   foot,  with  the  tip  of  the  opened  paper  clip  over  the  entrance  wound.   2. Send  the  patient  for  x-­‐rays  AP/LAT  view  of  the  foot.   3. If   the   needle   appears   very   deep   in   x-­‐rays   then   refer   the   case   to   surgical   team       43  
    • 4. If  the  needle  is  superficial  then  tourniquet  the  foot,  elevate  the,  apply  BP   cuff  at  thigh  and  inflate  approximately  200  mm  HG.   5. Remove  the  tourniquet  and  paint  the  area  with  Povidine.   6. The  x-­‐rays  should  give  you  an  idea  of  the  location  of  the  needle  relative  to   the  paper  clip  skin  marker.   7. With  the  patient  lying  prone  and  planter  surface  of  his  foot  facing  upward.   8. Make   an   incision   that   crosses   perpendicular   to   the   needle’s   apparent   position  at  its  midpoint,  use  iris  scissors  with  the  blade  open  to  advance  a   few  millimeters  at  time  before  closing  the  scissor  blade.   9. Continue   repeating   this   process   until   needle   prevents   closure   of   the   scissors,   if   you   are   using   the   scalpel   blade   then   there   will   be   audible   clicking  sound.   10. Visualize  the  needle  and  grasp  it  with  Kelly  clamp.   11. Now  push  the  needle  out  in  the  direction  from  which  it  entered.   12. Let   the   thigh   cuff   down   and   suture   over   the   skin   and   apply   appropriate   dressings,   13. Provide  inj  Tetanus  Toxoid.   WHAT  NOT  TO  DO:   a) Do   not   ignore   the   patient   who   thinks   he   stepped   on   a   needle   but   in   whom   you   cannot   find   a   puncture   wound,   Get   an   x-­‐rays   anyway.     44  
    • b) Do   not   give   impression   to   the   patient   that   removal   is   easy   and   quick.   c) Do  not  make  incision  near  the  tip  of  the  needle  or  directly  over   and  parallel  to  the  needle.   d) Do  not  extend  the  incision  if  you  don’t  find  the  needle.   e) If   you   don’t   find   the   needle   with   10   minutes,   discontinue   the   attempt  and  call  ortho/surgical  team.   f) Do  not  attempt  to  remove  the  buried  needle  by  pulling  on  the   attached  thread.  PARONYCHIA  The  patient  will  come  with  finger  and  toe  pain  that  is  either  chronic  or  recurrent  in  nature  or  has  developed  rapidly  over  the  past  several  hours,  accompanied  by  redness  and  swelling  of  the  nail  fold,  there  are  three  distinct  varieties.  WHAT  TO  DO:   1-­‐ Perform  uni  or  bilateral  digital  block,  and  establish  a  blood  less  field,   2-­‐ Consider   conservative   treatment   and   put   a   cotton   wedge   under   the   corner  of  in  growing  nail,  and  place  the  patient  on  antibiotics.   3-­‐ Try   to   excise   the   entire   wedge   of   the   affected   nail;   nail   bed   and   lateral   skin  fold  down  to  the  periosteum  of  distal  phalanx.   4-­‐ Instruct   the   patient   to   soak   the   toe   in   warm   water   for   20   minutes   daily   two  to  three  times  and  arrange  an  ED  visit  if  required.     45  
    • 5-­‐ In  case  of  acute  paronychia  there  is  minimal  swelling  and  there  appears  to   be  only  cellulitis,  gently  use  an  18  gauge  needle  to  separate  the  cuticle  of   the  lateral  nail  fold  to  rule  out  or  drain  any  pus.   6-­‐ A  more  aggressive  approach  for  the  more  extensive  infection  is  to  excise  a   portion  of  the  nail.  After  establishing  a  digital  block  and  a  bloodless  field,   simple   insert   a   fine   straight   hemostat   between   the   nail   and   the   nail   bed   along  the  edge  adjacent  to  the  paronychia.   7-­‐ In   case   of   subungual   abscess   consider   a   conservative   treatment   not   requiring  a  digital  block.   8-­‐ When   there   is   a   distal   collection   of   pus,   simple   excision   of   an   overlying   wedge  of  nail  using  iris  scissors  should  provide  a  complete  drainage.  WHAT  NOT  TO  DO:   • Do  not  order  culture  or  X-­‐Rays  on  uncomplicated  cases.   • Do  not  make  an  actual  skin  incision     • Do   not   remove   an   entire   fingernail   or   toenail   to   drain   a   simple   paronychia.   • Do  not  confuse  a  felon  (tense  tender  finger  pad)  with  a  paronychia;  Felons   will  require  more  extensive  surgical  treatment.           46  
    • PENCIL  POINT  PUNCTURE  A  small  puncture  wound  lined  with  graphite  tattooing  will  be  present;  pencil  tip  may   or   may   not   be   present,   visible,   or   palpable.   If   the   puncture   wound   is  palpable,   an   underlying   pencil   point   may   give   the   patient   a   foreign   body  sensation.  WHAT  TO  DO:   1) Reassure  the  patient  or  parents     2) Palpate   and   inspect   for   foreign   body,   I   uncertain   get   an   x-­‐rays   or   ultrasound  to  rule  out  the  presence  of  foreign  body.  In  order  to  reduce  the   amount  of  tattooing,  the  wound  may  be  anesthetized  and  scraped    (derma   braded)   with   the   tip   of   a   scalpel   blade.   It   is   unwise   to   excise   the   entire   wound  because  the  resultant  scar  might  be  more  unsightly  that  the  tattoo.   1. Scrab  wound.   2. Administer  tetanus  prophylaxis,  if  necessary.   3. Warn  the  patient  or  family  about  signs  of  infection,  and  inform  them  that   there   will   be   a   permanent   black   tattoo   that   can   be   removed   later   if   the   resulting  mark  is  cosmetically  unacceptable.  WHAT  NOT  TO  DO:   • Do  not  excise  the  entire  wound  on  the  initial  visit.         47  
    • PERIORBITAL  AND  CONJUCTIVAL  EDEMA  An   allergen   or   chemical   irritant   on   the   hand   may   cause   periorbital   edema   long  before   reaction,   there   may   be   minimal   to   marked   generalized   conjuctival  swelling,   tenderness   and   pain   should   be   mild   or   absent   and   no   erthyma   of   the  skin.  Visual  acuity  should  be  normal  and  there  should  be  uptake  of  Fluorescein  over  the  cornea.  WHAT  TO  DO:   1. After  completing  the  full  eye  examination,  reassure  the  patient  that  this  is   not  as  serious  as  it  looks.   2. Instruct   the   patient   to   use   cool   compression   to   reduce   swelling   and   discomfort   3. Inquire  about  the  cause,  including  allergies  and  chemical  irritants     4. Warn  the  patient  about  the  potential  signs  of  infection   5. Prescribe   Hydroxizine   6   hourly   for   mild   to   moderate   cases   and   add   steroids  for  severe  cases.  WHAT  NOT  TO  DO:   • Do  not  apply  heat,  swelling  and  pruritis  will  increase.   • Do  not  confuse  this  with  periorbital  cellulitis           48  
    • PELVIC  INFLAMMATORY  DISEASE   A  woman  aged  15-­‐30,  may  complains  of  lower  abdominal  pain  and  there   could   be   associated   vaginal   discharge,   foul   odor,   dysuria,   and   dysparenuria.  Menorrhagia  or  intermenstrual  bleeding.  Patient  with  more   severe   infection   may   develop   fever,   malaise,   nausea   and   vomiting.   Woman   with   severe   pelvic   pain   tend   to   walk   slightly   bent   over   holding   their  lower  abdomen  and  shuffling  their  feet.    WHAT  TO  DO:   1. Perform  a  pelvis  examination     2. Obtain  end  cervical  culture     3. Obtain  blood  for  syphilis  serology.   4. Do  urinalysis  for  pregnancy  test.   5. Perform   pelvic   ultra   sound   if   there   is   suspected   mass,   severe   pain   or   positive  pregnancy  test.   6. Remove  any  intrauterine  device.   7. Treat  suspected  cases  while  awaiting  diagnostic  confirmation   8. Hospitalize  such  cases  with  salphingitis.   9. Treat   mild   to   moderate   cases   as   outpatients   with   one   dose   of   Ceftroxoe1gm  stat   10. Provide  for  follow  up  in  14  days.   11. Advise  analgesics.   12. Instruct  the  patient  to  avoid  intercourse  for  at  least  two  weeks.   13. Counsel  the  patient  for  the  sexually  transmitted  disease.       49  
    • WHAT  NOT  TO  DO:   • Don’t  use  Ofloxacine  in  pregnant  woman  or  patient  under  18  years  of  age.   • Do   not   miss   the   more   unilateral   disorder   like   ectopic   pregnancy,   appendicitis  ovarian  cyst  or  torsion.   • Do  not  diagnose  PID  in  pregnant  with  out  ruling  out  ectopic  pregnancy.   • Do   not   ignore   pelvic   symptoms   if   the   patient   has   prehepatic   inflammation.        PINWORM  OR  THREADWORM  The   patient   complains   of   perineal   itching,   which   is   worse   at   night   and   may  complain  to  insomnia  or  super  infection  of  the  excoriated  peri  anal  skin,  Often  a  entire  family  is  involved.  WHAT  TO  DO:   1. Examine  the  anus  to  rule  out  other  causes  of  itching.   2. Look   for   the   pinworm   directly   and   by   pressing   the   sticky   side   of   cellophane   tape   wrapped   around   tongue   blade   to   the   perineal   skin.   Examine  the  tape  under  the  low  power  of  microscope  for  female  worms.   3. If   you   suspect   or   still   see   pinworm,   administer   a   single   oral   dose   of   pyrantel  pamoate  11mg/75  kg.  Alternate  drug  is  mebandazole  (vermox)   100mg  in  a  single  dose  PO.(not  for  infants  and  pregnant  woman)   4. Explain   to   all   that   it   is   not   a   dangerous   infection   and   that   it   should   be   eradicated  from  all  family.     50  
    •  PLANTARIS  TENDON  RUPTURE  The   patient   will   come   in   limping,   having   suffered   a   whip   like   sting   in   his   calf  while   stepping   off   hard   on   his   foot.   The   deep   calf   pain   persists   and   may  accompanied   by   mild   swelling   and   ecchymosis,   Neurovascular   function   will   be  intact.  WHAT  TO  DO:   1. Rule   out   an   Achilles   tendon   rupture   (Squeeze   the   Achilles   tendon   and   palpate  for  tender  deformity  that  represent  a  torn  segment.   2. When   Achilles   tendon   rupture   is   ruled   out,   provide   the   patient   with   elastic  support  from  foot  to  tibial  tuberosity.   3. Provide  the  patient  with  crutches  for  several  days.   4. Permit  weight  bearing  only  as  comfort  allows.   5. Ask  the  patient  to  keep  legs  elevated  and  rest  for  next  24-­‐48  hours  with   heat  after  every  few  hour.   6. Have  an  analgesic  such  as  NSAID  or  Codeine  may  be  helpful  initially.  WHAT  NOT  TO  DO:   • Do   not   take   X-­‐Rays   unless   there   is   suspected   associated   injury.   This   is   a   soft  injury  that  is  not  having  fracture.       51  
    • POLYMYALGIA  RHEUMATICA  An   elderly   patient   (females   commonly)   complains   of   week   or   two   of   morning  stiffness,   which   may   interfere   her   ability   to   raise   up   from   bed   but   improves  during  the  day.  She  may  ascribe  her  problem  as  muscle  weakness  or  joint  pain.  Physical   examination   discloses   that   symmetrical   pain   and   tenderness   of   neck,  shoulder   and   hip   muscles   are   the   actual   source   of   any   weakness,   there   may   be  mild  arthritis  of  several  peripheral  joints  but  the  rest  of  the  physical  examination  is  normal.  WHAT  TO  DO:   1. Confirm   the   diagnosis   by   obtaining   an   ESR   that   should   be   in   the   30-­‐ 100mm/hr.   2. Mild  to  borderline  cases  may  respond  with  NSAID  (Ibuprofen/Naproxen)   more   severe   cases   will   respond   to   Prednisolone   20-­‐60   mg   QID   with   a   week  or  two  after  that  dose  should  be  tapered.     3. Failure   to   respond   to   corticosteroid   therapy   suggests   some   other   diagnosis.   4. Explain  the  syndrome  to  patient.  WHAT  NOT  TO  DO:   • Do  not  miss  temporal  artritis.   • Do   not   postpone   diagnosis   or   treatment   of   temporal   artritis   pending   result  of  a  temporal  artery  biopsy  showing  giant  cell  artritis.     52  
    • RHUS  CONTACT  DERMATITIS.  (POISON  IVY,  OAK,  SUMAC)  The   patient   is   troubled   with   pruritis   rash   made   up   of   tense   vesico-­‐papular  lesions   on   a   mildly   erythmatous   base.   Typically   these   are   found   in   groups   of  linear  streaks  and  may  be  weeping,  crusted  or  confluent.  If  involvement  is  severe  there   may   be   marked   edema.   Particularly   on   the   face   and   periorbital   and   genital  area.  WHAT  TO  DO:   1) Have   the   patient   apply   cool   compresses   of   Burrow’s   solution   for   20   -­‐30   minutes  every  3-­‐  4  hours.   2) Small   areas   can   be   treated   2-­‐3   times   per   day,   enhanced   at   night   with   a   occlusive   plastic   wrap   dressing   Diphenhydramine   or   Hydroxizine   (Atarax)  25  mg  PO  TDS  will  help  itching.   3) Taped   tub   bath   with   baking   powder   (1   cup   of   each   in   ½   tub)   will   provide   soothing  effect     4) When   there   is   involvement   of   face   in   severe   reactions   or   in   situations   where   the   patient’s   livelihood   is   threatened,   early   and   aggressive   treatment   with   Inj   Adrenaline   3mg   I/M   and   systemic   corticosteroids   should  be  initiated.   5) Prednisolone   (60-­‐80mg)/day   tapered   over   2   weeks   will   be   necessary   to   prevent  a  late  flare  up.       53  
    • WHAT  NOT  TO  DO:   • Do  not  institute  systemic  steroids  in  the  face  of  secondary  infection  such   as  impetigo,  cellulitis  or  erysipelas,   • Do  not  start  steroids  if  there  is  history  of  tuberculosis,  diabetes,  herpes  or   severe  hypertension.    PROSTITIS  A   man   complains   of   fever.   Chills,   perineal   or   low   back   pain     and   may   have  urinary   urgency   and   frequency     as   well   as   sign   of   obstruction   to   urinary   flow  ranging  from  a  weak  stream  to  urinary  retention.  WHAT  TO  DO:   1. Perform  a  rectal  examination  only  once,  gently  palpate  the  prostate  to  see   if  its  tender,  swollen  or  edematous.   2. Culture  the  urine  to  help  identify  the  organism  responsible.   3. For   patients   35   years   old   and   younger,   treat   with   Ceftrioxone   125   i/m   -­‐ 1000mg  i/v  and  Azithromycin  1gm  PO   4. For   men   over   35   years   old   begin   empirical   treatment   with   ciprofloxacin   400mg  i/v,  then  500  mg  PO  bid.   5. Arrange  for  Urologic  follow  up.         54  
    •  WHAT  NOT  TO  DO:   • Do  not  message  or  repeatedly  palpate  the  prostate      PULPITIS  The   patient   develops   a   sharp   and   throbbing   pain,   it   is   due   to   the   fluid   and  gaseous   pressure   with   in   closed   cavity.   Heat   increases   the   volume   and   hence   the  pain,  while  cold  reduces  it.  WHAT  TO  DO:   1) Administer   a   strong   analgesic   such   as   oxycodone   in   combination   with   acetaminophen   and   prescribe   additional   medication   for   home   use   including  NSAID.   2) Severe  pain  may  require  nerve  block.   3) If  small  cavity  is  present,  insert  a  small  cotton  pledge  soaked  in  xylocain   or  oil  of  cloves.  Cotton  should  fill  up  the  cavity  with  out  rising  above  the   opening.   4) Refer  the  patient  to  dental  OPD.  WHAT  NOT  TO  DO:   • Do   not   prescribe   antibiotics   with   out   signs   of   cellulitis   or   abscess   formation.       55  
    • PUNCTURE  WOUND  Most  commonly,  the  patient  will  have  stepped  or  jumped  on  to  a  nail,  there  may  be  pain  and  swelling  but  often  the  patient  is  only  asking  for  tetanus  and  shot  and  can   be   found   in   the   emergency   department   with   his   foot   soaking   in   a   basin   of  iodine  solution.  Small,  clean,  superficial  puncture  wounds  uniformly  do  well.  The  pathophysiology  and  management  of  wound  is  dependent  upon  the  material  and  punctured  the  foot,  the  location,  depth,  and  time  to  presentation.  WHAT  TO  DO:   1) Obtain  the  detailed  history  to  ascertain  the  force  involved  in  creating  the   puncture  and  the  relative  cleanliness  of  penetrating  object.   2) Clean   the   surrounding   skin   and   carefully   inspect   the   wound   with   the   patient  lying  prone,  with  good  light  and  adequate  time.   3) Most   puncture   wounds   only   require   simple   debridement   and   irrigation,   but   with   deep,   highly   contaminated   wounds,   seek   orthopedic   consultation.   4) Suture   the   puncture   wound   using   a   10#   scalpel   blade   to   remove   the   epithelium.   5) If   debris   is   found,   gently   slide   a   large   –   gauge   blunt   needle   catheter   down   the   wound   track   and   slowly   irrigate   with   physiologic   saline   solution   until   debris  no  longer  flows  from  the  wound.   6) Provide  tetanus  toxoid  prophylaxis.     56  
    • 7) Cover  the  wound  with  bandage,  instructs  the  patient  on  warning  signs  of   infection.   8) Arrange  the  follow  up  in  surgical  OPD.   9) Patients   presenting   after   a   day   will   often   have   established   wound   infection.  WHAT  NOT  TO  DO:   • Do  not  reassure  falsely  the  patient  soaked  its  wound  in  Povidine.   • Do  not  attempt  a  jet  lavage  with  in  puncture  wound.   • Do  not  get  X-­‐RAYS  for  simple  nail  punctures  except  for  the  unusual  case   where  large  particulate  debris  is  suspected  to  be  deeply  imbedded  with  in   the  wound.   • Do  not  prescribe  antibiotics  until  there  is  suspicious  of  infection.   • Do  not      allow  beginning  soak  at  home.    PYELONEPHRITIS  (UPPER  URINARY  TRACT  INFECTION)  The   patient   has   some   combination   of   urinary   frequency,   dysuria,   flank   pain,  nausea,  fever  and  chills.  There  is  tenderness  elicited  by  percussing  the    Costovertebral   angle   over   the   kidneys.   Urinalysis   may   help   establish   the  diagnosis   with   tubular   casts   of   white   cells.   Studies   have   shown   that   14   days   oral  treatment  is  beneficial  for  the  woman  with  clinical  evidence  of  pyelonephritis.     57  
    • WHAT  TO  DO:   1) Examine   urine   for   presence   of   gram   –positive   cocci   and   send   urine   for   culture.   2) Admission  is  arranged  if  the  patient  is  having  nausea.  Vomiting,  feverish   or  pregnant  and  WBC  are  increased.   3) For  stable,  otherwise  healthy  patients  start  with  first  dose  of  intravenous   antibiotics   in   ED   (Ceftrioxone   1000-­‐2000mg),   then   discharge   home   on   oral   hydration   and   two   weeks   of   oral   antibiotics   (Septran   800mg   BID,   Ciprofloxacin   500mg   BID,   Norfloxacin   400mg   BID   or   Ofloxacine   400mg   BID  X  14  Days)   4) Instruct   the   patient   to   return   to   the   ED   for   re   –evaluation   in   24   -­‐48   hours   and   sooner   if   the   symptoms   worsen.   Most   patients   improve   on   this   regimen,  but  others  require  hospital  admission.    WHAT  NOT  TO  DO:   • Do  not  miss  follow  up  in  ED     • Do  not  miss  an  infection  above  the  urethral  stone  by  doing  USG.   • Don’t  advise  blood  culture  if  the  patient  is  discharged  from  ED.           58  
    • RABIES  PROPHYLAXIS  When   a   contagious   animal   bites   the   patient,   saliva,   brain   tissue   or   CSF  contaminated   an   abrasion   or   mucous   membrane.   Patients   with  immunosuppressive  illness  or  those  taking  corticosteroids  or  antimalarial  drugs  may   an   inadequate   immune   response   to   vaccination.   Pregnancy   is   not   a  contraindication  to  vaccination.  Incubation  period  of  Rabies  varies  from  weeks  to  months  roughly  in  proportion  to  the  length  of  the  axons  up  which  the  virus  must  propagate  to  the  brain  ,  which  is  why  prophylaxis  is  essentially  urgent  in  facial  bites.  WHAT  TO  DO:   1) Cleaning   of   all   bite   and   scratch   wounds   with   soap   and   water,   2%   benzalkonium   chloride,   and/or   a   veridical   agent   (Povidine-­‐iodine   solution)   2) When appropriate, wound closure should be avoided. 3) Rabies vaccines 20 IU /kg, the human diploid cell vaccine (HDCV, Imovax) and the purified chick embryo cell vaccine (PCECV, RabAvert) is given I/M in deltoid muscle. 4) Make arrangement for repeat doses of HDCV at 3, 7, 14 and 28 days post exposure. 5) Tetanus prophylaxis is usually indicated, to prevent bacterial infection. 6) Inform the Public Health department. 7) Notify the case.   59  
    • WHAT NOT TO DO: • Do not change the vaccine once a vaccination series is initiated, it is usually completed with the same vaccine product. • Do not treat the bites of Rodents and Lagomorphs (hamsters , rabbits, squirrels , rats etc) unless rabies is endemic in area, because they don’t cause human rabies. • Do not use the gluteal region, because this could result in a decreased immunologic response. • HRIG should not be administered.RECTAL FOREIGN BODY.The   treatment   of   rectal   foreign   bodies   has   been   discussed   in   the   medical  literature   for   many   years.   Controlled   studies   of   patients   with   rectal   foreign  bodies   have   not   been   conducted.   These   patients   usually   present   to   the   ED  because   the   object   is   inserted   by   him/herself   with   of   pain,   acute   urinary  retention   often   after   multiple   attempts   to   remove   the   object.   Presentation   is  almost   always   delayed   because   of   embarrassment.   Sometimes   the   patient   will  not  volunteer  that  any  object  has  been  inserted  or  give  outlandish  explanations  such  as  having  sat  or  fallen  on  to  object.  When  interviewed  privately.  WHAT  TO  DO:   1) Respect   for   their   privacy,   evaluation   of   the   type   and   location   of   the   foreign   body,   if   removal   can   be   performed   in   the   ED   or   if   surgical   referral   is  needed,  and  use  appropriate  techniques  for  removal     60  
    • 2) Perform  an  abdominal  and  rectal  exam,  check  for  rebound  tenderness.   3) Start   bilateral   intravenous   lines   and   take   blood   for   CBC,   BIO   and   do   X-­‐ RAYS  Plain  abdomen  to  look  for  free  air  under  diaphragm.   4) Sedate  the  patient  with  benzodiazepines  and  narcotics  to  help  to  remove   the  object.   5) If  the  patient  feels  pain  then  use  local  1%  Lidocain  Jelly.   6) When  the  examining  finger  can  reach  the  object  and  it  is  of  a  nature  that   will   allow   it   to   be   grasped,   lax   anal   sphincter   may   allow   you   slowly   to   insert  as  much  as  gloves  grab  the  object  and  gradually  take  it  out.   7) If  you  are  unable  to  to  pull  out  then    Slide   a   large   Foley’s   catheter   with   30   cc   balloon   past   the   object,   inflate  the  balloon  and  apply  traction  to  the  catheter,  two  catheters   may   occasionally   be   needed   and   air   can   be   instilled   through   the   lumen  of  catheter.    Under   direct   visualization   with   a   endoscope   or   vaginal   speculum,   grasp  the  object  with  tenaculum,  sponge  forceps,  Kelly’s  clamp  or   Tonsil  snare.    An  open  object,  like  a  jar  or  bottle,  can  be  filled  with  wet  plaster,   into  which  a  tongue  blade  can  be  inserted  like  a  pop  stick  .  When   the  plaster  hardens,  retraction  can  be  used  to  remove.    Forceps  or  soupspoons  can  be  used  to  deliver  a  round  object.   8) With  an  object  that  is  too  high  to  reach,  the  patient  can  be  admitted  and   sedated  for  removal.     61  
    • 9) When   blood   is   present   in   the   rectum   or   the   object   is   capable   of   doing   harm   to   the   bowel,   then   sigmoidoscopy   should   be   performed   after   removal  the  object.   10)Keep  the  patient  for  observation  until  the  bleeding  and  pain  s  relieved.      WHAT  NOT  TO  DO:   • Don’t  pressurize  the  patient  to  give  you  the  exact  story.   • Do  not  push  the  object  higher  into  the  colon  while  attempting  to  remove   it.   • Do  not  blindly  grasp  the  object  with  tenaculum  or  other  such  device,  this   can  itself  cause  perforation.   • Do  not  attempt  to  remove  sharp,  jagged  objects  such  as  broken  glass  via   the  rectum;  these  should  only  be  removed  under  anesthesia  in  OP.   • Do   not   send   the   patient   home   who   is   having   pain   home,   admit   and   observe  for  peritoneal  signs,  increased  pain,  fever  and  rising  white  count.    REMOVAL  OF  DISLOCATED  CONTACT  LENS  The   patient   may   know   the   lens   has   dislocated   into   one   of   the   recesses   of   the  conjuctiva   and   complains   of   only   refractory   correction.   There   have   been   rare  cases   of   lens   perforation   of   the   conjuctival   sac   and   migrating   posterior   to   the  globe.  Pain  and  blepharospasm  suggests  a  corneal  abrasion.  WHAT  TO  DO:     62  
    • 1) If  pain  and  blepharospasm  are  a  problem,  topically  anesthetize  the  eye.   2) Pull   back   lids   as   when   looking   for   conjuctival   foreign   bodies,   invert   the   upper  lid  and  if  necessary  instill  Fluorescein  dye.   3) If  the  lens  is  loose,  slide  it  over  the  cornea  and  let  the  patient  remove  it  in   the  usual  manner.   4) Irrigate  the  eye  as  it  looses  the  stuck  lens.   5) For  a  more  adherent  lens  use  commercially  available  lens  suction  cup.   6) After  removing,  put  the  lens  in  a  proper  container  (sterile  saline)   7) Complete  the  eye  examination,  bright  light  and  Fluorescein  examination.   8) Patch  the  eye  if  there  is  corneal  abrasion.   9) Instruct  the  patient  not  to  wear  the  lens  until  all  symptoms  have  abated   for  24  hours     10)Arrange  the  appointment  for  ophthalmologist.    WHAT  NOT  TO  DO:   • Do  not  give  up  so  easily.  Lost  lens  have  been  excavated  already.   • Do  not  omit  the  Fluorescein  test  for  fear  of  spoiling  a  soft  contact  lens         63  
    • RING  REMOVAL   A   Ring   has   become   tight   on   the   patient’s   finger   after   an   injury   or   after   some   other   cause   of   swelling,   tight   fitting   rings   obstruct   lymphatic   drainage  causing  swelling  and  further  constriction,  sometime  person  has   very   personal   attachment   with   ring   therefore   he/she   does   not   that   ring   is   cut  off.   WHAT  TO  DO:   1. Limit  further  swelling  by  applying  ice  and  elevating  the  extremity   above  the  level  of  the  heart.   2. When  there  is  suspicion  of  fracture,  order  for  x-­‐rays.   3. Apply  a  digital  block  for  comfortable  removal.   4. Lubricate  with  soap  and  water.   5. When   the   ring   is   too   tight   to   twist   off   this   way,   exsanguinate   the   finger   by   applying   a   tightly   wrapped   spiral   of   Pensore   drain   or   felt   rubber  phlebotomy  tourniquet  tape  around  the  exposed  portion  of   the  finger,  elevate  the  hand  above  the  head,  wait  five  minutes  and   then  apply  a  BP  cuff  inflated  to200-­‐300  mmHg,  wrap  the  cuff  with   cotton  cast,  remove  the  tight  rubber  wrapping  from  the  finger  and,   leaving  the  tourniquet  in  place,  again  attempt  to  twist  the  ring  off   using  soap  and  water  lubrication.     64  
    • 6. If   the   ring   is   still   too   tight   or   there   is   too   much   pain   to   allow   the   above  technique,  a  ring  cutter  /bone  cutter  can  be  used  through  a   narrow  ring  band.   7. Another  technique  which  tends  to  be  effective  is  the  coiled  string   technique,   slip   the   end   of   string   under   the   ring   and   wind   a   single   – layer  coil  down  the  finger,  compressing  the  swelling  as  you  go.  Pull   up   on   the   end   of   string   under   the   ring,   then   slide   and   wiggle   the   ring  down  over  the  coil.   8. Another  ring  removal  method  is  to  pull  a  length  of  string  under  the   ring  and  tie  it  into  large  loop  that  you  can  place  around  your  own   wrist,   This   will   allow   you   to   apply   traction   and   slide   the   string   around   the   circumference   of   the   ring   while   you   pull   the   ring   off   using  lubricant  as  above.  WHAT  NOT  TO  DO:   • If  the  patient  request,  not  to  cut  the  ring,  don’t  cut  until  there  is   vascular  compromise  (pallor,  cyanosis  or  pain).  He  should  then   be   understood   that   he   is   to   return   for   further   care   if   the   circulation  becomes  compromised.    RUPTURED  EAR  DRUM  (Perforated  Tympanic  Membrane)  The  patient  will  present  with  ear  pain  after  barotraumas,  such  as  a  blow  to  the  ear  or  deep  water  diving  or  after  direct  trauma  with  a  stick  or  other  sharp  object,     65  
    • Hemorrhage  will  often  be  noticed  with  in  the  external  canal  and  the  patient  will  experience  some  hearing  loss.  Tinnitis  or  vertigo  may  also  be  present.  Otoscopic  examination   will   reveal   a   defect   in   the   tympanic   membrane   that   may   or   may   not  be  accompanied  by  disruption  of  the  ossicles.    WHAT  TO  DO:   1. Clear  out  any  debris  from  the  canal,  using  gentle  suction.     2. Test  for  nystagmus  and  gross  hearing  loss.   3. Place   a   protective   cotton   plug   inside   of   the   ear   canal   and   instruct   the   patient  to  keep  the  canal  dry.   4. Prescribe  an  appropriate  analgesics.   5. Ensure  that  the  patient  gets  early  follow  up  by  an  ENT  team.  WHAT  NOT  TO  DO:   • Don’t   instill   any   fluid   into   the   external   canal   or   allow   the   patient   to   get   water  into  his  ear.    SATURDAY  NIGHT  PALSY  (RADIAL  NEUROPATHY)  The   patient   has   injured   his   upper   arm,   usually   by   sleeping   with   his   arm   over   the  back   of   a   chair   and   now   presents   holding   the   affected   hand   and   wrist   with   his  good   hand,   complaining   of   decreased   or   absent   sensation   on   the   radial   and     66  
    • dorsal   side   of   his   hand   and   wrist,   and   inability   to   extend   his   wrist,   thumb   and  finger   joints,   With   the   hand   supinated   (palm   up)   and   the   extensor   aided   by  gravity,   hand   function   may   appear   normal,   but   when   the   hand   is   pronated   (palm  down)  the  wrist  and  hand  will  drop,  WHAT  TO  DO:   1. Look  for  associated  injury   2. Document  in  detail  all  motor  and  sensory  impairment     3. Draw  a  diagram  of  the  area  of  decreased  sensation  and  grade  the  muscle   strength.   4. Put   a   splint,   extending   extending   from   proximal   forearm   to   just   beyond   metacarpophalyngeal  joint  (leaving  the  thumb  free).   5. Explain   to   the   patient,   nature   of   the   nerve   injury,   slow   rate   of   regeneration  and  importance  of  splinting  and  physical  therapy.  WHAT  NOT  TO  DO:   • Don’t   be   misled   by   the   patient   ‘s   ability   to   extend   the   interphalangeal   joints   of   the   fingers   that   may   be   accomplished   by   the   ulner   –innervated   interosseous  muscles.    SCABIES  Patient  develops  itching  and  unable  to  sleep,  Papules  and  vesicles  along  thread  like  tracks  are  chiefly  found  in  the  longitudinal  web  spaces  as  well  as  on  the  volar     67  
    • aspects  of  the  wrists,  antecubital  fossa,  olecranon  area,  nipples  umbilicus,  lower  abdomen,   genitalia   and   gluteal   cleft,   secondary   bacterial   infection   is   often  present.  WHAT  TO  DO:   1. Attempt  identification  of  the  mite  by  placing  mineral  oil  over  the  papules   or   vesicles   at   the   proximal   end   of   a   track   and   scraping   it   with   scalpel   blade.   2. If   the   clinical   picture   is   convincing,   treatment   must   be   started   immediately.   3. Treat  with  Linden  lotion;  apply  a  very  thin  layer  of  lotion  once  over  entire   body   from   the   neck   down   to   the   bottoms   of   feet.   Tell   the   patient   that   itching   will   not   go   soon   as   dead   mites   and   eggs   continue   to   itch   as   the   body  absorbs  them.   4. Alternatively,   treat   the   patient   with   similar   application   of   crotamiton   (Eurax)   lotion   or   cream   at   the   body   after   taking   bath,   advise   to   repeat   after  24  hours,   5. Advise   the   patient   that   clothing,   bedding,   and   towel   should   be   washed   with  hot  water  or  dry  cleaned  to  prevent  reinfection.  WHAT  NOT  TO  DO:   • Do  not  use  Linden  lotion  on  infants,  young  children  or  pregnant  women,     • Do  not  leave  it  on  the  skin  more  than  12  hours.     68  
    • SEIZURES  A   seizure   is   a   general   term   for   a   sudden   attack.   The   term   seizure   is   used   in  neurology   to   refer   to   the   sudden   onset   of   abnormal   electrical   discharge   within  the   brain   that   can   lead   to   convulsions.   Convulsions   are   uncontrolled   violent  spasms   (jerking)   of   muscles   of   the   body.   Epilepsy   is   the   medical   term   for   the  condition   of   having   chronic   seizure   disorder.   There   are   two   kinds   of   seizures,  focal  and  generalized.  There  are  many  causes  of  epilepsy.  Treatment  of  epilepsy  (seizures)   depends   upon   the   cause   and   type   of   seizures   experienced.   Patient  with  grand  mal  seizures  can  injure  themselves  and  generalized  seizures  can  be  prolonged   for   more   than   a   couple   or   minutes   and   can   lead   to   hypoxia,   acidosis  and  even  brain  damage.  WHAT  TO  DO:   1. If   the   patient   is   having   grandmal   seizure,   do   suctioning   and   turn   the   position  on  his  side,  but  the  breathing  will  be  uncoordinated  until  the   phase  is  over.   2. Watch  the  pattern  of  the  seizure  for  clues  to  the  etiology.   3. If   the   seizure   has   last   more   than   two   minutes   and   recurs   before   the   patient  regains  consciousness,  this  is  defines  as  status  epileptics  and  is   best   treated   with   inj.   Diazepam   (valium)   5-­‐10   mg   i.v.   Followed   by   gradual  loading  of  i.v  Phenytoin  sodium.   4. Check   finger   stick   blood   sugar   and   administer   intravenous   50%   glucose  in  case  of  adult  and  5%in  case  of  children.     69  
    • 5. If   the   patient   arrives   postictal,   examine   him/her   thoroughly   for   external  injuries.   6. Repeat  neurological  examine  after  recovering  from  the  postictal  phase.   7. If  the  patient  arrives  awake  and  oriented  following  an  alleged  seizure,   corroborate   the   history   through   witnesses   or   the   presence   of   injuries   like  a  scalp  laceration  or  bitten  tongue.   8. Check   old   record,   if   the   record   is   not   available   regarding   the   anticonvulsant  medications,  then  take  drug  history     9. If   the   drug   history   is   not   clear   and   the   patient   is   known   case   of   epilepsy,  draw  blood  for  drug  level.   10. If  the  seizures  are  clearly  related  to  alcohol  withdrawal.  Ascertain  the   reason,   and   giving   Benzodiazepines   should   medically   treat   his   withdrawal.   11. If   the   seizure   is   of   new   onset,   and   present   with   postictal   state,   never   discharge  the  patient  and  make  necessary  arrangement  for  the  EEG  or   CT  scan  brain  either  by  admission  or  OPD  appointment  and  draw  blood   for  Serum  electrolytes,  glucose  and  calcium,  magnesium  and  albumin,   12. If   the   patient   is   being   discharged   from   emergency   department,   prescribe  tab  Tegretal  200mg  TDS  until  the  date  of  appointment  in  OPD  WHAT  NOT  TO  DO:   • Do  not  stick  anything  in  the  mouth  of  seizing  patient.  The  ubiquitous   padded  throat  sticks  may  be  nice  for  a  patient  to  hold  and  bite  on  the     70  
    • first   sign   of   a   seizure,   but   do   nothing   to   protect   his   airway   and   is   ineffective  when  the  jaw  is  clenched.   • Do  not  rush  to  give  intravenous  diazepam  to  a  seizing  patient.  Most   seizures  stop  in  a  few  minutes,  it  is  diagnostically  useful  to  see  how   the  seizure  resolves  on  its  own,  the  patient  will  awake  soon,  if  he  has   not   been   medicated   and   don’t   give   diazepam   in   postictal,   reserve   for   genuine  status  epileptics.   • Do   not   treat   alcohol   withdrawal   seizures   with   Phenobarbital   or   Phenytoin.  Both  lack  efficacy.   • Do   not   rule   out   Alcohol   withdrawal   symptoms   on   the   basis   of   a   toxic   serum  ethanol  level   • Don’t   confuse   seizure   with   pseudo   seizures   and   give   pinching   or   irritating  solutions    or  the  patient  comes  in  postictal  state.   • Do   not   release   a   patient   with   persistent   neurological   abnormalities   with  out  a  CT  Brain  or  specially  consultation.   • Do  not  let  seizure  victim  drive  at  home.    SEROUS  OTITIS  MEDIA  Following   an   upper   respiratory   tract   infection   or   an   airplane   flight,   an   adult   may  complain   of   feeling   of   fullness   in   the   ears,   inability   to   equalize   middle   ear  pressure  decreased  hearing  and  clicking,  popping  or  crackling  sounds  especially     71  
    • when  the  head  is  moved.  There  is  a  little  pain  or  tenderness.  Through  Otoscope,  tympanic   membrane   appears   retracted   with   dull   to   normal   light   reflex   and   air  fluid   level   or   bubbles   could   be   seen   through   ear   drum,   hearing   would   be  decreased  and  Rinne  test  will  show  decreased  air  conduction.  WHAT  TO  DO:   1. Tell  the  patient  to  lay  down  supine  with  head  tilted  back  and  towards   the   effective   side   and   then   instill   vasoconstrictive   nose   drops   like   Phenylephirine   or   Oxymetazoline   0.05%   wait   two   minutes   for   nasal   mucosa  to  shrink,  reinstill  nose  drops  and  wait  an  additional  2  minutes   for   the   medication   to   seep   down   to   the   posterior   Pharyngeal   wall,   around   the   opening   of   the   Eustachian   tube,   Advise   the   patient   to   repeat  the  same  after  every  4  hours  for  3  days.   2. After   each   treatment   with   nose   drops,   instruct   the   patient   to   insufflate   his  middle  ear  via  his  Eustachian  tube  by  closing  his  mouth,  pinching   his  nose  shut  and  blowing  until  his  ear  “POP”   3. Unless   contraindicated   by   hypertension   or   other   medical   conditions   add  a  systemic  vasoconstrictor  (Pseudoephedrine60mg  qid).   4. Ask  the  patient  to  follow  up  in  ENT  clinic  if  there  is  no  improvement.  WHAT  NOT  TO  DO:   • Do   not   allow   the   patient   to   become   habitual   of   vasoconstrictor   drops.     72  
    • • Do   not   prescribe   anti   histamines   (which   dry   out   secretion)   unless   clearly  indicated  by  an  allergy.    SHINGLES  (HERPES  ZOSTER)  Patient   complains   of   pain,   paresthesia   or   an   itch   that   covers   a   specific  dermatome   and   then   develops   into   a   characteristics   rash.   Prior   to   the   onset   of  rash,   Zoster   can   be   confused   with   pleuritic   or   cardiac   pain,   cholecystitis   or  urethral   colic.   After   3-­‐5   days   from   the   onset   of   symptoms   an   eruption   of  erythmatous   macules   and   papules   will   appear,   first   posteriorly   then   spreading  anteriorly   along   the   course   of   the   involved   nerve   segment.   In   most   instances  grouped   vesicles   will   appear   with   in   next   24   hours.   Herpes   zoster   most   often  occurs  in  the  thoracic  and  cervical  segment.  WHAT  TO  DO:   1. Prescribe  Acyclovir  (Zovirax)  800  mg  five  times  a  day.  Skip  a  dose  at  night   or  Famiclovir  500mg  TDS  x  7d.   2. Prescribe   analgesics   appropriate   for   the   level   of   pain   the   patient   is   experiencing,  antinflamtory  may  help  but  narcotics  are  required.   3. Dressing  the  lesions  with  gauze  and  splinting  them  with  elastic  wrap  may   also  help  bring  relief.   4. Secondary   infection   should   be   treated   with   Povidine   iodine   (Betadine)   ointment  or  systemic  antibiotics.     73  
    • 5. An  ophthalmologist  should  evaluate  ocular  lesions.  WHAT  NOT  TO  DO:   • Don’t  prescribe  systemic  steroids  to  prevent  post  herpetic  neuralgia,   especially  for  patient  at  risk  i.e.  with  latent  tuberculosis,  peptic  ulcer,   diabetes  mellitus,  hypertension  and  congestive  heart  failure.    SHOULDER  DISLOCATION  Patient  was  holding  his  shoulder  abducted  horizontally  to  the  side  when  a  blow  knocked  the  humeral  head  anteriorly  .he  arrives  holding  the  shoulder  abducted  ten   degree   from   his   side,   unable   to   move   it   without   increasing   the   pain,   the  deltopectoral  groove  is  now  a  bulge  and  acromian  is  prominent  laterally  with  a  depression  below.  WHAT  TO  DO:   1. Provide  analgesia,  and  intravenous  narcotics  are  preferable.   2. A   qualified   Physician   can   give   conscious   sedation   that   may   be   mild   to   moderate.   3. Intra-­‐articular  Lidocain  2cm  inferiorly  and  directly  lateral  to  the  acromian   in  the  lateral  sulcus  left  by  the  absent  humeral  head   4. Take  pre-­‐reduction  x-­‐rays  to  rule  out  fracture  or  unreduceable  injuries.     74  
    • 5. Test  and  record  the  sensations  over  the  deltoid  to  establish  if  there  is  an   injury   of   the   axillary   nerve   and   confirm   the   circulation,   sensation   and   movement  in  the  elbow,  wrist  and  hand.   6. Gain   the   confidence   by   holding   his   arm   securely,   asking   him   to   relax   telling  that  you  will  not  do  anything  suddenly  and  that  if  any  pain  occurs   you  stop.  Then  in  very  calm  and  gentle  manner  ask  him  to  let  his  muscle   go  loose  so  his  shoulder  can  stretch  out.   7. With   the   elbow   flexed   at   90   degrees,   apply   steady   traction   at   the   dorsal   humerus,   pull   inferiorly   by   applying   sheet   under   the   arm   pit   and   one   stabilizes   the   shoulder   and   other   holds   the   sheet.   If   the   patient   complains   of  pain,  stop  rotation  and  increase  the  dose  of  analgesia.   8. If   you   do   not   feel   or   see   the   reduction   of   shoulder   joint,   then,   while   maintaining   traction   and   external   rotation,   slowly   and   gently   adduct   the   humerus  until  it  is  against  the  chest  wall  and  softly  rotate  internally  the   forearm  against  the  anterior  chest.   9. An   alternative   technique   when   you   can   palpate   the   lateral   border   of   the   scapula  is  reduced  by  scapular  manipulation.  With  the  patient  sitting  up,   place  the  uninjured  shoulder  firmly  against  an  immoveable  support  such   as   wall   or   the   raised   head   of   the   stretcher.   Have   an   assistant   face   the   patient   and   gently   lift   the   outstretched   wrist   of   the   affected   arm   until   it   is   horizontal.   Assistant   then   gently   put   firmly   pulls   the   patient   ‘s   arm   towards   him   .At   the   same   time   manipulate   the   scapula   by   adducting   the     75  
    • inferior   tip   using   thumb   pressure,   while   stabilizing   the   superior   aspect   with  your  upper  hand.   10. When  the  patient  is  comfortable  and  range  of  motion  has  restored,  secure   the  reduction  in  a  sling  and  swath  around  the  arm  and  chest.  Obtain  post   reduction   X-­‐Rays   and   discharge   the   patient   once   he   is   alert   with   a   prescription  of  analgesics  as  needed  and  an  appointment  for  Orthopedic   follow  up  in  a  week  or  sooner.  WHAT  NOT  TO  DO:   • Don’t  use  forearm  as  a  lever  to  fracture  the  neck  of  the  humerus.     • Don’t   redislocate   the   shoulder   by   repeating   the   motions   of   the   mechanism  of  injury    SHOULDER  SEPARATION(  Acromio  –  Clavicular  Joint)  The  patient  fell  on  the  point  of  the  shoulder.  He  my  come  in  right  away  because  it  hurts   even   with   out   movement,   or   he   may   come   in   days   later   with   out   pain,  having  noted  the  injured  shoulder  hangs  lower  or  the  clavicle  rides  higher  WHAT  TO  DO:   1. Examine   the   shoulder;   the   diagnosis   is   supported   by   tenderness   at   the   lateral  end  of  the  clavicle  where  it  joins  the  acromian  process  coming  up   from  the  scapula  and  by  pain  on  pulling  the  humerus  down  towards  the   feet,   distracting   the   acromioclavicular   joint.   Strength   may   be   decreased     76  
    • because   of   pain,   but   other   bones,   joints;   range   of   motion,   sensation   and   circulation  should  be  documented  as  intact.   2. X-­‐Rays   of   the   shoulder   to   be   sure   that   there   is   no   associated   fracture   of   the  lateral  clavicle  or  fracture  or  dislocation  of  the  humerus.   3. Support  the  injured  joint  with  a  sling.   4. Provide  additional  analgesia.  Ibuprofen  or  Naproxen  500mg.   5. Arrange  for  re-­‐evaluation  by  an  orthopedic  surgeon  and  physical  therapy   to  begin  shoulder  range  of  motion  exercise  with  in  a  week.  WHAT  NOT  TO  DO:   • Don’t   bother   with   weight   –bearing   x-­‐rays   view   to   differentiate   first,   second   and   third   degree   separations   based   on   the   widening   of   the   distance   between   the   clavicle   and   scapula.   These   are   painful   and   do   not   change  the  initial  treatment.   • Don’t   allow   the   patient   to   wear   a   sling   and   immobilize   the   shoulder   for   more   than   a   week   with   out   at   least   beginning   pendulum   exercise   .The   shoulder  capsule  will  contract  and  restrict  the  range  of  motion.    SINUSITIS:  Follow   a   viral   infection,   the   patient   will   usually   complain   of   a   dull   pain   in   the  face,  gradually  increasing  over  a  couple  of  days,  exacerbated  by  sudden  motion     77  
    • of   the   head,   or   holding   the   head   dependent,   between   the   knees   and   perhaps  radiating  to  the  upper  molar  teeth  or  with  eye  movement.  WHAT  TO  DO:   1. Rule   out   other   causes   of   facial   pain   or   headache   through   taking   proper   history   taking   and   physical   examination   (palpate   scalp   muscles,   temporal   arteries  tempromandibular  joint,  eyes  and  teeth).   2. Shrink   swollen   nasal   mucosa   with   1%   Phenylephirine   or   0.05%oxymetazolin   nose   drops.   Drip   2   drops   in   each   nostril,   have   the   patient  lie  supine  2  minutes  and  then  repeat  the  process.   3. Examine   the   nose   for   purulent   drainage   before   and   after   shrinking   the   nasal  mucosa  with  topical  vasoconstrictor.   4. Add  a  systemic  sympathomimetic  decongestant  (Sudafed)  60mg  6  hourly   or  Phenylepropanolamine  75mg  OD.   5. If   there   is   fever,   pus,   heat   or   any   other   sign   of   bacterial   super   infection,   add  antibiotics  (Erythromycin+Septrin  or  sefuroxime)   6. Provide   pain   relief,   when   necessary   (Ibuprofen,   Naproxen,   Acetaminophen)   7. Recommend   symptomatic   relief   with   hot   water   vapour   inhalation   using   a   simple  teakettle  or  hot  shower  or  if  available,  steam  vaporizer.   8. Sinusitis   can   sometimes   be   demonstrated   on   x-­‐rays   and   can   usually   get   adequate  visualization  of  maxillary,  frontal  and  ethmoid  sinuses.  With  one     78  
    • upright   Water’s   view.   Chronic   sinusitis   appears   as   thickened   mucosa:   acute  as  an  emergency  basis.   9. If   symptoms   and   physical   findings   of   sinusitis   are   classic.   Plain   sinus   radiographs  need  to  be  obtained  before  treatment.   10. Arrange  for  follow  up  with  in  1-­‐7  days  in  ENT  OPD.  WHAT  NOT  TO  DO:   • Don’t  ignore  signs  of  an  orbital  cellulitis  with  swelling  erthyma,  decreased   extra   ocular   movements   and   possible   proptosis.   These   patients   require   consultation  and  admission  for  intravascular  antibiotics.   • Don’t   ignore   the   toxic   patient   with   marked   swelling.   High   fever,   severe   pain,   profuse   drainage,   or   other   signs   and   symptoms   of   a   serious   infection.   • Don’t   prescribe   antihistamines,   which   can   make   mucous   secretions   dry   and  thick  and  interfere  with  necessary  drainage.  Antihistamines  only  cure   sinusitis  when  it  is  due  to  allergic  rhinitis.   • Don’t   allow   patient   to   use   decongestant   nose   drops   more   than   3   days,   thereby   allowing   their   nasal   mucosa   to   become   habituated   to   sympathomimetic.   When   they   will   stop   the   drops   they   will   suffer   a   rebound   nasal   congestion   that   requires   time,   topical   steroids   and   re-­‐ education  to  resolve.     79  
    • • Don’t   prescribe   topical   or   systemic   sympathomimetic   decongestant   to   a   patient  who  suffers  from  hypertension,  tachycardia  or  difficulty  initiating   urination.  SORE  THROAT          (PHARYANGITIS)  The  patient  with  a  bacterial  phyarngitis  complains  of  a  rapid  onset  of  throat  pain  worsened   by   swallowing.   There   is   usually   a   fever,   pharyngeal   erthyma   and   a  purulent,   patchy,   yellow,   gray   or   white   exudate,   tender   cervical   adenopathy,  headache   and   absence   of   cough.   Conjunctivitis,   nasal   congestion,   hoarseness,  coughs;   aphthous   ulcers   on   the   soft   palate   and   myalgias   typically   accompany  viral   infections.   It   is   helpful   to   differentiate   pain   on   swallowing   from   difficulty  swallowing,   the   later   being   more   likely   caused   by   obstruction   or   abnormal  muscular  movement.  WHAT  TO  DO:   1. First  examine  the  ears,  nose  and  mouth  that  are  after  all,  connected  to  the   pharynx  and  often  contain  clues  to  the  diagnosis.   2. Depress  the  tongue  with  a  blade,  have  the  patient  raise  his  soft  palate  by   saying  “AH”,  Inspect  the  posterior  pharynx,  and  swab  both  tonsiller  pillars   for   a   culture   (depends   upon   the   clinical   decision   and   ENT   verbal   consultation,  provided  that  rapid  strep  test  is  available).   3. If   the   patient   is   visiting   ER   when   there   is   epidemic   of   group   A   streptococcal  phyarngitis:  and  the  patient  is  in  between  3  to  25  years  old   has  history  of  rheumatic  fever  and  recurrent  “strep  throat”  and  has  been   exposed  and  if  the  patient  has  a  red  throat  fever,  tender  anterior  cervical     80  
    • nodes   and   no   viral   URI   symptoms   give   antibiotics   .The   recommended   treatment  is  oral  penicillin  VK250mg  8  hourly  for  10  days.  Inj  penicillin  is   preferred  for  patients  unlikely  to  finish  ten  days  of  pills  and  those  with  a   personal  or  family  history  of  rheumatic  fever.   4. Patients   under   60,   or   30   kg   weight   get   an   intramuscular   injection   of   benzathine  penicillin  G6000000  units  and  those  over  30  kg  get  1200000u   i/m.   5. Those   who   are   allergic   to   penicillin   give   Erythromycin   250   mg   tid;   Amoxicillin  has  no  role  in-­‐group  A  strep.   6. For   resistant   or   recurrent   infections   with   possible   beta-­‐lactamse   – producing   co   pathogens,   consider   instead   10   days   of   cephalaxin,   cefadroxil,  cefaclor  or  cefuroxime.   7. If  you  suspect  mononucleosis,  draw  blood  for  atypical  lymphocytes  and  a   hetrophile  or  monospot  to  confirm  the  diagnosis.   8. Relieve  pain  with  acetaminophen  ibuprofen,  aspirin,  warm  saline  gargles   or   gargles   or   lozenges   containing   phenol   as   a   mucosal   anesthetic.   Viscous   Xylocain   gargles   anesthetize   the   throat   but   patient   may   still   have   difficulty   swallowing   because   of   lack   of   sensation.   For   severe   pain   in-­‐ patient   with   out   contraindication,   Dexamethasone   10mg   i/m   once   has   been  used  along  with  antibiotics.         81  
    • WHAT  NOT  TO  DO:   • Don’t  miss  an  acute  epiglottitis.  In.  In.  In  a  child,  this  presents  as  a  sudden,   severe   phyarngitis,   with   gluteal,   rather   than   hoarse   voice,   drooling   and   respiratory   distress.   Adults   usually   have   a   more   gradual   onset   over   several   days   and   are   not   a   prone   to   a   sudden   airway   occlusion,   unless   they   present   later   in   the   progression   of   the   swelling,   already   with   some   respiratory  distress.   • Don’t  give  Ampicillin  to  a  patient  with  mononucleosis,  the  resulting  rash   helps  make  the  diagnosis  and  does  not  imply  ampicillin  allergy,  but  can  be   uncomfortable.   • Don’t   miss   abscesses   that   usually   require   hospitalization   and   intravenous   penicillin,   if   not   drained.   Peri   tonsiller   abscesses   or   cellulitis   make   the   tonsiller  pillar  bulge  towards  the  midline.  Retropharyngeal  abscesses  may   require  soft  tissue  lateral  neck  film  to  visualize.   • Do   not   miss   gonocccal   phyarngitis   that   can   produce   a   mild   clinical   syndrome  and  require  special  culture  (if  the  patient  is  admitted).   • Don’t   miss   the   rare   but   deadly   causes   of   sore   throat,   a   patient   with   paresthesia   at   the   site   of   an   old,   healed   bite   and   painful   spasm   when   he   even   thinks   of   swallowing   may   have   rabies.   A   patient   with   facial   palsy   ,   myocarditis   and   a   tough   ,   white   ,   membrane   adherent   to   the   posterior   pharynx   may   have   diphtheria   ,   you   can   not   diagnose   them   unless   you   think  of  them.       82  
    • SPLIT  EAR  LOBES    A  patient  will  present  with  an  earlobe  split  by  a  sudden  pull  on  earrings  WHAT  TO  DO:   • Excise   the   skin   edges   on   both   sides   of   the   wound,   leaving   the   apical   epithelium   intact.   Suture   these   freshened   wound   edges   together   using   a   fine  monofilament  material.   • If   the   patient   wants   to   maintain   a   pierced   ear   lobe,   tie   a   loop   of   sterile   suture  material  through  the  hole  to  maintain  a  tract  while  the  rest  of  the   lobe  heals,   • Provide  tetanus  prophylaxis  if  needed.  WHAT  NOT  TO  DO:   • Don’t  suture  the  wound  primarily.  The  edges  may  epitheliaze,  resulting  in   the  split  redeveloping  after  the  suture  are  removed    STREAKHOUSE   SYNDROME   (Esophageal   Food   Bolus  Obstruction)  The  patient  develops  symptoms  immediately  after  swallowing  a  large  mouthful,  usually  of  inadequately  chewed  meat.  Resulting  of  intoxication,  wearing  dentures  .The   patient   often   develops   substernal   chest   pain   that   mimic   the   pain   of  myocardial   infarction.   Discomfort   increases   the   swallowing,   is   followed   by     83  
    • retained   salivary   secretions   that   unlike   infarction   leads   to   drooling.   At   times  these  secretions  will  cause  coughing,  gagging  or  choking.  WHAT  TO  DO:   1. Take  complete  history  and  do  physical  examination.   2. Take  PA  and  lateral  x-­‐rays  view.   3. Insert   a   small   NG   tube   to   the   point   of   obstruction   and   attach   it   to   low   intermittent  suction.   4. If   there   is   question   of   esophageal   obstruction,   with   the   help   of   invasive   radiologist,  give  5  ml  of  dilute  barium  orally  and  x-­‐rays  the  chest  to  locate   the  foreign  body.   5.  When   the   history   and   physical   findings   are   classic   for   meat   impaction,   there  is  no  need  to  perform  barium  swallow.   6. Give   1   unit   of   glucagon   i/v   to   decrease   lower   esophageal   sphincter   pressure  (infuse  slowly).  This  will  allow  passage  of  food.   7. If   6   hours   are   passed   of   meat   impaction   then   after   glucagon   is   to   have   patient   sit   up   and   drink   100   ml   of   a   carbonated   beverage   or   EZ   Gas   (sodium   bicarbonate,   citric   acid,   simithicone)   followed   by   240   ml   of   water.   8. If   the   food   does   not   pass   spontaneously,   and   there   is   no   access   to   gastroenterologist   with   an   endoscope,   prepare   the   patient   for   manual   extraction.   Start   an   i/v   line   for   drug   administration   and   anesthetize   the   pharynx  with  Cetacaine  spray  or  viscous  lidocain  2%.  Place  the  patient  on     84  
    • his  side  and  slowly  administer  diazepam  intravenously  until  the  patient  is   drowsy   (moderate   conscious   sedation).   Take   gastric   EDWALD   Lavage   tube,  cut  off  the  end  until  there  are  no  side  ports  and  round  off  the  new   tip   with   scissors.   Push   the   Ewald   lavage   tube   through   the   patient’s   mouth   until  the  obstruction  is  reached.  Take  a  large  aspiration  syringe,  have  an   assistant   apply   suction   to   the   free   end   of   the   Ewald   tube   and   slowly   withdraw  it.  If  suction  is  maintained,  the  bolus  will  come  up  with  tubing.   9. If   the   patient   is   unable   to   tolerate   this   procedure   or   you   are   unsuccessful,   need  to  admit  in  the  hospital.  WHAT  NOT  TO  DO:   • Don’t   ignore   a   patient   ‘s   claims   of   foreign   body   stuck   in   the   esophagus,   they  are  usually  right.   • Do  not  try  to  force  the  food  bolus  down  with  the  Ewald  tube  or  an  other   catheter  or  dilator.  This  may  cause  an  esophageal  tear  or  perforation.   • Don’t   use   oral   enzymes   such   as   papain,   trypsin   or   chymotrypsin,   this   treatment   is   slow,   ineffective   and   may   carry   a   risk   of   enzyme   –induced   esophageal  perforation.   • Do   not   attempt   to   remove   a   hard,   sharp,   esophageal   foreign   body   using   any  of  the  above  techniques.   • Don’t  give  glucagon  to  patients  with  pheochromocytoma  or  insulinoma.   • Do  not  use  barium  –impregnated  cotton  balls  to  detect  esophageal  FB’       85  
    • SUBCONJUCTIVAL  HEMORRHAGE  This   condition   may   be   spontaneous   or   follow   a   minor   trauma,   coughing   episode,  vomiting,  or  drinking  binge.  There  is  no  pain  or  visual  loss,  but  the  patient  may  be  frightened  by  appearance  of  his  eye.  Often  it  is  friend  or  family  member  that  insists  the  patient  should  be  seen  in  the  ED.    This  hemorrhage  usually  appears  a  bright  red  area  covering  part  of  the  sclera.  WHAT  TO  DO:   1. Look   for   associated   trauma,   or   other   signs   of   a   potential   bleeding   disorder.   2. Perform  a  complete  eye  exam.   3. Reassure   the   patient   that   there   is   no   serious   eye   damage:   explain   that   the   blood  may  continue  to  spread,  but  all  the  redness  should  resolve  in  two  to   three  weeks.  WHAT  NOT  TO  DO:   • Don’t  forgot  to  tell  the  patient  that  the  redness  may  spread  over  the  next   two  days.   • Don’t  ignore  any  significant  finding  discovered  on  the  complete  eye  exam.           86  
    • SUBCUTANEOUS  FOREIGN  BODY  Small,   moderate   –velocity   metal   fragments   can   be   released   when   a   hammer  strikes   a   second   piece   of   metal,   such   as   a   chisel.   Patient   has   stinging   sensation  and  is  worried  that  there  is  something  inside.  WHAT  TO  DO:   1. Be   suspicious   of   a   retained   body   in   all   wounds   produced   by   a   high   velocity   missile   or   sharp   fragile   object.   The   most   common   error   in   the   management   of   soft   tissue   foreign   bodies   is   failure   to   detect   their   presence.     2. X-­‐rays  the  wound.   3. Remove  the  foreign  body  if  it  is  easy  to  remove.   4. If   the   foreign   body   is   in   extremity   then   it   is   possible,   preferable   to   establish  a  bloodless  field.   5. Anesthetize   the   area   with   a   small   infiltration   of   1%   Xylocain   with   epinephrine.   6. Take  a  blunt  stiff  metal  probe  (not  a  needle)  and  gently  slide  it  down  the   apparent   track   of   the   puncture   wound.   Move   the   probe   back   and   forth   ,   fanning  it  in  all  direction  ,until  a  clicking  contact  between  the  probe  and   foreign  body  can  be  felt  and  heard  .     87  
    • 7. After  contact  is  made,  fix  the  probe  in  place  by  resting  the  hand,  cut  down   along  the  probe  with  #15  scalpel  blade  until  you  reach  the  foreign  body.   Do  not  remove  the  probe.   8. Reach   into   the   incision   with   a   pair   of   forceps   and   remove   the   foreign   body.   9. Close  the  wound  with  suture.   10. If   the   track   is   relatively   long   and   foreign   body   is   very   superficial   and   easily  and  easily  palpable  beneath  the  skin,  then  it  may  be  advantageous   to  eliminate  the  probe  and  just  cut  down  directly  over  the  foreign  body.   11. Provide  Tetanus  prophylaxis.   12. Warn  the  patient  about  signs  of  developing  infection.   13. If  you  are  unable  to  locate  foreign  body  in  15-­‐30  minutes,  refer  the  case  to   on  call  surgical  team.   14. Schedule  a  wound  check  with  in  48  hours  in  ED.  WHAT  NOT  TO  DO:   • Don’t   cut   down   on   the   metal   probe   if   there   is   any   possibility   of   cutting   across  a  neurovascular  bundle,  tendon  or  other  important  structure.   • Don’t  attempt  to  cut  down  to  the  foreign  body,  unless  it  is  very  superficial   with  out  a  probe  in  place  and  in  contact  with  the  foreign  body       88  
    • SUBUNGEAL  ECCHYMOSIS  The   patient   will   have   had   a   crushing   injury   over   the   fingernail:   getting   caught  between  two  heavy  objects  for  example  or  striking  it  with  hammer.  The  pain  is  initially  intense  but  rapidly  subsides  over  the  first  half  hour,  and  by  the  time  he  is  examined   only   mild   pain   and   sensitivity   may   remain.   There   is   light   brown   or  light  blue  –brown  discoloration  beneath  the  nail.  WHAT  TO  DO:   1. Get  an  x-­‐rays  to  rule  out  a  possible  fracture  of  the  distal  phalangeal  tuft.   2. Apply  a  protective  fingerprint  splint,  if  necessary  for  comfort.   3. Explain  that  you  are  drilling  a  hole  in  the  patient’s  nail,  because  there  is   not   a   subungual   hematoma   to   evacuate.   Inform   the   patient   that,   in   time,   he  may  lose  the  fingernail,  but  that  a  new  nail  will  replace  it.  WHAT  NOT  TO  DO:   • Don’t  perform  a  trephination  of  the  nail    SUBUNGEAL  HEMATOMA.  After   a   blow   or   crushing   injury   to   a   the   finger   nail   ,   the   patient   experiences  severe   and   sometimes   excruciating   pain   that   persists   for   hours   and   may   even   be  associated   with   a   vasovagal   response   .   The   finger   nail   has   an   underlying   deep  blue   –black   discoloration   that   may   be   localized   to   the   proximal   portion   of   the  nail  or  external  beneath  its  entire  surface.     89  
    • WHAT  TO  DO:   1. X-­‐Rays   of   the   finger   to   rule   out   an   underlying   fracture   of   the   distal   phalanx  and  test  for  a  possible  avulsion  of  the  extensor  tendon.   2. Paint  the  nail  with  Povidine  (Betadine)  solution.   3. Adhere  to  universal  blood  and  bodily  –fluid  precautions.   4. Perform   trephination   at   the   base   of   the   nail,   using   the   free   end   of   a   hot   paper   clip,   electric   cauterization   lance   or   drill.   When   performed   quickly,   patient   does   not   feel   the   heat,   just   relief   from   pain.   Tap   rapidly   with   cautery  or  drill  a  few  times  in  the  same  spot  at  the  base  of  hematoma  until   the  resistance  is  finished.   5. Pressing  with  4x4  gauze  can  control  persistent  bleeding  from  this  spot.   6. Apply   an   antibacterial   ointment   such   as   a   Betadine   and   cover   the   trephination  with  a  bandage.   7. To   prevent   infection,   instruct   the   patient   to   keep   his   finger   dry   for   2   days   and  not  to  soak.   8. Inform  the  patient  that  he  will  eventually  lose  hid  fingernail,  until  a  new   nail  grows  out  after  two  to  six  months.  WHAT  NOT  TO  DO:   • Don’t  perform  a  trephination  on  a  subungual  ecchymosis.   • Don’t  apply  digital  block.   • Don’t  remove  nail  even  with  a  large  subungual  hematoma.     90  
    • SUNBURN  Patient  generally  seeks  help  only  if  there  is  severe  sunburn.  There  will  be  history  of  extensive  exposure  to  sunlight  or  to  artificial  source  of  ultraviolet  radiations;  Sunburn   also   results   from   too   much   sun   or   sun-­‐equivalent   exposure.   Almost  everyone  has  been  sunburned  or  will  become  sunburned  at  some  time.  Anyone  who  visits  a  beach,  goes  fishing,  works  in  the  yard,  or  simply  is  out  in  the  sun  can  get  sunburned.  Improper  tanning  bed  use  is  also  a  source  of  sunburn.  Although  seldom   fatal.   Chills   Fever   Nausea   or   vomiting,   or   both   Flulike   symptoms.  Blistering  may  range  from  a  very  fine  blister  that  is  only  found  when  you  begin  to  "peel"  to  very  large  water-­‐filled  blisters  with  red,  tender,  raw  skin  underneath.    WHAT  TO  DO:   1. Inquire  as  to  whether  or  not  the  patient  is  using  a  photosensitizing  drugs   (tetracycline,   thiazide,   sulphonamide,   phenothiazine   s)   and   have   the   patient  discontinue  its  use.   2. Have   the   patient   apply   cool   compresses   of   water,   as   often   as   desired   to   relieve  pain,  this  is  the  most  comfortable  therapy.   3. Applying   topical   steroids   sprays   such   as   Dexamethasone   may   help   the   patient.   4. With   a   more   sever   burn;   prescribe   a   short   course   of   systemic   steroids   (40-­‐60   mg   Prednisolone).   This   will   reduce   the   inflammation,   swelling.   Pain  and  itching.       91  
    • WHAT  NOT  TO  DO:   • Don’t  allow  the  patient  to  use  OTC  Sunburn  medications  that  contain  local   anesthetic   (benzocain,   dibucaine   or   lidocain).   They   are   usually   ineffective   or   only   provide   very   transient   relief.   In   addition   there   is   the   potential   hazard  of  sensitizing  the  patient  to  these  ingredients.   • Don’t  trouble  the  patient  with  unnecessary  burn  dressings.  These  wounds   have  low  probability  to  be  infected.  Treatment  is  directed  at  making  the   patient  comfortable  as  much  as  possible.    SWALLOWED  FOREIGN  BODY.  Parents   bring   in   young   child   shortly   after   he/she   she   has   swallowed   a   coin,  safety   pain   ,   toy,   etc.   The   child   may   be   asymptomatic   or   have   recurrent   or  transient   symptoms   of   vomiting,   drooling,   dyspahgia,   pain   or   foreign   body  sensations.  WHAT  TO  DO:   1. Ask   about   symptoms   and   examine   the   patient,   looking   for   signs   of   airway   obstruction  (coughing,  wheezing)  or  bowel  obstruction  r  perforation.   2. Obtain   two   plain   x-­‐rays   views   of   throat   to   at   least   the   mid   abdomen   to   determine  the  FB.   3. A  foreign  body  with  sharp  edges  or  blunt  FB  lodged  in  the  esophagus  for   more  than  one  day  must  be  called  upon  to  Gastroentrogist  for  endoscopy,     92  
    • 4. When   a   coin   or   smooth   object   is   obstructed   in   the   upper   esophagus   for   less   than   24   hours,   it   can   be   usually   removed   using   simple   Foley’s   catheter  technique.  Inflate  the  balloon  behind  the  coin  and  slowly  take  out   until  it  reaches  the  base  of  the  tongue  and  encourage  the  patient  to  cough.     5. When  a  FB  has  passed  into  the  stomach  and  there  are  no  symptoms  the   patient  is  discharged  with  instruction  to  return  for  reevaluation  in  seven   days.  WHAT  NOT  T  DO:   • Don’t  push  the  Foley’s  catheter  if  you  are  not  experienced  or  fluoroscope   is  not  available.  TAILBONE  FRACTURE  (Coccyx  Fracture)  The   patient   fell   on   his   tailbone   and   now   complains   of   pain   that   is   worse   with  sitting   and   perhaps   with   defecation,   there   should   be   little   or   no   pain   with  standing   but   walking   may   be   uncomfortable.   On   Physical   examination,   there   is  point  tenderness  and  perhaps  deformity  of  the  coccyx  that  is  best  palpated  by  a  finger  in  the  rectum.  WHAT  TO  DO:   1. Verify   the   history   and   examine   thoroughly,   including   the   lumber   spine,   pelvis   and   the   legs.   Palpate   the   coccyx   from   inside   and   out   feeling   primarily  for  point  tenderness  and  /or  pain  on  motion.   2. X-­‐rays  are  optional.     93  
    • 3. Instruct   the   patient   how   to   sit   forward,   resting   his   weight   upon   ischeal   tuberosity  and  thighs,  instead  of  coccyx.   4. If  necessary  prescribe  anti  inflammatory  drugs  or  stool  softener.   5. Inform   the   patient   that   the   pain   will   gradually   improve   over   a   week   as   bony   callus   forms   and   motion   decreases   and   arrange   for   follow   up   as   needed.  TEAR  GAS  EXPOSURE  (Lacrimtor)  The  patient  may  have  been  in  a  riot  dispersed  by  the  police  or  accidently  sprayed  by   his   own   can   of   Mace,   He   complains   of   burring   of   the   eyes   nose,   mouth   and  skin:  tearing  and  inability  to  open  eyes  because  of  the  severe  stinging:  sneezing,  coughing,  a  runny  nose  and  perhaps  a  metallic  taste  with  a  burning  sensation  of  the   tongue,   nausea   vomiting   and   abdominal   pains.   These   signs   and   symptoms  last   for   15-­‐30   minutes   after   exposure.   Redness   and   edema   may   be   noted   from  one  to  two  days  following  exposure  to  these  agents.  WHAT  TO  DO:   1. Segregate   victims   lest   they   contaminate   others.   Medical   personnel   should   wears   gown,   gloves   and   masks   and   help   victims   remove   contaminated   clothes  and  shower  with  soap  and  water  to  remove  tear  gas  from  the  skin   2. Exposed  eyes  should  be  irrigated  with  copious  amount  of  tepid  water  for   at   least   fifteen   minutes.   If   eye   pain   lasts   longer   than   15-­‐20   minutes.   Examine  with  Fluorescein  for  corneal  erosions.     94  
    • 3. Look   for   signs   of   and   warn   patient   about   allergic   reaction   to   tear   gas   including  bronchospasm  and  contact  dermatitis.   4. Don’t   rush   to   help   or   allow   others   to   rush   in   heedlessly   and   themselves   become  incapacitated.    TENSION  HEADACHE  Patient   complains   of   dull   steady   pain   described   as   an   ache,   pressure,   throb,   or  constricting   band,   located   anywhere   from   eye   to   occipit   perhaps   including   the  neck   or   shoulders.   Most   commonly,   the   headache   develops   near   the   end   of   the  day  or  after  some  particular  stress.    WHAT  TO  DO:   1. Perform   a   complete   physical   exam   (including   environmental   factors   and   food  which  precede  the  headache)  and  physical  examination  (CNS)   2. If   the   patient   complains   of   sudden   onset   of   the   “worst   headache   of   my   life”   accompanied   by   any   change   in   mental   status,   weakness,   vomiting,   seizure,   stiff   neck   or   persistent   neurological   abnormalities,   suspect   a   cerebrovascular  cause  especially  SAH.  Refer  the  patient  to  neurologist  or   arrange  urgent  follow  up.   3. If  the  headache  is  accompanied  by  fever  and  stiff  neck  or  change  in  mental   status,  you  need  to  rule  out  bacterial  meningitis  as  soon  as  possible.     95  
    • 4. If  the  headache  is  preceded  by  ophthalmic  or  neurologic  symptoms,  now   resolving,   suggestive   of   a   migraine   headache,   you   may   want   to   try   sumatriptan   or   ergotamine   therapy   .If   a   vasospastic   symptoms   persists   into   the   headache   phase,   the   etiology   mat   still   be   a   migraine,   but   it   becomes  more  important  to  rule  out  other  CNS  causes.   5. If   the   headache   follows   the   prolonged   reading,   driving   or   television/internet   sitting   and   there   is   decreased   visual   acuity,   but   improved  through  pinhole,  the  headache  may  be  due  to  optical      refraction   and  is  curable  by  eyeglass  lenses.   6. If   the   temples   are   tender,   check   for   visual   defects   and   myalgias   that   accompany  temporal  artritis.   7. If   there   is   a   history   of   recent   dental   work   or   grinding   of   teeth,   tenderness   anterior  to  the  tragus  or  crepitus  on  motion  of  jaw,  suspect  arthritis  of  the   tempromandibular  joint.   8. If   there   is   fever,   tenderness   to   percussion   over   the   frontal   or   maxillary   sinus,  purulent  drainage  visible  in  the  nose,  or  facial  pain  exacerbated  by   lowering  the  head,  consider  sinusitis.   9. If  pain  radiates   to   the   ear,   be   sure   to   inspect   and   palpate   the   teeth,   which   are  a  common  site  of  referred  pain.   10. Finally,  after  checking  for  all  these  other  causes  of  headache,  palpate  the   temporalis,   occiptalis   and   other   muscles   of   the   calvarium   and   neck,   looking  for  areas  of  tenderness  and  spasm.     96  
    • 11. Prescribe   NSAID,   recommend   rest,   and   have   the   patient   try   cool   compresses  and  message  of  any  trigger  point.   12. Arrange  for  follow  up,  instruct  the  patients  to  return  the  ED  or  the  contact   his  own  Physician.  WHAT  NOT  TO  DO:   • Don’t   discharge   with   out   follow   up   instructions.   Many   serious   illnesses   begin  with  minor  cephalgia  and  patient  may  postpone  urgent:  care  in  the   belief  that  they  have  been  definitely  diagnosed  on  the  first  visit.   • Don’t  miss  subarachnoid  and  meningitis.    TETANUS  PROPHYLAXIS.  The   patient   may   have   stepped   on   a   nail   or   sustained   any   sort   of   laceration,  abrasion  or  puncture  wound.  WHAT  TO  DO:   1. If  the  patient  has  not  had  tetanus  immunization  in  the  past  5  years,  give   adult  tetanus  and  diphtheria  toxoid  (TD)  0.5  ml  i.m.  Give  Tetanus  toxoid   (DT)  to  children  under  seven  (7)  years  old.   2. If  there  any  doubt  the  patient  has  had  his  original  series  of  three  tetanus   immunizations,   add   tetanus   globulin   250mg   i.m   and   make   arrangement   for   him   to   complete   the   full   series   with   additional   immunization   at   4-­‐6   weeks  and  6-­‐12  months.     97  
    • 3. With   history   of   true   tetanus   immune   globulin.   Instruct   the   patient   that   he   does  not  have  protection  from  Tetanus  from  future  injuries.  WHAT  NOT  TO  DO:   • Don’t   assume   adequate   immunization   .The   groups   most   at   risk   are   immigrants,  elderly  women  and  rural  population   • Don’t  believe  every  story  of  allergy  to  tetanus  toxoid  (that  is  actually  very   rare).  THRUSH  An  infant  will  have  white  patches  in  his  mouth  or  an  older  patient  (usually  with  poor   oral   hygiene   diabetes   a   hematologic   malignancy   or   on   steroid   therapy).  These   white   patches   wipe   off   easily   with   a   swab,   leaving   an   erythmatous   base  that   may   bleed.   There   may   intense   dark   red   inflammation   throughout   the   oral  cavity.  WHAT  TO  DO:   1. If   there   is   any   doubt   about   the   etiology,   confirm   the   diagnosis   by   smearing  the  exudate.   2. For   the   topical   treatment,   prescribe   an   oral   suspension   of   nystatin   200,000  units  for  infants  and  400,000-­‐600,000  u  for  children  and  adults,   gargled   and   swished   in   the   mouth   a   long   as   possible   before   swallowing,   four  times  a  day  for  at  least  two  days  beyond  resolution  of  symptoms.     98  
    • 3. For   adults   Fluconazole   200mg   once,   then   100   mg   qid   for   7   days   may   be   better  regimen.  Sometime  single  oral  dose  is  effective.   4. Look  elsewhere  for  Candida,  esophagitis,  vaginitis  ,  dipper  rash      TINEA  (Athlete’s  Foot,  Ring  worm)  Patient   usually   seek   emergency   care   for   athlete’s   foot   ,or   ringworm   when  pruritis   is   severe   or   when   secondary   infection   causes   pain   and   swelling   .Tinea  Pedis   is   usually   seen   as   interdigital   scaling   ,   maceration   and   fissuring   between  toes.   At   times   tense   vesicular   lesions   will   be   present   instead.   Tinea   cruris   is  usually  a  moist,  mildly  erythmatous  eruption  symmetrically  affecting  both  groin  and   upper   inner   thigh.   Tinea   Corporis   appears   most   often   on   the   hairless   skin   of  children   as   dry   erythmatous   lesions   with   sharp   annular   and   arciform   borders  that  are  scaling  or  vesicular.  WHAT  TO  DO:   1. When   microscopic   examination   of   skin   scrapping   is   readily   available,   definite  identification  of  hypae  or  spores.   2. Clotrimazole,   miconazole,   haloprogin   and   tolnefate   solution   or   cream   applied  to  rash  BID  will  cause  involution  of  most  superficial  lesions  with   in  1-­‐2  weeks.   3. With   signs   of   secondary   infection,   begin   treatment   first   with   wet   compresses   of   Burrow’s   solution,   with   signs   of   deep   infection   (cellulitis,   Lymphangitis)  begin  systemic  antibiotics  in  addition,  like  cefadroxil  1  gm   qid  x5-­‐7  days  or  cephalaxin  250-­‐500mg  tid  x  5-­‐7  days.     99  
    • 4. With  inflammation  and  weeping  lesions,  a  topical  antifungal  and  steroids   cream   such   as   (Vioform-­‐Hydrocortisone)   in   addition   to   the   compresses   will  be  most  effective.  WHAT  NOT  TO  DO:   • Don’t   attempt   to   treat   deep,   painful   infections   of   the   scalp   with   local   therapy.   • Don’t  treat  with  corticosteroids  alone.  They  will  reduce  s  and  symptoms,   but  allow  increased  fungal  growth.    TEMPROMANDIBULAR  JOINT  (TMJ)  The   pain   is   usually   dull   and   unilateral,   centered   in   the   temple,   above   and   behind  the  ear;  the  pain  may  be  associated  with  instability  of  TMJ,  crepitus  or  crackling  with  movement  of  the  Jaw.  WHAT  TO  DO:   1. Examine  the  head  thoroughly  for  other  causes  of  the  pain,  including  visual   acuity,   cranial   nerves   and   palpation   of   the   scalp   muscles   and   temporal   arteries.   2. If   pain   is   severe,   you   may   call   Dental   surgeon,   if   he/she   is   not   available   then  refer  to  pain  management  centre,  In  case  if  you  are  expert  in  giving   block  then  you  can  inject  10  mg  of  Depo-­‐Medrol  anterior  to  the  tragus.     100  
    • 3. Prescribe   anti-­‐inflammatory   analgesics,   a   soft   diet,   heat   and   muscle   relaxants  (Diazepam).   4. Refer   the   patient   for   follow   up   to   a   Dentist   or   ENT   OPD.   Long-­‐term   treatment  includes  Orthodontic  correction.  WHAT  NOT  TO  DO:   • Don’t  rule  out  TMJ  arthritis  simply  because  the  joint  is  not  tender  on  your   examination.   • Don’t  omit  the  TMJ  in  your  workup  of  any  headache.   • Don’t  give  narcotics  unless  there  is  going  to  be  early  following  up.    TOOTH  TRAUMA  (Sublxation  and  Displacement).  After  a  direct  blow  to  the  mouth  the  patient  may  have  a  portion  of  a  tooth  broken  off,   or   a   tooth   may   be   loosened   to   variable   degree.   Ellis   class   1   dental   fracture  involves   only   enemal,   Class   II   fractures   expose   yellow   dentin,   Ellis   class   III  expose  pulp  that  bleeds  and  hurts.  WHAT  TO  DO:   1. Assess  the  patient  for  any  associated  injuries  such  as  facial  or  mandibular.   2. Consider  where  any  tooth  fragments  are  located.   3. For   sensitive   Ellis   II   fracture   of   dentin,   cover   the   exposed   surface   with   calcium  hydroxide  composition  (Dycal),  tooth  varnish.  Provide  analgesics.     101  
    • 4. A  dentist  should  see  Ellis  III  fractures  into  pulp  right  away.   5. Minimally   subluxed   (loosened)   teeth   may   require   no   emergency   treatments.   6. Intruded  primary  teeth  and  permanent  teeth  of  young  patient  can  be  left   alone  and  allowed  to  re-­‐erupt    WHAT  NOT  DO:   • Don’t   miss   associated   injuries   of   alveolar   ridge,   mandible,   facial   bone   or   neck.  UPPER  RESPIRATORY  TRACT  INFECTION.  Occlusion   of   the   Ostia   of   paranasal   sinuses   buildup   of   permits   mucous   and  pressure,  leading  to  pain  and  predisposing  bacterial  super  infection.  WHAT  TO  DO:   1. Perform  complete  history  and  physical  examination  to  document  which  of   the   above   signs   and   symptoms   are   present:   to   rule   out   some   other,   underlying   ailment:   and   to   find   any   sign   of   bacterial   super   infection   of   ears.   Sinuses,   pharynx   tonsils   epiglottis,   bronchi   or   lungs   that   might   require  antibiotics  or  other  therapy.   2. Explain   the   course   of   the   viral   illness   and   the   inadvisability   of   indiscriminate   antibiotics.   Tailor   drug   treatment   to   the   patient’s   specific   complaint  as  follows.     102  
    • o For   fever,   headache   and   myalgias   prescribe   acetaminophen   650mg     qid  or  ibuprofen  600mg  6hourly.   o To   decongest   the   nose,   Ostia   of   sinuses   and   Eustachian   tubes   start   with   topical   sympathomimetic   (0.5%   Phenylephirine   nose   drops   4   hourly   but   only   for   3   days)   and   add   systemic   sympathomimetic  (Pseudoephedrine  60mg  6  hourly)   o To  dry  out  nose,  or  if  the  symptoms  are  probably  caused  by  an   allergy,  try  antihistamine.   o To   suppress   coughing,   prescribe   dextromethorphan   or   codeine   10-­‐20  mg  6  hourly.   o To  avoid  sedation  and  narcotics,  prescribe  benzonate  (Tessalon)   100-­‐200  mg  8  hourly.   o With   bronchitis   or   suspected   bronchospasm,   treat   the   cough   with   inhaled   bronchodilators   like   albuterol   two   puffs   and   inhaled  steroids  like  beclomethasone  four  puffs  12  hourly.   3. Arrange  for  follow  up  if  symptoms  persist  or  worsen  or  if  new  problems   develop.  WHAT  TO  DO:   • Don’t  get  bullied  into  inappropriate  prescribing  of  antibiotics.  Most  colds   are   self-­‐limiting   illness   and   many   treatments   may   appear   to   work   by   coincidence  alone,     103  
    • • Don’t  prescribe  inappropriate  antibiotics  simply  because  you  suspect  the   insistent  patient  will  obtain  them  elsewhere.   • Don’t  undertake  expensive  diagnostic  testing  on  uncomplicated  cases.    URINARY  RETENTION.  The  patient  may  complain  of  increasing  dull  low  abdominal  discomfort  and  the  urge   to   urinate,   with   out   having   been   able   to   urinate   for   many   hours.   A   firm  distended  bladder  can  be  palpated  between  the  symphysis  pubis  and  umbilicus.  Rectal  exam  may  reveal  an  enlarged  and  tender  prostate  or  suspected.  WHAT  TO  DO:   1) Pass  a  Foley  catheter  and  collect  the  urine  in  bag,  Reassuring  the  patient   and   having   him   breath   through   his   mouth,   this   maneuver   will   help   the   patient   to   relax   the   external   sphincter   of   the   bladder   and   facilitate   the   passage  of  the  catheter.   2) If  the  passage  remains  difficult  in  a  male  patient,  distend  the  urethra  with   lubricant   (diluted   lidocain   jelly)   in   a   catheter   tip   and   try   a   16,   18,   0r   20   French  Foley.   3) If   you   fail   then   take   the   consultation   of   urologist   for   stylet,   sounds,   filiforms,  and  followers.   4) Check  renal  profile  and  ascertain  the  cause  of  obstruction.   5) If  there  is  infection  of  bladder  start  I/V  antibiotics.     104  
    • 6) To  relieve  pain  give  Perfalgan  (Paracetamol)   7) If   the   volume   drained   is   modest   (1-­‐2   liters)   and   the   patient   is   stable,   ambulatory   then   attach   the   Foleys   catheter   to   large   leg   bag   and   discharge   him  for  follow  up  and  catheter  removal  next  day.   8) If   the   volume   drained   is   small   (100-­‐200ml)   remove   the   catheter   and   search   for   alternate   etiologies   of   the   abdominal   mass   and   urinary   urgency.  WHAT  NOT  TO  DO:   • Don’t  use  stylets  or  sound  s  unless  you  have  experience  of  instrument  the   urethra  as  these  devices  can  cause  iatrogenic  trauma.   • Don’t   remove   the   catheter   in   emergency   department   if   the   bladder   was   significantly  distended.   • Don’t   clamp   the   catheter   to   slow   decompression   of   the   bladder   ,   even   if   the  volume  drained  is  greater  than  2  liters.   • Don’t   take   sample   for   bacterial   culture   from   distended   bladder;   it   may   represent  colonization  that  will  resolve  with  drainage.    VAGINAL  BLEEDING  A   menstruating   woman   complains   of   greater   than   usual   bleeding,   that   is   either  off  her  usual  schedule  lasts  longer  than  a  typical  period  or  is  heavier  than  usual  (menorrhagia)  perhaps  with  crampy  pains  and  passage  of  clots.     105  
    • WHAT  TO  DO:   1) Obtain  orthostatic  pulse  and  blood  pressure  measurements,  a  hematocrit   and  pregnancy  test  (urine  or  serum  beta  hCG).   2) Try  to  quantify  the  amount  of  bleeding  by  number  of  saturated  pads  used.   3) A   pulse   increase   more   than   20   /min   on   standing   or   hematocrit   below   30%,   start   an   intravenous   line   of   lactated   Ringer’s   solution   and   have   blood  ready  to  transfuse  on  short  notice.   4) Obtain   a   sexual,   menstrual   and   reproductive   history   that   her   periods   usually   irregular,   occasionally   heavy,   Does   she   take   OCP   and   has   missed   enough  to  produce  estrogen  withdrawal  bleeding.   5) Is   IUD   in   place   and   contributing   to   cramps,   bleeding   and   infection,   was   her   last   period   missed   or   late,   suggesting   an   anovulatory   cycle   or   an   ectopic?  Might  she  be  pregnant?   6) Perform   a   speculum   and   manual   vaginal   examination.   Look   particularly   for   signs   of   pregnancy,   such   as   soft,   blue   cervix,   enlarged   uterus   or   passage  of  fetal  parts  with  the  blood.   7) Ascertain   that   blood   is   coming   from   the   cervical   os   and   not   from   a   laceration,  polyp  or  other  vaginal  or  uterine  pathology.   8) Confirm   suspicion   of   ectopic   pregnancy   either   with   sonogram   showing   the  ectopic  gestational  sac.     106  
    • 9) Discharge   the   stable   patent   home   on   oral   contraceptive   pills   (Ortho-­‐ Novum   1/50   or   Norinyl   1+50)   one   qid   followed   by   low   dose   oral   contraceptives  for  the  next  two  to  three  months.   10)If  the  cause  of  the  uterine  bleeding  was  missed  OCP,  patient  may  resume   the  pills  but  should  use  additional  contraception  for  the  first  cycle.   11)  If  the  cause  is  new  IUD,  the  patient  may  try  to  have  it  removed  and  use   other  contraceptives.   12)Patient   should   be   referred   for   follow   up   to   a   gynecologist   and   may   be   evaluated  via  endometrial  biopsy.  WHAT  NOT  TO  DO:   • Don’t  leap  to  a  diagnosis  of  dysfunctional  uterine  bleeding  with  out  ruling   out  pregnancy   • Don’t  rule  out  pregnancy  or  venereal  infections  on  the  basis  of  a  negative   sexual  history-­‐-­‐-­‐  confirm  with  physical  examination  and  laboratory  tests.    VAGINAL  FOREIGN  BODIES  This  commonly  is  a  problem  of  children  who  may  insert  foreign  body  and  not  tell  their   parents.   The   patient   is   finally   brought   to   the   emergency   department   with   a  foul  smelling  purulent  discharge  with  or  with  out  vaginal  bleeding.  Vaginal   foreign   bodies   in   the   adult   may   be   result   of   psychiatrist   disorder   or  unusual  sexual  practice.     107  
    • Occasionally  a  tampon  or  pessary  is  forgotten  or  lost  and  causes  discomfort  and  vaginal  discharge.  WHAT  TO  DO:   1) Visualize   the   foreign   body   using   a   nasal   speculum   in   the   pediatric   patient   or  vaginal  speculum  in  the  adult.   2) Pediatric   patients   may   be   placed   in   a   knee-­‐chest   position,   while   performing   a   rectal   examination;   you   may   be   able   to   expel   the   foreign   body  from  the  vagina  by  pushing  with  examining  finger  in  the  rectum.   3) Friable   foreign   bodies   such   as   wads   of   toilet   paper   may   be   flushed   out   using  warm  water,  an  infant  feeding  tube.   4) Lost   or   forgotten   tampons   can   be   removed   with   vaginal   forceps;   the   vagina  should  then  be  swabbed  with  a  Betadine  solution.   5) In  difficult  cases  or  when  large  or  sharp  objects  are  involved,  young  and   adult   patients   may   require   general   anesthesia   or   conscious   sedation   to   allow  removal  under  direct  vision.   6) The  patient  should  empty  her  bladder  and  lie  in  stirrups  in  the  lithotomy   position,   Insert   Foley   catheter   to   break   any   suction   between   the   foreign   body   and   the   vaginal   mucosa;   Most   Objects   can   then   be   grasped   with   ring   forceps.   7) Reserve   x-­‐rays   for   radio-­‐opaque   bodies   concealed   in   the   bladder   or   urethra.  Objects  in  the  vagina  are  usually  apparent  on  examination.       108  
    • WHAT  NOT  TO  DO:   • Don’t  ignore  a  vaginal  discharge  in  a  pediatric  patient  or  assume  it  is  the   result   of   a   benign   vaginitis.   Perform   a   bimanual   or   recto   abdominal   examination  to  palpate  a  hard  object.   • Don’t   forget   to   ask   about   possible   sexual   abuse   and   consult   with   a   protective  services  if  it  cannot  be  ruled  out.    VAGINITIS  A   woman   complains   of   itching   and   irritation   of   the   labia   and   vagina,   Speculum  examination   may   disclose   a   disclose   a   diffusely   red,   inflamed   vaginal   mucosa  with  vaginal  discharge.  WHAT  TO  DO:     1) Take  a  brief  sexual  history.   2) Perform  speculum  and  bimanual  pelvic  exam     3) Collect  urine  for  culture   4) Most   common   organism   is   either   Trichomonous   Vaginitis   or   Candida   albican   then   advise   the   patient,   Tab.   Metronidazole   500mg   bidx7days,   Miconazole  or  clotrimazole200mg  vaginal  suppositories.   5) If   the   diagnosis   is   bacterial   vaginitis   which   is   an   overgrowth   of   gardnerella   vaginitis   or   other   anerobes   the   strongest   treatment   is     109  
    • metronidazole   500mg   bid   or   clindamycin   300mg   bid   x7days,   Metronidazole  vaginal  gel  0.75%  5  gram  bid  x  7  days   6) Arrange  for  follow  up  WHAT  NOT  TO  DO:   • Don’t   prescribe   underlying   pelvic   inflammatory   disease,   pregnancy,   or   diabetes.  All  of  which  can  potentiate  vaginitis.   • Don’t  miss  underlying  pelvic  inflammatory  disease,  pregnancy  or  diabetes   • Don’t   miss   candidiasis   because   the   vaginal   secretions   appear   essentially   normal   in   consistency,   color,   volume   and   odour   .Non   pregnant   patient   may  not  develop  thrush  patches  curds  or  caseous  discharge.  VASOVAGAL  SYNCOPE  The   patient   experience   a   brief   loss   of   consciousness,   preceded   by   sense   of  anticipation.   Transient   bradycardia   and   few   clonic   limb   jerks   may   accompany  vasovagal   syncope,   but   there   is   no   sustained   palpitations   arrhythmias   or  seizures,  incontinence,  tongue  bite.  WHAT  TO  DO:   1) Arrange   for   patients,   family   and   friends   anticipating   unpleasant   experiences  in  the  ED  to  sit  or  lie  down  and  be  constantly  attended.   2) If  someone  faints  in  the  ED,  catch  him  so  he  is  not  injured  in  the  fall  ,  lie   him/her  supine  on  the  floor  for  5-­‐10  minutes  protect  his  airway  ,  record   several  sets  of  vital  signs  and  be  ready  to  proceed.     110  
    • 3) If   a   patient   is   brought   to   the   ED   following   a   faint   elsewhere,   ask   about   setting,  precipitations  of  several  eyewitnesses  and  sequence  of  recovery.   Be   alert   for   evidence   of   seizures,   hysteria   and   hyperventilation,   record   several   sets   vital   signs,   including   orthostatic   changes   and   examine   carefully  for  signs  of  trauma.   4) After   full   recovery,   explain   to   the   patient   that   this   is   a   common   physiological   reaction   and   how,   in   future   recurrences.   He   can   recognize   the   early   lightheadedness   and   prevent   a   full   swoon   by   lying   down   or   putting  his  head  between  his  knees.  WHAT  NOT  TO  DO:   • Don’t  let  families  stand  for  bad  news,  let  not  parents  or  relatives  to  stand   near  by  while  suturing  or  venipunctures.   • Don’t   traumatize   the   faint   victim   with   ammonia,   slapping   or   dousing   with   cold  water.    VERTIGO  A   nonspecific   complaint,   which   may   be   refined   further   into   either,   an   altered  somatic   sensation   (giddiness)   orthostatic   blood   pressure   changes   or   the  sensation   of   the   environment   spinning.   In   the   inner   ear   disease,   vertigo   is  virtually   always   accompanied   by   nystagmus,   which   is   the   ocular   compensation  for   the   unreal   sensation   of   spinning.   Nausea   and   vomiting   are   common  symptoms.     111  
    • WHAT  TO  DO:   1) Have   the   patient   tell   you   in   his   own   words   what   it   feels   like   .   ask   about   any   sensation   of   spinning   ,   factors   which   make   it   better   or   worse   and   associated   symptoms   ,   ask   about   drugs   or   toxins   which   could   be   responsible.   2) Determine  whether  the  patient  is  describing  vertigo  (feeling  of  movement   of   one’s   body   or   surroundings)   or   sensation   of   an   impending   faint   or   vague  unsteady  feeling.   3) If   the   problem   is   near   syncope   or   orthostatic   lightheadedness,   then   consider   potentially   serious   etiologies   such   as   heart   disease,   cardiac   dysarrythmia  or  blood  loss.   4) An   elderly   patient   feeling   that   he   is   going   to   fall,   look   for   peripheral   neuropathy,  cervical  spondylosis,  stiff  legs  and  vasodilator  medications.   5) Instruct   the   patient   to   hyperventilate   by   breathing   deeply   in   and   out   fifteen  times.   6) If   the   patient   has   true   vertigo,   examine   for   nystagmus,   which   can   be   horizontal,  vertical  or  rotatory.   7) Examine  ears  for  cerumen,  foreign  bodies,  otitis  media  and  hearing  loss.   8) Examine   the   cranial   nerve,   test   cerebellar   function,   and   Check   the   corneal   blink  reflexes.   9) In   the   ED   treat   moderate   to   severe   symptoms   of   vertigo   with   intravenous   Valium  10mg  or  Diphenhydramine  50mg  .Add  promethazine  (Phenergan)     112  
    • 25mg   I/V   for   nausea   Nifidipine   had   been   used   to   alleviate   motion   sickness  but  is  no  longer  better  than  Scopolamine  patch.   10)  Treat   vertigo   symptoms   in   outpatient   with   diazepam   (Valium)   5-­‐10mg-­‐ qid  meclizine  (Antivert)  12.5-­‐25  mg  qid,  Diphenhydramine  (Dramamine,   Benadryl)  25-­‐50mg  qid,  and  bed  rest  as  needed  until  symptoms  improve.   11)  Arrange   for   follow   up   if   there   is   no   clear   improvement   in   2   days   or   if   there  is  any  suggestion  of  a  central  etiology.    WHAT  NOT  TO  DO   • Don’t  attempt  provocative  maneuvers  if  the  patient  is  symptomatic  with   nystagmus.   • Don’t   give   anti   vertigo   drugs   to   elderly   patients   with   disequilibrium.   Theses  medications  have  sedative  properties  that  can  make  them  worse.   • Don’t   make   the   diagnosis   of   Meniere’s   disease   with   out   triad   of   paroxysmal   vertigo,   sensorial   deafness   and   tinnitus,   along   with   a   feeling   of  pressure  or  fullness  in  the  affected  ear.    WEAKNESS  An   older   patient   comes   to   the   emergency   department   or   is   brought   by   family  complaining  of  weakness  or  an  inability  to  carry  on  his  usual  activities  or  care  for  himself.     113  
    • WHAT  TO  DO:   1) Obtain  as  much  history  as  possible.   2) Ask   about   headache,   weight   loss,   cold   intolerance   appetite,   and   bowel   habit.   3) Check  the  strength  of  all  muscle  groups  (graded  on  a  scale  of  1-­‐5),  deep   tendon  reflexes  and  neurological  status   4) Do  CT  scan  brain  that  there  is  an  unexplained  change  in  mental  status  o  if   there  are  abnormal  neurological  findings.   5) Obtain  a  spectrum  of  laboratory  tests  i.e.,  Renal  profile,  electrolyte  CBC  as   well   as   attach   pulse   oximeter,   ask   for   x-­‐rays   chest,   ECG,   to   rule   out   Hypoxia,   anemia,   infection,   diabetes,   uremia   polymyalgia   rheumatica,   hyponatremia   and   hypokalemia,   all   of   which   are   common   causes   of   “weakness”.   6) If   no   etiology   for   weakness   can   be   found,   probe   the   patient,   family   and   friends   once   again   for   any   hidden   agenda   and   if   non   is   found,   reassure   them   about   all   the   serious   illnesses   which   have   been   ruled   out   .At   this   time,  discharge  the  patient  and  make  arrangements  for  definite  follow  up.  WHAT  NOT  TO  DO:   • Don’t   order   any   lab   test   the   results   of   which   you   will   not   see.   Your   best   strategy   is   to   stick   to   tests   that   will   return   while   the   patient   is   in   the   emergency   department   and   defer   any   long   investigations   to   the   follow   up   physician.     114  
    • • Don’t   insist   upon   making   the   diagnosis   in   the   Emergency   department   in   every   case,   in   this   clinical   situation,   your   role   in   the   ED   is   to   rule   out   acutely   life   threatening   conditions   and   then   make   arrangements   for   further  evaluations  elsewhere.      WRY  NECK    (Torticollis)  The   patient   complains   of   neck   pain   and   is   unable   to   turn   his   head,   usually  holding   it   twisted   to   one   side,   with   some   spasm   of   the   neck   muscle   with   the   chin  pointing   to   the   other   side.   These   symptoms   may   have   developed   gradually,   after  minor  turning  of  the  head,  after  vigorous  movement  or  injury  or  during  sleep.  WHAT  TO  DO:   1) Ask   the   patient   precipitating   factors   and   perform   a   thorough   physical   examination,   looking   for   muscle   spasm,   point   tenderness   and   sign   of   injury,   nerve   root   compression,   masses   or   infection,   include   a   careful   nasopharyngeal  examination  as  well  as  basic  neurologic  examination.   2) When   forceful   trauma   is   involved   and   subluxation   is   possible,   then   obtain   lateral,  anteroposterior  and  odontoid  X-­‐Rays  view  of  cervical  spine.   3) If   there   is   neurological   deficit   then   do   CT   or   MRI   to   visualize   nerve   involvement.   4) When   there   is   no   suspicion   of   serious   illness   or   injury,   apply   heat,   give   NSAID  and  oral  cyclobenzaprine  (Flexeril)  or  diazepam,  Alternating  heat     115  
    • with   ice   massages   may   also  be  helpful  as  well  as  gentle  range  of  motion   exercises.   5) If   there   is   point   tenderness   posterior   to   the   sternocleidomastoid   muscle   and  the  head  cannot  turn  towards  the  side  of  point  tenderness  suspect  a   facet   syndrome,   obtain   x-­‐rays   and   gently   test   neck   motion   again   after   a   few  mintes  of  manual  traction  along  a  longitudinal  axis.   6) If   there   is   any   arm   weakness   or   paresthesia   corresponding   to   a   cervical   dermatome,  suspect  nerve  root  compression  as  the  underlying  cause  and   arrange  for  neurosurgical  or  orthopedic  consultation.   7) With   signs   and   symptoms   of   infection   e.g.   ,   fever   ,   toxic   appearance   ,   lymphadenopathy.   Tonsiller   swelling,   trismus,   phyarngitis   or   dyspahgia,   take   soft   tissue   lateral   neck   film   s   and   CBC,   ESR   to   help   rule   out   early   abscess  formation.  Arrange  for  specialty  consultation.  WHAT  NOT  TO  DO:   • Don’t   overlook   infectious   etiologies   presenting   as   Torticollis,   especially   the  pharyngiotonsillitis  of  young  children  that  can  soften  the  atlantoaxial   ligaments  and  allow  subluxation.   • Don’t  undertake  violent  spinal  manipulations  in  the  ED  that  can  make  an   acute  torticollis  worse.   • Don’t  confuse  torticollis  with  a  dystonic  drug  reaction  from  phenothiazine   or  butyrophenes.       116  
    • ZIPPER  CAUGHT  ON  PENIS  OR  CHIN.  Usually   a   child   has   gotten   dressed   too   quickly   and   not   wearing   underpants,  accidently   pulled   up   penile   skin   in   to   zipper,   The   skin   becomes   entrapped   and  crushed  between  the  teeth  and  side  of  the  zipper,  thereby  painful  attaching  the  article  of  clothing  to  the  body  part  involved.  WHAT  TO  DO:   1) Paint  the  area  with  small  amount  of  Povidine-­‐iodine  and  infiltrate  the  skin   with   1%   lidocain,   this   will   allow   the   comfortable   manipulation   of   the   zipper  and  article  of  clothing.     2) Cover  the  area  with  mineral  oil,  this  lubricates  the  moving  parts  and  often   frees  the  skin  with  out  having  to  cut  the  zipper.   3) If  the  mineral  oil  does  not  work,  then  cut  the  zipper  away  from  the  article   of  clothing.   4) Cut  the  slide  of  zipper  in  half  with  pair  of  metal  snips  or  an  orthopedic  pin   cutter   or   use   two   surgical   towel   clamps   and   place   their   tongs   into   side   grooves  at  both  ends  of  the  slide.  Then  grip  one  clamp  firmly  in  each  hand   and  then  twist  your  wrist  s  in  opposite  directions.  This  often  will  pop  the   two  halves  of  the  zipper  slide  part,  releasing  the  entrapped  skin.   5)  Pull   the   exposed   zipper   teeth   apart,   cleanse   the   crushed   skin   and   apply   an  ointment  such  as  Povidine-­‐  iodine.   6) Tetanus  prophylaxis  should  be  administered  as  needed.     117  
    • WHAT  NOT  TO  DO:   • Don’t  clothing  if  mineral  oil  releases  the  zipper.   • Don’t  destroy  the  entire  article  of  clothing  by  cutting  into  it,  you  only  need   to  cut  the  zipper  away  allowing  repair  of  the  clothing.   • Don’t  excise  and  area  of  skin  or  perform  a  circumcision.                 118