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Defensive Medicine

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4981. Hidradenitis Suppurativa (Diagnosis)

hygiene Weight reduction in patients who are obese Use of ordinary soaps and antiseptic and antiperspirant agents (eg, 6.25% aluminum chloride hexahydrate in absolute ethanol) Application of warm compresses with sodium chloride solution or Burow solution Wearing of loose-fitting clothing Laser hair removal Discontinuation of cigarette smoking Medical anti-inflammatory or antiandrogen therapy (eg, oral or topical antibiotics, intralesional triamcinolone, spironolactone, finasteride) Biological therapy (...) patients may reveal abnormalities in the deep part of the follicle. See for more detail. Management Medical management is recommended in early stages, whereas surgery should be performed after the formation of abscesses, fistulas, scars, and sinus tracts. [ ] Systemic treatment does not restore the skin’s original architecture; therefore, once the inflammation has been treated, epithelialized cysts and sinus tracts remain in the affected skin. [ ] Conservative treatment may include the following: Local

2014 eMedicine Emergency Medicine

4982. Grief Support in the ED (Diagnosis)

-in-Chief, Medscape Drug Reference Disclosure: Received salary from Medscape for employment. for: Medscape. Robert Harwood, MD, MPH, FACEP, FAAEM Senior Physcian, Department of Emergency Medicine, Advocate Christ Medical Center; Assistant Professor, Department of Emergency Medicine, University of Illinois at Chicago College of Medicine Robert Harwood, MD, MPH, FACEP, FAAEM is a member of the following medical societies: , , , , , Disclosure: Nothing to disclose. Chief Editor Barry E Brenner, MD, PhD (...) , shock, anger, disbelieving, numbness, crying, or even with violence. [ ] The response of physicians and medical personnel must be adapted to the needs of the situation. Some common reactions that may need to be addressed include the following: [ ] Denial: This common personal defense mechanism allows assimilation of tragic information at a tolerable pace. Early phases of denial should be accepted. If denial persists beyond a few minutes, reiterate the facts. Be direct: use the words "died or dead

2014 eMedicine Emergency Medicine

4983. Leishmaniasis (Diagnosis)

for economic reasons. In the city of Kabul, Afghanistan, which has a population of less than 2 million, an estimated 270,000 cases of cutaneous leishmaniasis occurred in 1996. The resurgence of visceral leishmaniasis has occurred because of deficiencies in the control of the vector (sandfly), absence of a vaccine, and lack of access to medical treatment due to cost and increasing drug resistance to first-line treatment. Coexistence of leishmaniasis with human immunodeficiency virus (HIV) infection (...) individuals with intact immune systems, full recovery from visceral disease is expected after treatment with the appropriate medication. With early therapy and supportive care, mortality in patients with visceral disease is reduced to approximately 5%; without therapy, most patients with visceral disease (kala-azar) (75-95%) die within 2 years, often from malnutrition and secondary infection, such as bacterial pneumonia, septicemia, dysentery, tuberculosis, cancrum oris, and uncontrolled hemorrhage or its

2014 eMedicine Emergency Medicine

4984. Impetigo (Diagnosis)

mechanisms for disruption of skin that can facilitate bacterial colonization or infection include the following: Scratching Dermatophytosis Varicella Herpes simplex Scabies Pediculosis [ ] Thermal burns Surgery Trauma Radiation therapy Insect bites Immunosuppression by medications (eg, systemic corticosteroids, oral retinoids, chemotherapy), systemic diseases (eg, HIV infection, diabetes mellitus), intravenous drug abuse, and dialysis encourages bacterial growth. After initial infection, new lesions may (...) of New York Downstate College of Medicine; Consulting Staff, Department of Emergency Medicine, Staten Island University Hospital, Kings County Hospital, University Hospital, State University of New York Downstate at Brooklyn Mark A Silverberg, MD, FACEP, MMB is a member of the following medical societies: , , , and Disclosure: Nothing to disclose. Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug

2014 eMedicine Emergency Medicine

4985. Hypothermia (Diagnosis)

of the following medical societies: Disclosure: Nothing to disclose. Jamie Alison Edelstein, MD Staff Physician, Department of Emergency Medicine, State University of New York, Kings County Hospital Center Disclosure: Nothing to disclose. Specialty Editor Board Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Received salary from Medscape for employment. for: Medscape. James Steven Walker (...) thermoregulation, but, generally, it is associated with failure of the hypothalamus to regulate core body temperature. This may occur with CNS trauma, strokes, toxicologic and metabolic derangements, intracranial bleeding, Parkinson disease, CNS tumors, Wernicke disease, and multiple sclerosis. Other causes Miscellaneous causes include sepsis, multiple trauma, pancreatitis, prolonged cardiac arrest, and uremia. Hypothermia may be related to drug administration; such medications include beta-blockers, clonidine

2014 eMedicine Emergency Medicine

4986. Hyperphosphatemia (Diagnosis)

in and out of cells under several influences, the serum concentration of phosphate may not reflect true phosphate stores. Often, persons with alcoholism who have severely deficient phosphate stores may present for medical treatment with a normal serum phosphate level. Only after refeeding will serum phosphate levels decline, often abruptly plummeting to dangerously low levels. Phosphate homeostasis Phosphate is plentiful in the diet. A normal diet provides approximately 1000-1500 mg of phosphate, two (...) tubule. In the proximal tubule, phosphate reabsorption by type 2 sodium phosphate cotransporters is regulated by dietary phosphate, PTH, and vitamin D. High dietary phosphate intake and elevated PTH levels decrease proximal renal tubule phosphate absorption, thus enhancing renal excretion. Defense against hyperphosphatemia is depicted in the image below. Hyperphosphatemia inhibits 1-alpha hydroxylase in the proximal tubule directly and indirectly through stimulation of FGF23, thus inhibiting

2014 eMedicine Emergency Medicine

4987. Hyperosmolar Hyperglycemic State (Diagnosis)

, major infections, myocardial infarction [MI], or pancreatitis) or stress (eg, surgery, major psychiatric illness, or multiple injuries), when counterregulatory hormones are given as therapy (eg, glucocorticoid medications), and as a result of their overproduction (eg, in Cushing syndrome or acromegaly). Often, parenteral nutrition and administration of some medications (notably, tretinoin, antiretrovirals, antipsychotics, [ , ] and immunosuppressive agents, such as cyclosporine) also cause insulin (...) Resident Physician, Department of Internal Medicine, Einstein Healthcare Network Dipa Avichal, DO is a member of the following medical societies: , Disclosure: Nothing to disclose. Coauthor(s) Nissa C Blocher, MD Attending Physician, Division of Endocrinology, Associate Program Director, Endocrinology Fellowship, Albert Einstein Medical Center Nissa C Blocher, MD is a member of the following medical societies: , , , Disclosure: Nothing to disclose. Chief Editor George T Griffing, MD Professor Emeritus

2014 eMedicine Emergency Medicine

4988. Millipede Envenomation (Diagnosis)

species. [ , , , , , , ] See the images below. The desert millipede, Orthoporus ornatus. Photo by Robert Norris, MD. Millipede contact injury on day 3 following exposure. Next: Pathophysiology Millipedes do not have biting mouthparts or fangs. Their medical importance comes from their ability to secrete an irritating defensive liquid from pores along their sides. Such secretions contain benzoquinones, aldehydes, hydrocyanic acid, phenols, terpenoids, nitroethylbenzenes, and other substances (...) , Reineke D, Vujisić LV, Todosijević MM, Antić DŽ, et al. Chemical Ecology of Cave-Dwelling Millipedes: Defensive Secretions of the Typhloiulini (Diplopoda, Julida, Julidae). J Chem Ecol . 2017 Apr. 43 (4):317-326. . Erickson TB, Marquez A. Arthropod envenomation and parasitism. Auerbach PS, ed. Wilderness Medicine . 6th ed. Philadelphia, Pa: Elsevier Mosby; 2012. Chapter 50. Hendrickson RG. Millipede exposure. Clin Toxicol (Phila) . 2005. 43(3):211-2. . Mason GH, Thomson HD, Fergin P, Anderson R. Spot

2014 eMedicine Emergency Medicine

4989. Mediastinitis (Diagnosis)

, Department of Emergency Medicine, Einstein Medical Center Philadelphia James R Gardner, MD is a member of the following medical societies: , Disclosure: Nothing to disclose. Specialty Editor Board Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Received salary from Medscape for employment. for: Medscape. Chief Editor Jeter (Jay) Pritchard Taylor, III, MD Assistant Professor (...) are in their third to fifth decades of life; however, it can occur in all age groups, with documented mediastinitis in patients as young as 2 months and as old as the eighth decade of life. Previous Next: Prognosis Early diagnosis and aggressive therapy seem to provide the best chance for recovery. Despite vast improvements in IV antibiotics, critical care medicine, and CT imaging in the last 30 years, mediastinitis still carries a high mortality rate. [ ] Previous References Scaglione M, Pezzullo MG, Pinto

2014 eMedicine Emergency Medicine

4990. Meningitis (Diagnosis)

and Medication.) The specific infectious agents that are involved in bacterial meningitis vary among different patient age groups, and the inflammation may evolve into the following conditions: Ventriculitis Empyema Cerebritis Abscess formation Meningitis can also be also classified more specifically according to its etiology. Numerous infectious and noninfectious causes of meningitis have been identified. Examples of common noninfectious causes include medications (eg, nonsteroidal anti-inflammatory drugs (...) Headache Neck stiffness Other symptoms can include nausea, vomiting, photalgia (photophobia), sleepiness, confusion, irritability, delirium, and coma. Patients with viral meningitis may have a history of preceding systemic symptoms (eg, myalgias, fatigue, or anorexia). The history should also address the following: Epidemiologic factors and predisposing risks Exposure to a patients or animals with a similar illness Previous medical treatment and existing conditions Geographic location and travel

2014 eMedicine Emergency Medicine

4991. Lionfish and Stonefish (Diagnosis)

Nov. 7(4):291-6. . Auerbach PS. Marine envenomations. N Engl J Med . 1991 Aug 15. 325(7):486-93. . Auerbach PS. Medical Guide to Hazardous Marine Life . 2nd ed. Flagstaff, Az: Best Pub; 1991. 17-19. Auerbach PS. Wilderness Medicine: Management of Wilderness and Environmental Emergencies . 4th ed. 2001. 1492-1497. Bove AA. Bove and Davis' Diving Medicine . 3rd ed. Philadelphia, Pa: WB Saunders; 1997. 310-311. Burnett JW. Aquatic adversaries: stonefish. Cutis . 1998 Dec. 62(6):269-70. . Chan TY, Tam (...) , Anterior view of left pelvic spine (proximal portion) of the brown rockfish. Bottom, Lionfish spine. of 8 Tables Contributor Information and Disclosures Author Scott A Gallagher, MD, FACEP Physician, Department of Emergency Medicine, Aspen Valley Hospital; Senior Clinical Instructor, Department of Surgery, School of Medicine, University of Colorado Health Sciences Center Scott A Gallagher, MD, FACEP is a member of the following medical societies: Disclosure: Nothing to disclose. Specialty Editor Board

2014 eMedicine Emergency Medicine

4992. Hookworm (Diagnosis)

: and Disclosure: Nothing to disclose. Russell W Steele, MD Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine Russell W Steele, MD is a member of the following medical societies: , , , , , , , , and Disclosure: Nothing to disclose. Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference (...) variants predisposing to psoriasis. Nat Genet . 2014 Jan. 46(1):45-50. . Reddy M, Gill SS, Kalkar SR, et al. Oral drug therapy for multiple neglected tropical diseases: a systematic review. JAMA . 2007 Oct 24. 298(16):1911-24. . Hotez PJ, Molyneux DH, Fenwick A, et al. Control of neglected tropical diseases. N Engl J Med . 2007 Sep 6. 357(10):1018-27. . Easton AV, Oliveira RG, O'Connell EM, Kepha S, Mwandawiro CS, Njenga SM, et al. Multi-parallel qPCR provides increased sensitivity and diagnostic

2014 eMedicine Emergency Medicine

4993. Munchausen Syndrome (Diagnosis)

Virginia Medical School; Attending Physician, Division of Emergency Medicine, Children's Hospital of The King's Daughters Disclosure: Nothing to disclose. Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Medscape Salary Employment What would you like to print? What would you like to print? Sections Factitious Disorder Imposed on Self (Munchausen's Syndrome) Find Us On About (...) helpful. Options include the following: Family therapy Cognitive-behavioral therapy Supportive psychotherapy There is little evidence to support the efficacy of any particular pharmacologic intervention in treating factitious disorder; however, the following principles should apply: Pharmacologic therapy may be indicated for concurrent psychiatric diagnoses Drugs may also be considered for treatment of the presenting symptoms Caregivers should routinely copy each other on every progress note

2014 eMedicine Emergency Medicine

4994. Pediatrics, Fifth Disease or Erythema Infectiosum (Diagnosis)

Health Sciences Center, Paul L Foster School of Medicine; Consulting Staff, Mountain View Dermatology, PA Richard P Vinson, MD is a member of the following medical societies: , , , and Disclosure: Nothing to disclose. Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Nothing to disclose. Wayne Wolfram, MD, MPH Associate Professor, Department of Emergency Medicine, Mercy St Vincent Medical (...) , University Hospital, Tamarac, Florida Disclosure: Nothing to disclose. Chief Editor Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine Dirk M Elston, MD is a member of the following medical societies: Disclosure: Nothing to disclose. Acknowledgements Megan Boysen, MD Resident Physician, Department of Emergency Medicine, University of California Irvine Medical Center Megan Boysen, MD, is a member

2014 eMedicine Emergency Medicine

4995. Gastroenteritis (Diagnosis)

: , Disclosure: Nothing to disclose. Specialty Editor Board Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Received salary from Medscape for employment. for: Medscape. BS Anand, MD Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine BS Anand, MD is a member of the following medical societies: , , , Disclosure: Nothing to disclose. Chief (...) Postcolonization toxins include V cholera, C perfringens, enterotoxigenic E coli, and Aeromonas. and poisoning from other marine animals Shellfish and marine animal poisoning include the following: Paralytic shellfish poisoning (PSP) - Saxitoxin Neurologic shellfish poisoning (NSP) - Brevetoxin Diarrheal shellfish poisoning (DSP) - Okadaic acid Amnesic shellfish poisoning - Domoic acid (ciguatoxins) (conversion of histidine to histamine) Drug-associated diarrhea Medications associated with diarrhea include

2014 eMedicine Emergency Medicine

4996. Asthma (Follow-up)

to an inhaled glucocorticoid in the add-on therapy trial. [ ] The results of these two trials suggests that a leukotriene antagonist is equivalent to both comparison drugs with regard to asthma-related quality of life at 2 months, but equivalence was not proven at 2 years. A Cochrane review found that inhaled corticosteroids are superior to anti-leukotrienes when used as monotherapy in adults and children with persistent asthma. The superiority of inhaled corticosteroids is most pronounced in asthma (...) for medication in a 2003 meta-analysis of 75 randomized controlled trials by Abramson et al. [ ] Another study showed improved peak expiratory flow rate (PEFR) and decreased use of medications in a highly selected group of children, but only for the first year of therapy. Patients receiving subcutaneous immunotherapy (SCIT) demonstrated improved medical outcomes and cost savings in one study designed to evaluate the cost-effectiveness of SCIT in addition to symptomatic therapy (ST), compared with ST alone

2014 eMedicine Emergency Medicine

4997. Urinary Tract Infection, Female (Diagnosis)

(Fortaz, Tazicef) 500 mg IV or IM q8-12h for 7-14d Duration of therapy: shorter courses (7d) are reasonable if patient improves rapidly; longer courses (10-14d) are reasonable if patient has a delayed response or is hospitalized. Parenteral therapy can be switched to oral therapy once clinical improvement is observed. Contributor Information and Disclosures Author John L Brusch, MD, FACP Assistant Professor of Medicine, Harvard Medical School; Consulting Staff, Department of Medicine and Infectious (...) of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Medscape Salary Employment Mark Zwanger, MD, MBA Assistant Professor, Department of Emergency Medicine, Jefferson Medical College of Thomas Jefferson University Mark Zwanger, MD, MBA is a member of the following medical societies: , , and Disclosure: Nothing to disclose. What would you like to print? What would you like to print? Sections Urinary Tract Infection (UTI) and Cystitis (Bladder Infection

2014 eMedicine Emergency Medicine

4998. Urinary Tract Infection, Male (Diagnosis)

Associate Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center Richard H Sinert, DO is a member of the following medical societies: and Disclosure: Nothing to disclose. Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference (...) the following: Intravenous (IV) antimicrobial therapy with a third-generation cephalosporin (eg, ceftriaxone, ceftazidime), a fluoroquinolone (eg, ciprofloxacin, levofloxacin, ofloxacin, norfloxacin), or an aminoglycoside (eg, gentamicin, tobramycin) (beware ototoxicity) Antipyretics Analgesics IV fluid resuscitation: To restore appropriate circulatory volume and promote adequate urinary flow Other medications used in the management of male UTIs—or etiologic conditions such as prostatitis; epididymitis

2014 eMedicine Emergency Medicine

4999. Tuberculosis (Diagnosis)

of drug-resistant TB is increasing worldwide. Anteroposterior chest radiograph of a young patient who presented to the emergency department (ED) with cough and malaise. The radiograph shows a classic posterior segment right upper lobe density consistent with active tuberculosis. This woman was admitted to isolation and started empirically on a 4-drug regimen in the ED. Tuberculosis was confirmed on sputum testing. Image courtesy of Remote Medicine (remotemedicine.org). See , a Critical Images (...) therapy consists of the following 4-drug regimens: Isoniazid Rifampin Pyrazinamide Either ethambutol or streptomycin [ ] Special considerations for drug therapy in pregnant women include the following: In the United States, pyrazinamide is reserved for women with suspected MDR-TB Streptomycin should not be used Preventive treatment is recommended during pregnancy Pregnant women are at increased risk for isoniazid-induced hepatotoxicity Breastfeeding can be continued during preventive therapy Special

2014 eMedicine Emergency Medicine

5000. Trichomoniasis (Diagnosis)

, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Medscape Reference Salary Employment Robert W Tolan Jr, MD Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine Robert W Tolan Jr, MD is a member of the following medical societies: , , , , , , , and Disclosure: Novartis Honoraria Speaking (...) Emergency Medicine Disclosure: Nothing to disclose. Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Nothing to disclose. Martin Weisse, MD Program Director, Associate Professor, Department of Pediatrics, West Virginia University Martin Weisse, MD is a member of the following medical societies: , , and Disclosure: Nothing to disclose. Jeffrey M Zaks, MD Clinical Associate Professor

2014 eMedicine Emergency Medicine

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