Signs and Symptoms in Clinical Practice Devendra Richhariya, Jesus Daniel López Tapia, Khusrav Bajan, Bhawana Sharma
INDEX
Page numbers followed by b refer to box, f refer to figure, fc refer to flowchart, and t refer to table.
A
Abdomen 177
acute 4, 16t
computed tomography of 15
red flags of acute 15t
surgical causes of acute 13
ultrasonography of 15
ultrasound 16, 297
Abdominal anatomy 1, 11
Abdominal examination 444
ultrasound 10
Abdominal pain, 1, 8, 9t, 12fc, 13, 14, 18, 86, 138
acute 13, 17t
causes of acute 13t
chronic 18
diffuse 2
localized 20
lower 14
mild-moderate 11
pathophysiology of 13
presence of 86
recurrent 18
signs in 3t
symptoms in 3t
Abdominal surgery 86
previous 9
Abdominal symptoms 355
Abdominal X-ray, role of 10
Abetalipoproteinemia 28
ABG analysis 187
Abortions, recurrent 58
Abscess 280
brain 375
deep 117
dental 203
intra-abdominal 3
lactation 80
lung 112, 117, 357
pain to 193, 196
parotid 74
perirectal 9
peritoneal 19
peritonsillar 177, 628, 637
retropharyngeal 628, 637
spinal epidural 483
subphrenic 375
Absorptive function, loss of 85
Acarus scabiei 573
Acetaminophen 372
Acetyl choline, release of 26
Achalasia 234
cardia 233
Achilles tendon 38
injury 41
Acid
injuries 271
reflux 22
suppression 497
Acid-fast bacilli 360, 394, 462
Acidosis 183
Acne, neonatal 571, 571f
Acoustic neuroma 242
Acquired asplenia 412
Acquired bleeding disorders 56, 61, 64, 71
Acquired genetic defects 28
Acquired immunodeficiency syndrome 231
Acropustulosis, infantile 572, 572f
Acute coronary syndrome 105, 236, 238
Acute scrotum 584, 592
diagnostic evaluation 586
differential diagnosis of 588
epidemiology 585
etiology 584
history taking in 587
pathophysiology 586
physical examination of 587
sifferential diagnosis of 588t
ultrasound 587
Acyclovir 529
ADAMTS13 enzyme 69
Adenoid hypertrophy 631
Adenoma, bronchial 357, 363
Adenosine triphosphate 128, 441
Adequate hydration, maintenance of 172
Adequate renal function 89
Adrenal crisis 19
Advanced airway management equipment 559
Advanced trauma life support 120
guidelines 133
Aedes aegypti 437
Aerobic culture 360
Afebrile seizures 154
Agranulocytosis 332
Air fluid levels, multiple 17
Airway 161, 235, 241
breathing and circulation 338, 359, 450
maintain 158
management 496
equipment, basic 559
reflex, protective 169
resistance, level of 162
secretions, presence of 169
secure 158
Albumin 544
Alcohol 104, 129, 143
withdrawal 143
seizure 151
Alcoholic hepatitis 49
Alcoholism 318, 444, 680
Aldehydes 619
Aldolase 505
Alendronate 231
Aleukemic leukemia 295
Alkali burns 271
Allergen
exposure 170
implicated 597
Allergic contact dermatitis 596
clinical features 596
etiopathogenesis 596
treatment 597
Allergic disorders, suspected 171
Allergic reaction 68
Allergic rhinitis 172, 626
Allergic vasculitis 295
Allergy 155, 245, 247
Allopurinol 598
Alpha-adrenergic agonists 340
Alpha-methyldopa 375
Aluminum 414
containing antacids 137
phosphate 414
Alveolar-arterial oxygen gradient, elevated 240
Amantadine 378
Amebiasis 295
American National Athletic Trainers 41
American Society of Anesthesiologists 557
Aminoglycosides 388
Aminotransferases 505
Amiodarone 181183
Amnesia 95, 124
Amniotic fluid embolism 236
Amoxicillin 475, 630
clavulanate combination 475
Amphotericin B 524
Ampicillin 475
sulbactam combination 475
Amylase 88
Amyloidosis 138, 442
Amyotrophic lateral sclerosis 657
Anal fissure 24
chronic 24
differential diagnosis of 9
management of chronic 26
Anal injury 24
Anal rectal muscle function, evaluation of 139
Analgesia 461
airway assessment procedures for 557
procedural 556
Anaphylactic shock, history of 11
Anaphylaxis 236, 282, 636
Anasarca 281
Ancillary tests 654
Androgen receptor molecules, selective 507
Anemia 20, 27, 27t, 69, 237, 282, 433
approach to 31
causes of 33fc
classification of 27
differential diagnosis of 32t
of chronic
disease 29, 32
disorder 29
pathophysiology of 31
signs of 57
to blood loss, treatment of 33fc
types of 29t
Anesthesia, general 310
Aneurysms, diagnosis of 479
Angina 100, 102
abdominis 5
unstable 100
Angioedema 279
Angiotensin-converting enzyme 164, 166, 276, 626
inhibitors 170
Angle closure glaucoma 273
Anhidrotic ectodermal dysplasia 300
Anidulafungin 524
Ankle anterior drawer test 38
Ankle joint, level of 38
movements of 43
Ankle sprain 36, 37, 43, 44fc
diagnosis of 38, 40
isolated simple 43
management of 42
recurrent 43
symptoms of 37
treatment of chronic 41
Ankylosing spondylitis 295
Anomalous 141
Anorectal manometry 139
Anorexia 19
Antalgic gait 321, 322
Anterior drawer test 38, 39f
Antiaggregants 126
Antiallergic drugs 279
Antiarrhythmic agent 183
Antibiotic therapy 5, 475
Antibody 54
detection 567
mediated destruction 28
Anticancer treatment 665
Anticoagulant 261
therapy 56
use of 515
Anti-cyclic citrullinated peptide 460
Anti-D antibody 68
Antidepressant 137, 378, 380, 665
tricyclic 151, 665
Antidiuretic hormone 361
Antiepileptic drug 147, 148, 160
noncompliance with 144
Antigen detection 567
testing, rapid 628
Anti-hepatitis A virus, detection of 397
Antihistamine agents 287, 437, 445, 668
Antihistaminic therapy 172
Antihypertensive drug ACE inhibitors 164
Anti-inflammatory drugs 343
Antineutrophil cytoplasmic antibody 505
Antinuclear antibody 276, 297, 460, 505
Antiphospholipid syndrome 295
Antiplatelet 126
agents 474
therapy 261
Antipyresis, pharmacological 306
Antipyretics 172
Antirheumatic drugs, disease-modifying 298
Anti-rheumatic drugs
modifying 413
start disease-modifying 462
Antitetanus 437
Antithrombin III deficiency 477
Antithrombotic agents 474
Antithyroid drugs 328
Antitussives 173
role of 172
Antiviral drugs 75
Anxiety 238
cause of 442
history of 652
Anxious state 530
Aortic aneurysm 2, 9
abdominal 1, 9
leaking 363
Aortic dissection 9, 102, 109, 110, 237
acute 101
Aortic stenosis 144
Aortic syndrome, diagnosis of 11
Aplastic anemia 29, 32
Appendicitis 16, 17, 592
acute 1, 4, 13
diagnostic of 16
harbinger of acute 13
Appendix
epididymidis 590
testicularis 590
Appetite, loss of 396
Arcanobacterium haemolyticum 626
Arch support 343
Arcus senilis 105
Argatroban 61
Argemone alkaloid-contaminated cooking 358
Argon plasma coagulation 361
Arnold-Chiari malformation 642
Arrhythmia 134, 183, 184, 236, 237, 538, 539
acute 539
cardiac 177, 382
respiratory 623
Arrhythmogenic causes of palpitations 531
Arterial blood
gas 88, 120, 133, 135, 185, 239, 241, 360, 380, 667
analysis 239
pressure 31, 470
specimen, heparinized 185
Arterial embolism, peripheral 470
Arterial hypertension 73
Arterial hypoxemia 185
detecting 184
Arterial oxygenation, decreased 182
Arterial ulcers 478
treatment of 479
Arteriovenous malformation 33, 183, 360
Artery disease, peripheral 469, 478
Arthritic cause 342
Arthritis
in women 395
infective 455
inflammatory 463
post-traumatic 122
Arthropod 423
types of 423f
Asbestosis 112
Ascites 45
cardiac 45
causes of 46t
etiology of 46t
evaluation of 50fc
fluid
analysis 48
cell count of 48
malignant 46
nonhepatic 51
pathophysiology of 47
Ascorbic acid 231
Asperger's syndrome 75
Aspergillus niger 245
Asphyxiating gases 618
Aspiration
acute 236
recurrent 164
Aspirin 474
Asplenia, anatomic 412
Asterixis 132
Asthma 163, 238
acute 236
bronchial 104, 237
Ataxia 133
telangiectasia 318
Ataxic dysarthria 318
Ataxic gait 318, 322
Atelectasis 162
Atmospheric pressure 382
Atonia 153
Atopic dermatitis 570
Atresia, congenital 84
Atrial fibrillation 535f, 538
Atrial myxoma 112, 117
Atrial natriuretic peptide 46
Aubergine sign 553
Auditory canal, external 243, 252, 253
Aura 142
Autism 75
Autoimmune 282, 324
conditions 295
disease 68, 73, 455
disorders 28
thrombocytopenia 56
Autonomic cephalalgias, trigeminal 370
Autonomic dysfunction 132
Autonomic function 141, 153
Avil 279
Axillary nerve injury 593
Axillary node 80
Axonal injury, diffuse 129
Azithromycin 389, 630
B
Babesiosis 28
Bacillus anthracis 405
Bacillus calmette-guérin vaccine 394, 409, 413, 417
Bacillus cereus 665
Back pain 20
management of simple 483
nonpharmacological modalities simple 483
pharmacological therapy simple 483
Bacteremia 388
Bacterial cultures 171
Bacterial endocarditis 679
Bacterial fermentation, translocation of 85
Bacterial hydrolysis 441
Bacterial infection 184, 625f
secondary 168
suspected 171
Bacterial labyrinthitis, acute 655
Bacteroides 4
Baker's cyst 471
Balance error scoring system 125
Balanitis xerotica obliterans 545
Ball and socket joint 593
Barbiturates 318
short-acting 375
Bariatric surgery 673
Barium swallow 232
Barotrauma 242
Barr virus 297
Barrett's esophagus 234
Bartonella quintana 437
Basal cell cancer 436
Basal ganglia diseases 321
Baylor bleeding score 345
Becker's muscular dystrophy 320
Bedside glucose
measurement 133
testing 176
Bedside testing 231
Behçet's disease 300
Bell's disease 76
clinical suspicion of 76
Bell's palsy 72, 73, 75
cause of 72
diagnosis 75
confirmation of 76
differential diagnosis for 74b
pathogenesis of 73
Bell-Clapper deformity 586
Benzocaine 182
Benzodiazepine 147, 148, 151, 287, 380
Benzyl benzoate 609
Beriberi 282
Berlin edema 270
Bernard-Soulier syndrome 54, 56
Beta-haemolytic streptococci, group A 247
Bethesda system 327t
Bevacizumab treatment 358
Bicuspid aortic valve 101
Biliary cirrhosis 112, 114
Biliary obstruction 442
Bilirubin, metabolism of 442f
Biopsy
image-guided 79
vacuum-assisted 79
Biphasic fever 300
Birmingham eye trauma terminology 262, 265b
Birth injury 74
Bisacodyl 22
Bitot spots 443
Bivalirudin 61
Bladder obstruction, presence of 11
Bladder trauma 519
Bleeding
history of 55
managing active 63
mild-to-moderate 70
noninjury-related 56
sources of 345b
Bleeding disorders 52, 54, 56, 57, 59t, 62, 63, 70, 71
classification of 52t, 55fc
congenital 61
diagnosed 55
etiology of 52
inherited 56, 71
laboratory investigation of 60fc
mucocutaneous manifestation of 57
screening 60b
Blood
alcohol content 284
and urine tests 133
counts, differential 491
cultures 88, 297
gases 283
glucose 158
investigations 171
malignancies 282
massive transfusion of stored 52
stained discharge 79
sugar regulation 479
tests 139, 353
traces of 79
urea nitrogen 88, 347, 496
Blood loss 28
acute 28, 31t
chronic 28
Blood pressure 259
low 183
Blood products
administration of 61
components derivation 64fc
transfusion
complications of 68
pitfalls 66
principles of 63
Blood smear 62
peripheral 31, 491
Blood transfusion 35, 443, 496
guidelines 34
effect of 34
Blood-brain barrier 667
Blumberg's sign 4, 8
Blunt injuries 264, 276
Blunt trauma 591
chest 358
Body mass index 670
interpretation of 677t
Body's equilibrium, maintenance of 650
Boerhaave syndrome 101
Bone
deformity of 37
fracture 202, 470
lesions, malignant 473
marrow transplantation 358
pains 326
tissues 474
trauma, evidence of 133
Bony crepitus, presence of 177
Bony tenderness, absence of 40
Bordetella pertussis 388
Borrelia recurrentis 437
Borrelia vincentii 332
Bothersome symptoms 167
Botulinum toxin 26, 645
use of 76
Bowel gangrene 15
Bowel gas, paucity of 17
Bowel obstruction 5, 14, 49, 83, 91fc, 92, 175
causes
of large 84b
of small 84b
Bowel perforation 17
Brachial plexus injury 119
Bradycardia 132, 283
relative 295
symptomatic 539
Bradycardic heart rate 8
Bradykinin 18
Brain
computed tomography of 157
development, disorders of 152
functions, maintain core 128
infarcts, bilateral 317
injury, traumatic 123, 517
malformations 156
natriuretic peptide 48, 107
stimulation, deep 645
tumor 129, 156, 296, 317
Brainstem
infarct, upper 129
neoplasms 375
reflexes 132
absent 134
Breast
biopsy 81
cancer 45
varies, frequency of 77
contralateral 80
disease 77
disorders 77
fatty enlargement of 82
inspection of 80
lesions, vast majority of 77
lump, feeling of 79
mass 79
evaluation of 80
management of 81
mild tenderness in 278
pain 77
evaluation of 77
problems 77
skin, redness of 77
tissue, examination of 177
ultrasonography 78
ultrasound 79
Breathing 134, 158, 161
and circulation, assess 158
exercise 381
holding spells 156
rapid 380
shortness of 380
sounds, bronchial 105
Breathlessness 382
Brincidofovir 404
Bronchial artery 362
embolization 362
Bronchial hyper-reactivity 168
Bronchiectasis 112, 164, 165, 168, 170, 357
Bronchoalveolar lavage 360
Bronchodilator
role of 172
therapy 172
Bronchogenic carcinoma 165, 357
Bronchopneumonia 165
Bronchoscopy
diagnostic 168
flexible 172
Bronchospasm 162
Brucella serology 297
Brucellosis 286, 295, 303
Buck's fascia 553
Budd-Chiari syndrome 48, 441
Bullous emphysema 357
Bullous impetigo, clinical features of 608f
Bupivacaine 314
Burns 175
Burrow's solution 614
Butyraldehyde 619
Bystander 143
C
Cachexia 282
metabolic syndrome 674
Caffeine, avoidance of 78
Calcaneofibular ligament injury 37
Calcium 500
channel blockers 25, 137, 340, 469
Calcium-binding protein B antibody 125
Caliber esophagus, small 233
Canadian C-spine rule 96
Cancer, diagnosis of 77, 79
Candida 572, 573
albicans 520, 573
skin 570
Candidal diaper rash 574f
Candidal stomatitis 525fc
Candidiasis, pathophysiology of 521fc
Cannulas, common 514t
Capillary hemangiomas, simple 578
Carbamazepine 318, 598
Carbon dioxide, pressure of 134
Carbon monoxide 129, 371
poisoning 236, 237, 537, 620
Carboxyhemoglobin 185, 620
Carboxyhemoglobinemia 181
Cardiac abnormalities 168
Cardiac arrest 134, 382
Cardiac disease, structural 539
Cardiac disorders 282
Cardiac examination 144
Cardiac failure 501
Cardiac output 31
Cardiac tamponade 236
Cardiac traumatic hemolysis 28
Cardiac troponin 106
Cardiac valves, defective 28
Cardiocirculatory arrest 620
Cardiopulmonary compromise 557
Cardiopulmonary diseases 162, 182
Cardiopulmonary illness 184
Cardiorespiratory arrest 132
Cardiovascular abnormalities 234
Cardiovascular collapse 149
Cardiovascular diseases, chronic 412
Cardiovascular disorders 620
Cardiovascular system 543
Carnett sign 21
Carotene 181
Caspofungin 524
Catamenial hemoptysis 358
Catheter thrombolytic therapy 474
Cat-scratch disease 486
Causes of death, injury-related 508f
Cefazolin 476
Cefuroxime 476
Celiac disease 18, 20, 22, 112
Cell
area of network of 142
culture 528
Cellulitis 424, 470, 475, 540, 542, 603
clinical features 603
etiology 603
management 604
treatment 604
Central nervous system 69, 128, 129, 135, 152, 154, 164, 177, 283, 295, 374, 384
infection of 176
pathology, history of 143
Central retinal
artery occlusion 274, 276
vein occlusion 274, 276
Central venous pressure 31
Cephalexin 476, 630
Cephalosporins 475, 607, 630
Cerebellar ataxia 318
Cerebellar disease
bilateral 318
unilateral 318
Cerebellopontine angle tumors 74
removal of 74
Cerebral cortex 170
Cerebral hemispheres 128
Cerebral lacerations 129
Cerebral palsy 317, 321
Cerebral pathologies 141
Cerebral perfusion pressure 130
Cerebral vein thrombosis 371
Cerebrospinal fluid 130, 135, 252, 253, 297, 305, 372, 391, 401
analysis 157
Cervical
disk disease 101, 103
spine 628
sprain 93, 98fc
Cetirizine 279
Charcot-Marie-Tooth disease 319, 320
Chest
computed tomography of 185
injuries 363
tightness 380
trauma 236
tube insertion 518
wall 235
X-ray 75, 110, 335, 360
Chest pain 99, 108fc, 109fc, 231, 362, 382
approach to 110
causes of 99, 100fc, 102t
evaluation of 103
life-threatning causes of 99f
Cheyne-Stokes respirations 132
Chickenpox 396
Chikungunya 437
Child abuse 93
Chlamydia 626
trachomatis 586
Chloride channel activators 140
Chlorpromazine 181, 182, 377
oxidation products of 183
Cholangitis 10, 442
ascending 442
Cholecystitis 10, 16, 442
Cholera
DTP 422
vaccine 420
Cholestasis 443
Cholesteatoma 248
Cholesterol 672
Chorda tympani 73
Choreiform gait 321
Chronic illness, signs of 57
Churg-Strauss syndrome 295
Cidofovir 404
Ciliary neurotrophic factor 300
Ciprofloxacin 246
Circadian rhythm 300
Cirrhosis 49
chronic complication of 51
Cirrhosis-portal hypertension 45, 282
Clarithromycin 389, 630
Clavicle fracture 118, 121fc
Clay-colored stools 442, 443
Clindamycin 231, 476
Clomiphene 82
Clopidogrel 474
Clostridial sepsis 28
Clostridium
botulinum 26
perfringens sepsis 442
tetani 390, 410
Clotrimazole 246, 612
troches 524
Clotting disorder 52
Coagulopathy, correct 69
Cobalamin 623
Cochlear implants 412
Cognitive behavioral therapy 380
Cold
compresses 279
feeling of 326
Coleoptera 423
Colitis 18
Collagen vascular diseases 674
Collateral ligaments 465
lateral 464
medial 464
Colloid cyst 324
Colon, diseases of 137
Colorectal cancer 84, 137
Colorectal resection 86
Coma 128
diagnostic algorithm for 135fc
etiology of 129t
medically induced 128
Combined pill 278
Common bile duct 443
Communicable disease symptom 162
Compartment syndrome 470, 540
Complete blood count 21, 32fc, 60, 88, 96, 120, 145, 259, 276, 335, 371, 460, 543, 628, 667
Concussion 123, 129, 202
standardized assessment of 124
Condylar fracture 449
Congenital disorders 176
Congestive heart failure 163, 175, 183, 184, 237, 357, 444, 469
Conjunctiva 184
Conjunctival tears 265
Conjunctivitis 272, 395, 598
Connective tissue
diseases 38, 455
disorders 487
Consciousness
impaired level of 136
level of 128
loss of 382
state of 128
Constipation 8, 13, 16, 18, 86, 87, 137, 139fc, 175
chronic 22, 137
experience occasional 137
in adult, management of 138fc
risk of 137
Constrictive pericarditis 282
Contraceptive, use of emergency 278fc
Contusion 265
injuries 267
Convulsive status epilepticus, generalized 150
Core biopsy, advanced form of 81
Core needle biopsy 79, 81
Corneal abrasion 268, 268f
Corneal injury, penetrating 266
Corneal reflexes 131
Coronary angiogram 185
Coronary artery disease 104, 237
Coronary heart disease 100
Corpus spongiosum 552
Cortical sensory testing 144
Corticospinal tracts 503
Corticosteroids 69, 494
use of 136
Corynebacterium diphtheriae 389
Costal cartilage 579
Costochondritis 103
Cough 162, 167
acute 167
characteristics of 163, 165t
chronic 168, 173
complications of 163
consequences of ineffective 162
development of 164fc
dry 163, 169
effectiveness of 162
etiologies of 163, 167, 169t
acute 172
evaluation
of chronic 164, 164b, 166fc
of pediatric 171t
management of 172
pediatric 167
mechanism of 163, 164fc
nonspecific 168
normal 168
pathophysiology of 169
productive 163
recurrent 168
sound of 169
traditional recognizable 169t
subacute 168, 173
treatment of acute 173
type of 168
variant asthma 168
wet 169
Cowpox 404
Cramp
severe 500
symptoms for 500
Craniotomy, decompressive 136
C-reactive protein 4, 21, 171, 304, 457, 472, 482, 491
Creatine kinase 335, 505
muscle-brain 107, 240
Creatinine 10, 88, 96, 667
Cresylate acetate 246
Crigler-Najjar syndrome 441
Crimean-Congo hemorrhagic fever 58
Crohn's disease 6, 21, 22, 24, 84, 230, 286
Crotamiton lotion 609
Croup 636
Cruciate ligament
anterior 464
posterior 464, 465
Crush injury 74
Crush trauma 471
Crying episodes, intensity of 176
Crying infant, management of excessively 179fc
Cryoprecipitate 63, 64, 74
Cushing's reflex 132
Cushing's syndrome 320, 670
Cushingoid 281
Cutaneous disease 389
Cutis marmorata 577, 577f
Cyanide toxicity mechanism 622
Cyanosis 105, 114, 181, 186fc, 621
causes of 182t, 187
central 183, 183
deep 183
detection of 184
diffuse 114
etiology of 185
peripheral 183
presence of 183
threshold of 182
treatment of 187
Cyanotic heart diseases, congenital 114
Cyclooxygenase 97, 112, 306
Cyclosporine A 600
Cystic fibrosis 112, 164, 168, 170, 357, 364
suspected 171
Cystic masses 80
Cytomegalovirus 295, 303, 487
D
Da Costa's syndrome 531
Dabigatran 61
Danazol 82
Dapsone 182
Darier sign 576f
Decongestants 172, 279
Deep vein thrombosis 385, 470, 474
Defecography 139
Dehydration 175, 334, 374
Demyelination 317
Dengue 295
Dense adhesions 90
Dental problems 193
Dental surgery, bleeding after 204
Dental trauma 201
types of 201
Deoxyhemoglobin 181, 182, 185, 186
levels of 184
Depression 680
history of 652
Dermal melanosis 574
Dermatitis 486
Dermatomyositis 320, 455
Desmopressin 66
Detoxification of cyanides, mechanism of 623
Dexamethasone 375
Dexogenation, clinical signs of 183
Dextromethorphan 172
Diabetes
mellitus 471, 475, 478, 669, 680
risk for 670
Diabetic foot ulcers 477, 478
treatment of 479
Diabetic ketoacidosis 19, 130, 666
Diaper dermatitis 570, 573, 601
etiopathogenesis 601
management 602
Diaper, type of 602
Diarrhea 20
chronic 19
Diazepam 149, 375, 500
Dicloxacillin 476
Dieulafoy's disease 357
Dieulafoy's lesion 347, 495
Dimorphic anemia 31
Diphenhydramine hydrochloride 655
Diphtheria toxoid 410, 414
Diphtheria-tetanus-pertussis 407, 417
Diplegic gait 317
Diptera 423
Direct fluorescent antibody 402
method 528
testing 402
Disimpaction 22
Disk herniation 95
central 483
Dislocation without fracture, treatment of 309fc
Disseminated intravascular coagulation 28, 53, 54, 56, 69, 358
score 70t
Diuretic therapy 49
high doses of 49
intolerance to 49
Diverticular disease 5, 84
clinical suspicion of 5
Diverticulitis, acute 1, 5
Diverticulosis 5, 137
Dix-Hallpike maneuver 653
Dix-Hallpike position test 654f
Dizziness 58, 382, 650
Dolichocolon 5
Dorsal dislocation, treatment of 309fc
Dorsiflexion 36
Doxycycline 231
Drool rash 574f
Dropped head syndrome 502
Drug
abuse 128
antifungal 524
class of 11
fever 296
intoxication 130
overdose 130
reaction 236
toxicity 132
Drug-resistant Streptococcus pneumoniae 391
Dubin-Johnson syndrome 441
Duchenne muscular dystrophy 320
Duct
ectasia 78
inflammatory lesion of 78
localization of affected 79
Dysarthria 318
Dysdiadokokinesia 318
Dysfibrinogenemia 61
Dyslipidemia 104, 669
Dysmetria 318
Dysmnesic symptoms 145
Dysmorphic erythrocytes 349
Dyspepsia 22, 99
functional 19
Dysphagia 19, 229, 598
specific disorders causing 233
symptoms, evaluation of 232fc
transfer 230
Dyspnea 58, 183, 235, 282, 380
acute 241fc
causes
of acute onset 236b
of chronic 237b
etiologies of acute 238t
evaluation of 236
profile, multidimensional 235
Dysrhythmias 175
Dystonia 449
causes 667
reducing 645
Dystonic reaction 449
Dystonic torticollis 642
E
Ear
complete examination of 244
discharge 252, 254
causes of 253t
dry 246
fullness of 243
symptoms of 251
infection
external 242
middle 242
itching of 254
pain 243
plugs 245
pulling of 176
wax 242
Earache 242
Ecchymoses, location of 38
Ecchymosis 470, 471
Echocardiogram 185
Echocardiography 107
Ecstasy 129
Ectopic pregnancy 10
Eczema 245
infantile 574, 575f
Effort syndrome 531
Ehler-Danlos syndrome 54, 101, 456
Electrolyte 88, 96, 160, 335, 667
imbalance 12, 90
rich fluid, loss of 85
Elephantiasis 540
Emergency contraception 277
Emergency department, seizure in 147, 148fc
Emergency medical service 339, 510
Emergency medications 559
Emergency thoracotomy 518
Emotional stress 77
Emphysema 162
Empyema 112, 117, 388
Encephalitis 129, 152, 177, 296, 395, 565
Endemic fungi 164
Endocarditis, infective 112, 117
Endocrine
abnormalities, multiple 576
disorders 29, 137
Endocrinology disorders 675
Endogenous 53
Endolymph 651
Endometriosis 19, 84
Endoscopic retrograde cholangiopancreatography 445, 446
Endoscopic ultrasound 446
Endoscopy 497
Endothelial injury 53
Endothelin 46
Endotracheal tube 359
Enemas 22
Enteric fever 303
Enteric nervous system 19
Enteritis, regional 2
Enterocolitis, necrotizing 17
Enteroendocrine cells 665
Enzyme
deficiency 28
linked immunosorbent assay 460
Eosinophil 171
Eosinophilia 169
Eosinophilic esophagitis 18
Ephemeroptera 423
Epidermal necrolysis 600t
Epididymis 584
Epididymitis 351, 585, 591
Epidural hematoma 129
Epigastric artery, inferior 584
Epiglottitis 236, 388, 636
Epilepsy 141
recurrence 154
subsequent 154
Epistaxis 256, 355
management of 258, 258fc, 261
Epithelial cells, desquamated 246
Epitrochlear area, right 489
Epitrochlear lymphadenopathy 489
Epley's maneuver 653, 654f
Epstein-Barr virus 295
Erectile dysfunction 555
Erosive esophagitis 18
Erosive gastritis 495
Erysipelas 602
clinical features 603
etiopathogenesis 602
management 603
treatment 603
Erythema toxicum 572, 572f
Erythematous
itchy papules 574
lesions over gingiva 522f
swelling 245
Erythroblast maturation, defects affecting 28
Erythrocyte sedimentation rate 21, 96, 276, 290, 297, 372, 457, 482, 491
Erythromycin 497
deficiency 29
Escherichia coli 4, 245, 247, 462
Esophageal cancer 233, 234
Esophageal dysphagia 230
Esophageal motility, ineffective 232
Esophageal reflux 103
Esophageal varices 495
Esophagitis, acute 230
Esophagus 122, 231
Ethambutol 394
Ethmoidal artery 260
anterior 256
Ethylene glycol 129
Eustachian tube 382
dysfunction 243
Exacerbate angina 105
Examiner's thumb 39
Excessive crying 174
common causes of 175
Exogenous inhibition 53
Extra-abdominal diseases 1, 9t
Extracorporeal shock wave therapy 344
Extractable nuclear antigen 297
Extraocular movements 131
Extraocular muscle involvement 270
Extrapyramidal symptoms 667
Extrasystoles 538
Eye
abnormalities 131
movement, rapid 285
problems 262
F
Facial artery 260
Facial muscle 504
Facial nerve
cells 526
neurinoma 74
palsy 72
pathophysiology of 72
prevalence of idiopathic 72
Facial paralysis, idiopathic 72
Facial swelling 279
Falciparum malaria 442
Famciclovir 529
Familial mediterranean fever 19
Fasciitis, necrotizing 475
Fat
embolism 236
necrosis, traumatic 80
Fatigability 146
Fatigue 27, 284
causes of 288t
Febrile convulsion 153
Febrile seizure
complex 154
simple 153
treatment of 158
Fecal impaction 138, 139
Femur fracture 513
Fentanyl 562
Ferguson hemorrhoidectomy 367
Ferrous sulfate 231
Fever 126, 152, 243, 244, 294
evaluation for 303fc
history of 155
pathophysiology of 296fc
relapsing 300
types of 294
without localizing signs 299
Fiber supplements 140
Fiberoptic bronchoscopy 361
Fibrin clot formation 53
Fibrinogen 62
degradation products 61
disorders 52
congenital 54
level, measurement of 61
Fibroadenoma 80
Fibula fracture, distal 41
Fibular compression test 39
Fine-needle
aspiration cytology 81, 327, 492
biopsy 328
Finger and nail problems 307
Finger dislocation 307
Finger nail 245
avulsion 310
Finsterer study table 73
Fire smoke, toxicity of 619
First aid 500
Fissure 20
Fissurectomy 26
Fissure-in-ano, etiology of 24
Fistula 20
Fitz-Hugh-Curtis syndrome 2
Flaccid blisters 598
Flail chest 512
Flexion 132
contracture 310
Fluconazole 524, 612
Fluctuation test 113
Fluid
administration 176
ascites, accumulation of 45
imbalance 12
restoration 89, 496
wave test 457
Flu-like syndrome 165
Fluorescent bulbs 184
Fluoroquinolones 388
Focal motor seizures 142
Focal myositis 502
Focal nonmotor seizure 142
Focal seizures 142
Foley's catheterization 352, 354
Folic acid deficiency 29
Follicular hyperplasia 486
Folliculitis 600
clinical features 600
deep 601
etiology 600
superficial 600
treatment 601
Food
allergy, mediated 19
borne infections 666
lodgment, long-term 194
types of 230
Football sign 17
Foreign body 236, 242, 253, 636
aspiration 164, 175
intraocular 265
suspected 171
underneath nail 313
Foreskin score, etractability of 546
Formaldehyde 619
Fosphenytoin 149
Fracture
Allman classification of 119f
mid-clavicle 121
of distal third 119
of medial third 119
Fresh frozen plasma 63, 64, 67, 362
indications for 65b
Friedreich's ataxia 318
Frostbite 605
clinical features 605
pathophysiology 605
risk factors 605
treatment 606
Functional disorders 19
Fungal debris 246
Fungal infection 165, 295
chronic 300
Fungus culture 360
Furious rabies, stages of 566
Fusobacterium 626
G
Gabapentin 469
Gait abnormalities 316, 321
types of 317
Gait disorders, classification of 316, 316t
Gallbladder
disease 18
palpable enlarged 444
Gallstone ileus 84
Gamma-aminobutyric acid 375
receptors 149
Gastric antral vascular ectasia 345
Gastric cancer, causes of advanced stage 46
Gastric varices 495
Gastritis, chemical 18
Gastroenteritis 13, 16, 18
Gastroesophageal reflux 156, 164, 175
disease 18, 165, 172, 237, 377, 626
symptoms of 165
Gastrointestinal bleeding 11
risk of 49
Gastrointestinal blood loss 19
Gastrointestinal conditions 101
Gastrointestinal diseases 674
Gastrointestinal reflux 163
Gastrointestinal system 543
Genetic
defects, inherited 28
disorders 176
syndromes 156
Genital trauma 519
Genitourinary injuries 519
Genitourinary tract symptoms 19
Giant cell arteritis 295
Gianturco steel coils 362
Gilbert's syndrome 441, 443
Gingiva 522
Gingivitis
catarrhalis 331
desquamative 333
fibromatosa 332
necroticans ulcerosa 332
Ginkgo biloba 182
Glans penis 549
Glanzmann's thrombasthenia 56
Glanzmann's thrombocytopenia 54
Glasgow coma
scale 123, 130, 131t, 134, 135
score 241f
Glaucoma emergencies 273
Glenohumeral joint 593
Glenoid fossa 595
Global vaccine action plan 407
Globe injury, closed 267
Globins, structurally abnormal 28
Glucagon 45
Glucocorticoids 668
Glucose-6-phosphate dehydrogenase 445
deficiency 28
Glue n-butyl cyanoacrylate 361
Glutathione synthetase deficiency 28
Glycerin 22
Glycolytic enzyme deficiencies 28
Goiter 280, 323
Gonadotropin-releasing hormone 362
Gonococcemia 455
Goodpasture's syndrome 358
Gout 455, 458
Gouty arthritis 455
Gram stain 360
Gram-positive bacillus 389
Granulation tissue 478
Granulomatous
disease 29
inflammation 486
thyroiditis 324
Graves’ disease 280, 324, 326, 327
Guaiac-positive stool 20
Guillain-Barré syndrome 74, 236, 237, 319, 320
Gum disorders 330
Gum hyperplasia 331
Gut brain 19
Gut obstruction 666
Gynecomastia 82, 496
H
Hair loss 326
Hallucination 146
Hampton's hump 106
Hand muscles, intrinsic 502
Hansen's disease 74
Hard palate 522f
Harlequin color change 577, 577f
Hartmann's procedure 92
Hashimoto's disease 324, 327
Head injury 152
evidence of 38
Head trauma 74, 129, 130, 156, 375, 517
Headache 19, 38, 130, 369, 387
disorders 370t
history, previous 371
mild 278
tension-type 370
Head-to-toe examination 180
Healthcare professionals 404, 406
Healthy sleep, rules of quality of 291f
Hearing 254
aid 245
loss 251, 254
Heart
beating 530
defects, congenital 357
disease 669
congenital 115, 117, 177, 183, 184
cyanotic congenital 112
failure 46, 105, 282, 478, 540
murmurs 114
rate, assess 259
Heartburn 8, 100
Heat cramps 334, 335
Heat edema 334, 336
Heat exhaustion 334, 337
Heat illness 334
drugs contributing to 340b
investigations for 335, 335b
risk factors for 335, 335b
symptoms of 334t
types of 334t, 335
Heat rash 334, 336
Heat syncope 334, 336
Heat tetany 334, 336
Heatstroke 334, 338
Hectic fever 300
Helicobacter pylori
infection 18
stool 21
Hemarthrosis 61
presence of 57
traumatic 449
Hematemesis 8, 15, 345, 355, 496
Hematochezia 15
Hematogenous pathway 46
Hematologic disease
spectrum of 52
symptoms of 586
Hematoma 21, 471
Hematopoietic neoplasms, primary 29
Hematuria 348
causes of 349t
evaluation of 353fc
glomerular 352
nonglomerular 352
Heme, types of 187
Hemiparesis 132
Hemiplegic gait 317
Hemiptera 423
Hemoconcentration 6
Hemoglobin 27, 33, 182, 346
abnormal 182, 185
classification on 31
deoxygenated 182
electrophoresis 31
greenish derivative of 182
H disease 32
levels 30t
synthesis, deficiencies affecting 28
Hemoglobinopathy 412
Hemolysis 443, 444
chemical 68
Hemolytic anemia 300
Hemolytic disease 28
Hemolytic reaction 68
Hemolytic uremic syndrome 13, 28, 62
Hemophilia 54, 204, 205, 257, 455
A 52, 61, 66, 69
B 52
Haemophilus influenzae 247, 305, 387, 409, 412
Hemoptysis 113, 168, 282, 355, 355t, 358, 362
etiology of 357
grading of 356t
minor 355
Hemorrhage 94, 129
cause of internal 511
external 513
intracranial 65, 66, 69, 151
intraocular 163
postpartum 33
subarachnoid 129, 131, 133, 371
Hemorrhagic shock 442
Hemorrhagic stroke 317
Hemorrhoidectomy
complications of 368
excisional 367
stapled 368
Hemorrhoids 139, 365, 368
classification of 365
external 365
internal 365
Hemosiderin 183
Hemostasis
defect mechanism, classification on 53t
disorders 52
primary 53
process, pathophysiology of 53
secondary 53
Hemothorax 119, 122
Hemotympanum 130
Henoch-Schönlein purpura 16, 302, 591
Heparin 52, 474
unfractionated 261
Hepatic encephalopathy 45, 132
Hepatic failure, fulminant 442
Hepatic jaundice 443
causes of 441t
Hepatic metastasis 49
Hepatic veins 45
Hepatitis 397
A 298, 396, 418
vaccine 411
virus 396
B 397, 409, 417, 418, 422, 505
immune globulin 398
surface antigen of 398
vaccine 411, 413, 414
vaccines, vaccination of 398t
virus 397
C serologies 505
chronic active 112
Hepatoblastoma 303
Hepatocellular dysfunction 441
Hepatocellular injury 447
Hepatocellular liver disease 29
severe 28
Hepatopulmonary syndrome 237
Hereditary afibrinogenemia 54
Hereditary bleeding disorders 53
Hereditary elliptocytosis 28
Hereditary spastic paraparesis 317
Hereditary spherocytosis 28, 32
Hernia 13, 21
strangulated 3, 6
Herpes labialis 527fc
causes of 526fc
pathophysiology of 527
Herpes simplex 73, 74
virus 24
Herpes skin test 528
Herpes zoster 74, 101, 103, 393, 606
clinical features 606
etiopathogenesis 606
management 607
ophthalmicus 606
oticus 606
rule out of 75
treatment 607
viruses 73
Hexokinase deficiency 28
Hiatal hernia 18
Hiccup 374
bout 374
Hinge joint 464
Hip muscles 502
Hirschsprung's disease 13, 15, 16, 17
Histamine 18
Histiocytosis 303
malignant 295
X 75
Hodgkin's disease 490
Hodgkin's lymphoma 289
Homan's test 471
positive 471
Homeostasis, abnormal 52
Homonymous hemianopia 131
Hormonal changes 330
Hormonal disorder 78
Hormonal influences 94
Hormone replacement therapy 80
Horn cells, anterior 503
Hot fluids 384
Human immunodeficiency virus 24, 163, 280, 286, 295, 300, 371, 411, 471, 487, 549, 586, 609
infection 74
Human papillomavirus 393, 410, 422, 549, 610
vaccine 419, 421
Human tetanus immunoglobulin, dose of 639
Human tissues, invasion of 433
Humoral intraosseous access 514f
Huntington's disease 321
Hydatid cyst 357, 363
Hydatid torsion 590
Hydration 136
status 14
Hydro-air levels, presence of 6
Hydrocephalus 129, 133, 152, 375
Hydrocortisone 602
Hydrogen
cyanide 618
sulfide 182
Hydrophobia 402, 565
Hydrotherapy 305
Hydroxocobalamin 621, 624
Hyperbaric oxygen therapy 476, 621, 622
Hyperbilirubinemia
congenital 443
conjugated 441
unconjugated 441
Hypercalcemia 129, 494
Hypercapnia 129
Hypercarbia 582
Hyperfibrinolysis 56
Hyperglycemia 129
Hyperkalemia 494
Hypermobile joint syndrome, benign 456
Hypermotility syndrome 449
Hypernatremia 129
Hyperparathyroidism 502
Hyperphosphatemia 494
Hyperplastic candidiasis 522f
Hyperprothrombinemia 54
Hypersplenism 52, 56
Hypersynchronous discharges, uncontrolled 141
Hypertension 20, 104
portal 15, 45, 46, 444
Hypertensive encephalopathy 129
Hyperthermia 128, 129
exercise-induced 296
Hyperthyroidism 296, 320, 679
Hypertrophic cardiomyopathy 144
Hypertrophic osteoarthropathy 112
Hypertrophic pulmonary osteoarthritis 113
Hypertrophied papilla 24
Hyperuricemia 457
Hyperventilation 136, 379
cause of 379
physiological effects of 379
symptoms of 379, 380t
Hypoalbuminemia 540
Hypocalcemia 138, 494, 500
Hypochondrium pain
left 2
right 2
Hypoglycemia 129, 130, 144, 152
Hypogonadism
primary 82
secondary 82
Hypomagnesemic muscle 500
Hyponatremia 129
Hypoproteinemia 282, 469
Hypotension 101, 130, 302
cause 134
Hypothalamic-pituitary-thyroid axis 325f
Hypothermia 129, 130, 183
Hypothyroidism 21, 78, 129, 137, 138, 320
Hypoventilation 582
syndromes 182
Hypovolemia 85
Hypovolemic shock 183
Hypoxia 112, 129, 130, 384
Hypoxic encephalopathy 132
I
Iatrogenic pulmonary rupture 363
Ibuprofen 306
Ice fomentation 462
Ichthyotic scales 578
Icterus 105
prolonged 114
Idiopathic scrotal edema, acute 591
Idiopathic syndrome 72
Idiopathic thrombocytopenic purpura, acute 68
Ileus
functional 8
paralytic 83, 89
Illiac fossa pain
left 2
right 2
Illicit drug 104
Illness symptoms, severe 479
Immersion injuries, suggestive of 178
Immune
hemolytic anemia 32
system disorder 74
thrombocytopenic purpura 54
Immune-deficiency syndromes 24
Immune-mediated injury 29
Immunization 152, 422
passive 568
pre-exposure 568
Immunodeficiency diseases 25, 248
Immunoglobulin E 19, 171
Immunohistochemistry tests 81
Immunosuppressive diseases 475
Impacted tooth 242
Imperforate hymen 19
Impetigo 607
clinical features 607
etiology 607
treatment 607
Implant
bleeding after 205
placement 204
Incisional biopsy 81
Incontinentia pigmenti 576, 576f
Infantile colic 16, 175
affects 177
diagnosing 180
Infection 154, 169, 470, 487, 591
anaerobic 169
cases of suspected 171
dermatophyte 612
enteroviral 300
extra-abdominal 14
illness, signs of 144
localized 174
mycobacterial 490
respiratory 176
symptoms of 155
unusual 295
viral 184, 240
Infectious disease, recent 73
Infectious mononucleosis 303, 625, 626f
Inferior vena cava 240, 241f
Inflammation
acute 490
signs of 456
chronic 455
low-grade of 455
Inflammatory bowel
disease 2, 16, 18, 22, 84, 86, 112, 114, 117, 138
family history of 19
Inflammatory diseases 300
Inflammatory joint disease 321
Inflammatory obstructive disease 163
Influenza 74, 387, 422
vaccine 410
inactivated 418
Inframammary crease 80
Inguinal hernia 586
large 591
obstructed 13, 15, 16
Inhalation, management of victims of 618
Initiate diuretic therapy 49
Insect bite 175, 423, 439fc
Insomnia 94, 375
Inspiratory stridor 632
Intensive care unit 134, 358, 438
pediatric 179
Intercostal muscle 162
Interdental gingiva 196
Intermittent fever 300
International League against Epilepsy 142, 142f
Interphalangeal dorsal dislocation, classification of proximal 308fc
Interphalangeal joint
distal 455
proximal 309fc
Interstitial fluid 45
Interstitial lung disease 112, 164, 172, 183, 237
severe 181
Intestinal Candida albicans 602
Intestinal ischemia 4, 9
Intestinal obstruction 1, 13, 1517, 667
causes of 5
suspicion of 10, 12
Intestinal occlusion, causes of 6t
Intimal tears 362
Intra-abdominal
disorders 1
injuries 583
mass 14
pressure 163
Intracranial neoplasms 375
Intracranial pathway, longest 72
Intracranial pressure 130, 175
Intractable hiccups 374
causes of 375b
Intraductal papillomas 78
Intranasal instillation 149
Intranasal lidocaine 373
Intranasal steroids 172
Intraocular pressure 373
Intraocular steroids 279
Intraparenchymal hemorrhage 129
Intrapulmonary shunts 183
Intrathoracic injuries 122
Intravenous
access 176
diazepam 160
equipment 559
fluid 16, 500
fosphenytoin 160
immunoglobulins 600
ketamine 563
levetiracetam 160
lorazepam 159, 160
midazolam 159
narcotics 368
phenobarbital 160
phenytoin 159
secure 158
valproic acid 160
Invasive ductal carcinoma 79
Invasive mycetoma 357
Iodine
deficiency 324
radioactive 328
Ipsilateral pontine infarction 74
Iris injuries 269
Iron 675
binding capacity, total 31
defficiency anemia 34
deficiency 29
anemia 28, 32
sequestration, inflammation-mediated 29
supplements 137
Irrigation impairment, presence of 83
Irritability, general 193
Irritable bowel syndrome 2, 18, 19, 137
Irritant 245
diaper dermatitis 573f
Irritating gases 619
Irritation, chemical 170
Isabgol 366
Ischemia 6, 14, 83, 85, 87
and eventually necrosis 85
and subsequent necrosis 5
stimulate visceral pain fibers 14
Ischemic colitis 5, 84
Isobutyl-2-cyanoacrylate 362
Isolated axillary lymphadenopathy 77
Isoniazid 151, 394
Isoptera 423
Isotonic fluid 89
Itching 245
Itraconazole 612
Itraconazole solution 524
J
Janeway lesions 114
Japanese encephalitis 401, 409, 418
vaccine 411, 416
virus 401
Jaundice 114, 440, 496
causes of posthepatic 441t
differential diagnosis of 446fc
duration of 443
management of 446fc
mild 442
recurrent 443
types of 440f
Jaw dislocation 448
Jerky nystagmus, abnormal 653
Joint
capsule, shortened 36
complex 464
deformity of 37
disease, degenerative 466
hypermobility syndrome 456
instability, risk of 37
muscle-dependent 593
related conditions 38
structure 456
swelling 20, 456
Joint pain 453, 462, 471
acute 454
asymmetric 455
causes of 458t
chronic 454
clinical history 453
distribution of 455
evaluation of 457
examination of 456
involvement of number of 455
laboratory tests 457
location of 454, 455
past medical history 455
physical examination 456
role of surgery 463
symmetric 455
treatment 461
worsening factor 455
Jugular venous pressure 105
Juvenile idiopathic arthritis 302, 455
K
Kala-azar 303
Kaposi sarcoma 312
Kawasaki disease 300, 302
Keratic precipitates 273
Ketamine 562, 563
intramuscular 563
Ketoconazole 281
Ketofol 562, 563
Kidney
disease, chronic 374, 499
function test 146
injury, acute 69
Klebsiella 357, 600
pneumoniae 586
Kleiger test 3840
Knee
dislocation of 465
injuries 466
locked 466
stability 464
swelling 465
Knee joint 457, 466
clinical examination of 465
Knee problems 464
anatomy of 464
Kocher's leverage technique 594
Kyphoscoliosis 237
L
Lactate dehydrogenase 297, 491, 505
Lactulose 22
Lamellar laceration 265
Lamotrigine 598
Langerhans cell histiocytosis 300
Lansoprazole 22
Laparoscopic management 90
Laparoscopic surgeries 14
Laparotomy 90
Large bowel
obstruction, red flags of 86b
red flags of 86
Laryngeal edema 236
Laryngeal lesion, benign 661, 663
Laryngeal tumor, benign 657, 658, 660
Laryngitis 242, 657, 658, 659, 660, 662
Laryngomalacia 636
Laryngospasm 236
Laryngotracheitis 632
Laryngotracheomalacia 172
Larynx, surgery on 231
Lassar's paste 602
Laxatives 366
Lead poisoning 19, 28
Leduc technique 476
Leg pain, acute 468
Legionella 357
pneumonia 240
Legionellosis 295
Lemierre's syndrome 629
Lepidoptera 423
Lepirudin 61
Leprosy 74
Leptospirosis 295, 300
Lethal agents 618
Leukemia 24, 74, 295, 300, 303, 332, 609
acute 29, 490
inhibitory factor-m 300
Leukocytosis 5
Levetiracetam 149
Levine's sign 104, 105
Levodopa 675
Levothyroxine replacement 328
Lichen planus 230
Lid lacerations 265
Lidocaine 378
Life-threatening 68, 174
bleeding, locations of 513b
conditions 8
thoracic injuries 512t
Ligament
of treitz 496
previously injured 36
Lignocaine 314
Limb
asymmetry 144
coldness of affected 37
neurovascular damage of 38
Limb-girdle involvement 502
Lincosamides 630
Lindane cream 609
Linezolid 74, 475
Lip licking 142
Lipoprotein, high-density 672
Liquid albumin 48
Lithium 318
Live attenuated influenza vaccine 411
Liver
biopsy 445
cancer 397
cirrhosis 45, 397
disorders 441
failure 397
function test 10, 21, 133, 146, 297, 335, 376, 460
transplantation 49
Liver disease 54, 56, 62, 358, 496
advanced 45
chronic 29, 54, 57, 412, 469, 499
end-stage 443
progression of 46
sever 66
signs of 62
Lobar pneumonia 165
Local wound 424
care 436
Locoregional treatment 80
Lovibond's angle 113, 114
Low back pain 481, 483t, 484
causes of 481, 481t
diagnostic imaging 482
evaluation of 481
laboratory tests 482
management of 483
treatment for 483t
Low molecular weight heparin 61
Lower extremity pain 468
causes 468
clinical presentation 470
evaluation 470
pathophysiology 469
Lower extremity ulcers 476
causes 476
clinical presentation 478
evaluation 477
history 477
pathophysiology 477
treatment 479
Lower limb fracture 321
Lower lobe pneumonia 16
Lumbar pain
left 2
right 2
Lumbar puncture 65, 133, 135, 157, 372
Lumpiness 79
Lung
cancer 112
primary 164
carcinoma 114
chronic infections of 165
contusions 122
function test 172
injury, transfusion-related acute 68
point 240
sliding 240
varcinoma of 281
Lung disease
chronic obstructive 183
drug-induced 236
immunologic 358
occupational 237
severe chronic 171
suppurative 171
Lung elastic recoil 162
reduced 162
Lupus anticoagulants 59
Lupus erythematosus 295
Lupus like syndrome 456
Lyme disease 295
Lymph 45
drainage 476
Lymph node 488, 489
benign 493t
enlarged 486
group of 485
malignant 493t
regions 485f
retroauricular 489
Lymphadenitis, acute 486
Lymphadenopathy 105, 280, 443, 485, 491
causes of 487t
localized 488t
clinical evaluation 486
etiology 486
peripheral 491
treatment of 494
Lymphangitis 476, 604
clinical approach 604
etiology 604
management 605
treatment 605
Lymphatic capillaries 45
Lymphatic flow 45, 46
Lymphatic vascular system 45
Lymphatic vessels 46
Lymphedema 476, 540
Lymphoma 19, 45, 74, 112, 295, 300, 303, 490
Lymphoproliferative disorders 487
M
Macrolide 388, 389
therapy 172
Maculopapular skin rash 395
Magnesium 500
citrate 22
hydroxide 22
Malabsorption syndrome 680
Malaria 28, 295, 303
chronic 282
Malarial antigen 297
Malassezia furfur 571
Malignant cells, dissemination of 46
Malignant diseases, history of 73
Malingering 95
Malleolus, medial 40
Mallory-Weiss tear 101, 495
Malnutrition 332, 374
Malrotation 178
Mammography 79
Mandible fracture 449
Mantoux test 171
Markle's sign 4
Mass
malignant 79
parotid 75
Massive hemoptysis 356
management of 363fc
Massive hemothorax 512
Massive pleural effusion 236
Mastalgia 77
etiology of 77
management of 78
refractory cases of 78
Mastoiditis 74, 243
Maternal drug ingestion 175
Maternal tetanus 410
Maxilla, instability of 130
McCune-Albright syndrome 576
Mean arterial pressure 135
Mean corpuscular
hemoglobin 29
volume 32
Measles 395, 410
vaccine 415
Meatal stenosis 548
Mechanical causes 342
Mechanical injury, result of 36
Meclizine 655
Mediastinal tumors 165
Medical Research Council 235
Mefenamic acid 306
Megaloblastic anemia 32
Melanin 181
Melanoma 436
Melanotic pigment 183
Melena 3, 15, 289, 495, 496
causes 495
clinical features 495
initial evaluation 496
management 496
Melkersson-Rosenthal syndrome 75
Membrane lipid abnormalities 28
Meniere's disease 242
Meningeal signs 155
Meningismus 133
Meningitis 129, 152, 177
Meningococcal meningitis 392
Meningococcal vaccines 411
Meningococcemia 392
Meningococcus 392
Menometrorrhagia 61
Menorrhagia, history of 58
Menstrual cramps 19
Menstrual cycle 77
Mental deterioration 3
Mental status, altered 126
Mental stress 146
Mesenteric adenitis 13, 16
Mesenteric artery syndrome, superior 84
Mesenteric ischemia 1, 9
acute 5
chronic 4
Mesenteric lymphadenitis 16
Mesenteric vessels atherosclerosis 4
Metabolic acidosis 3, 236, 537
Metabolic alkalosis 85
Metabolic causes 666
Metabolic derangements 128
Metabolic disease 74
Metabolic disorders 132, 137, 143
diffuse 131
Metabolic disturbance 144
Metabolic storage disease 144, 487
Metabolism, inborn errors of 175
Metachlorpromide 79
Metastatic cancer 112, 357
Metastatic carcinoma 490
Metastatic epidural tumor 483
Metastatic infiltration 486
Metastatic neoplasms 29
Metformin 665, 675
Methanol 129
Methemalbumin 181, 182, 186
Methemoglobin 181, 185, 186, 623
Methemoglobinemia 181, 182, 184, 186, 237
Methicillin 475
resistant Staphylococcus aureus 476
Methylphenidate 378
Metoclopramide 182, 377, 497
Metronidazole 665
Metyrapone 281
Micafungin 524
Miconazole 612
Microangiopathic hemolytic anemia 28, 69
Microcalcification, form of 81
Microcytic hypochromic anemia 29
Micrognathia 558, 631
Microlaryngeal surgery 662
Microsporum canis 611
Microvascular thrombi 69
Micturition, painful 598
Midazolam 149, 150, 160, 378, 562, 563
buccal 160
intramuscular 160
Midgut
structures 14
volvulus 16, 17
Migraine, abdominal 19
Milch technique 595
Milia 571
Miliaria crystallina 571
Miliaria rubra 571, 571f
Miliary tuberculosis 442
Miller-Fisher syndrome 74
Milligan and Morgan hemorrhoidectomy 367
Minimally invasive therapy 551
Miscarriages 395
Mitotane 281
Mitral stenosis 357
Mittelschmerz 16, 19
Moebius syndrome 75
Molecular genetic techniques 492
Molecular weight heparin 474
Mondor's disease 554
Mongolian spots 570, 574, 575f
Monkeypox 404
Monospot test 628
Moraxella catarrhalis 247
Morbillivirus 395
Motor cortex 503
Motor dysfunction 132
variety of 132
Motor loss 470
Motor neuron disease 319
Motor vehicle
collision 96
traffic 123
Mucociliary function, enhances 169
Mucoid 252
Mucolytics 172, 173
Mucopurulent conjunctivitis 262
Mucosa 367
buccal 522
nasal 198
Mucosal ring 230
Mucous membrane 598
pale 57
Mucus production, excessive 169
Müllerian and Wolffian ducts 590
Multifocal myoclonus 132
Multinodular goiter 326
Multiple ribs, fracture of 579
Multiple trauma 508
management of 508
primary survey 510, 510b
secondary survey 515
treatment 517
Multisystem organ dysfunction 69
Mumps 395, 410
vaccine 416
Murmur 105
Muscle
atrophy, beneficial role in 507
biopsy 506
diagnosis of 473
diseases, progressive 504
disorders, primary 502
group wasting, individual 504
hematoma 61
pain 502
relaxants 368
spasm 95
tone 503
Muscle cramp 499, 502
causes of 499
clinical presentation 499
etiology 499
investigations 500
management 500
risk factors 499
Muscle wasting 501, 502
clinical evaluation 502
diseases 504
distal 504
field of 506
pathophysiology 501
proximal 504
treatment 506
types of 504t
Muscle weakness 505
localization of 505t
Muscular dystrophy 320
Musculoskeletal causes 101
Musculoskeletal injuries 42, 43, 519
Musculoskeletal syndromes 102
Mushroom poisoning 283
Mustard oil like urine 443
Myalgia 387
Myasthenia gravis 74, 231, 237, 502, 657
Myasthenic crisis 236
Mycobacterium 586
tuberculosis 394
Mycoplasma 626
pneumoniae 597
Myelodysplasia 29
Myelodysplastic syndrome 32, 295
Myelofibrosis 32
Myelopathy 95
Myeloproliferative disorders 29, 56
Myenteric plexus 83
Myocardial infarction 9, 104, 134, 184, 382
acute 9, 99, 102, 240
Myocarditis 184
Myoclonic jerking 153
Myopathic gait 320
Myostatin inhibition 507
Myotonia 502
Myotonic dystrophy 320
Myringotomy 248, 249
Myxedema 49, 469
N
N-acetylcysteine 590
Nafcillin 476
Nail
avulsion 311fc
of hands, clubbing of all 115f
root dislocation 311
Nail bed 184
ecchymosis 312
hematoma 312
injury 311
laceration 313
Naloxone 445
Nasal cavity 256
Nasal congestion 175
Nasal packing
anterior 260
posterior 260
Nasal secretions, clearing of 172
Nasal spray 387
Nasal vasoconstrictors 248
Nasogastric decompression 16
Nasogastric lavage 497
Nasogastric tube 6, 11, 89, 256
placement 90
Nasopharyngeal aspirate 171
Natriuretic peptide, B-type 46, 48, 239
Nausea 19, 126, 132, 146, 664
Neck
lymphadenopathy 79
muscle 504
pain of 243
space infection, deep 177
stiffness 95
trauma 517
zones of 517f
Necrotic tissue 478, 480
Necrotic venom 434
Negri bodies 565
Neisseria
gonorrhoeae 586, 626
meningitidis 392
Neodymium-doped yttrium aluminum garnet 361
Neomycin 246
Neonatal skin lesions, benign 571
Neoplasm 84, 143, 152, 230
Nephrolithiasis 2, 351
Nephrotic syndrome 49
Nerve
compression 499
conduction velocity, slowing of 506
diseases, peripheral 320
entrapment 321
ganglion, trigeminal 526
peripheral 503
Nervous stress 375
Nervous system 177
peripheral 505
Neuralgia 200
trigeminal 242
Neurinoma 74
Neuroblastoma 300
Neurocirculatory asthenia 531
Neurocutaneous syndrome 154
Neurodevelopmental disorders 171
Neurofibromas 576
Neurofibromatosis 574, 576f
Neurohormonal system, activity of 46
Neurologic cause 342
Neurologic disease 162, 657
Neurologic illnesses 675
Neurologic signs 371
Neurologic symptoms 371
Neurological complication 362
Neurological disorder 137, 565
Neurological dysfunction 147
Neurological examination 144
Neurological phase, acute 402
Neurological system 623
Neuromuscular diseases 233, 236
Neuromuscular innervation, transmission of 83
Neuromuscular junction 503
Neuro-ophthalmology emergencies 273
Neuropathic gait 319, 322
Neuropraxia, reversible 73
Neuropsychological assessment 157
Neurosyphilis 375
Neurotoxic venom 434
Neurotoxin 639
Neurovascular damage, distal 40
Neurovascular injuries 121
Nevirapine 598
Nevus flammeus 570, 578, 578f
Nevus simplex 577
New York Heart Association 235
Nicotinamide adenine dinucleotide 182
Nifedipine 378
Night blindness 443
Night cramps 499
Nipple areola complex 82
Nipple discharge 78
Nipple retraction 77, 79
Nitrate-containing foods 182
Nitric oxide 25, 45
donor 25
Nitrogen dioxide toxicity 358
Nitroglycerine 25, 182
Nitroprusside 182
Nocturnal enuresis 286
Nodular thyroid disease 324
Nonabdominal diseases, attention to 7
Nonaccidental injuries 175, 178
Nonaccidental trauma 177
Nonasthmatic eosinophilic bronchitis 164
Nonbullous impetigo 608t
Nonconvulsive status epilepticus 148, 155
treatment of 160
Nonheme pigment 184, 187
suspect deposition of 186
Non-Hodgkin's lymphoma 490
Nonimmune disease 69
Non-neurologic complications 134
Non-noxious stimuli 131
Nonproductive cough 163
Nonreactive pupils 371
Nonserious causes 481
Nonspinal causes 481
Nonsteroidal anti-inflammatory drug 11, 41, 84, 97, 126, 195, 231, 244, 298, 328, 368, 372, 461, 483, 496, 542, 547, 582, 617, 665, 675
use of 8, 49
Non-ST-segment myocardial infarction 109
Nontransfusion therapy 66
Nontraumatic causes 468
Nontraumatic ocular emergencies 264, 271
Nonvalvular atrial fibrillation, treatment of 61
Normobaric oxygen therapy 621
Normocytic normochromic anemia 29
Nose 244
blockage 243
discharge from 243
Noxious stimuli 14, 131
Nucleic acid amplification test 398, 401
Nutritional anemia, pathophysiology of 30fc
Nutritional deficiencies 28, 31
Nystagmus 318
Nystatin 246
lozenges 524
suspension 524
O
Obesity 669
Obstipation 86, 87
Obstruction, type of 88
Occipital headache 133
Occlusion, diagnosis for 180
Octreotide 497
Ocular bobbing 131
Ocular congestion 279
Ocular dipping 131
Ocular emergencies, treatment of 275t
Ocular injury, penetrating 264
Ocular muscle 504
Ocular trauma
classification for 265b, 266t
new classification for 266
score 263
Oculocephalic reflex 131, 132
loss of 131
Oculovestibular reflex 131, 134
Odynophagia 229
Ofloxacin 246
Olanzapine 378
Open globe injury 267
Operation theater 283, 368
Opiates 129, 137
Opioid 287
Opsoclonus 131
Optic neuritis 274
Optic tract 273
Oral
anticoagulant therapy 52
anticoagulation, direct 261
antifungals 612
antihistaminics 248
contrast agent 4
hygiene, poor 330
infections 570
polio vaccine 399
poliovirus vaccine 409, 413
problems 520
thrush 525fc
ulcers 20
viscous lidocaine 378
Oral candidiasis 520, 523fc, 573, 573f
causes 520
classification of 520, 521t
clinical presentation 522
etiology 520
evaluation 523
investigations 523
oral herpes simplex 520
pathophysiology 520
primary 521
red flags 523
secondary 521
treatment 524
types of 522
Oral contraceptive 469, 665
dose of 80
pills 79
Oral herpes simplex 525, 528, 529fc
causes 526
clinical presentation 526
etiology 526
evaluation 527
investigations 528
pathophysiology 526
red flags 526
treatment 528
Orchiectomy 589
Orchitis 591
Organic disease 21
Organic disorders 18
Orifice, blockage of 424, 438
Oropharyngeal candidiasis, treatment of 524t
Oropharyngeal disorders 230
Oropharyngeal dysphagia 232t
Orthopnea 282
Orthopoxvirus 404
Orthoptera 423
Orthostatic hypotension 25, 322
Oscillation, high-frequency 644
Osmotic laxatives 140
Osteoarthritis 95, 321, 455, 458
post-traumatic 43
Osteomyelitis 470
Otitic barotrauma 382
Otitis 245
fungal external 245
malignant external 74
media, chronic suppurative 252, 253
mild external 246
Otitis externa 176, 245, 252, 253
malignant 253
Otitis media 74, 175, 176, 247, 249
acute 247, 248
acute suppurative 243, 252, 253
chronic 247249
Otoscopic examination 177, 243, 244, 246, 248
Ottawa ankle rules 41
Ovarian cancer 45, 46
Ovarian cyst 19
Ovarian torsion 13, 16, 175
Overlap syndrome 231
Oxygen
administration 176
saturation 181, 183
supplementation 560
Oxyhemoglobin 181, 185
P
Pain
acute 265
analgesia to reduce 248
character of 103
colicky nature of 14
dental 243
duration of 20, 78
epigastric 2
heel 342, 343fc
hypogastric 2
in percussion 202
killer agents 373t
location of 20, 104
muscular 21
neuralgic 193
psychogenic 95
radiation of 104
referred 14, 193, 198
sciatic 482
severe 7, 236
teething 193
testicular 19
timing of 104
to caries 193
types of 77
umbilical 2
Palatine artery, greater 256
Palmar creases 443
Palmar erythema 496
Palpable solid masses 80
Palpable tender abdominal mass 15
Palpitation 58, 326, 530, 532
arrhythmic causes of 531
causes 530
chest pain 532
clinical presentation 532
continuous irregular 532
diarrhea 532
dyspnea 532
emergency department with 537fc
etiologies of 530, 531t
evaluation 536
intermittent 532
investigations 537
noncardiac causes of 531
pathophysiology 532
physical examination 536
polyuria 532
positional 532
red flags 536
sweating 532
syncope 532
treatment 538
Pancreatic cancer 444
Pancreatic dysfunction 66
Pancreatic mass 442
Pancreatitis 16, 18, 49
acute 442, 625
hepatitis myocartitis 14
severe acute 1
Panduroga 27
Panic attacks 238
Panic disorder 103
Panic syndrome 102
Pantoprazole 22
Papilledema 131, 273, 274
Paracetamol 306
Paracortical hyperplasia 486
Paragonimiasis 357
Paranasal sinuses 256
Paraneoplastic disease 319
Paraphimosis 549, 552
causes 550
clinical presentation 550
etiology 550
pathophysiology 550
treatment 550
Parasite 21
Parasitic worms 407
Parasomnias 286
Parenchymal inflammatory processes 165
Parenteral antibiotic treatment 474
Paresthesia 37, 94, 95, 380
absence of 36
Parietal pain 14
originates 14
Parietal peritoneum 14, 45, 51
Parkinson's disease 137, 233, 317, 647
Parkinson's syndrome 75
Parkinsonian gait 317, 322
Parotitis 74
Paroxysmal crying 176
Partial thromboplastin time, activated 58, 261
Parvovirus B19 303
infection 29
Patch
bluish discoloration 282
testing 597
Patellar dislocation 466
Patellar fracture 467
features in 467
Patellar tap test 457
Pectus excavatum 237
Pedal edema 443, 540
bilateral 543
causes of 540
classification of causes of 541fc
etiology 540
grading of 541t
investigations 543
management of 543
pathogenesis 540
red flags of 540, 541b
Pelvic inflammatory disease 11, 16, 19
Pelvic injury 518
Pelvic malignancy 540
Pelvic metastatic deposits 667
Pemberton's sign 326
Penetrate platysma 518f
Penicillin 475
G, intramuscular long-acting 630
V 630
Penicillinase inhibitors 607
Penile curvature 554
Penile fracture 552
causes 552
clinical presentation 553
epidemiology 552
etiology 552
investigations 554
treatment 554
Penile swelling 553
Pentavalent vaccine 414, 417
Pentobarbital coma 136
Peptic stricture 230
Peptic ulcer 18, 103
disease 19, 20, 101, 495
Percutaneous cholangiography 445
Perfusion, loss of 85
Perianal skin tag 20
Pericardial disease 237
Pericardial effusion 282
Pericardial rub 105
Pericarditis 102, 388
Periodic limb movement disorder 286
Periodontal pain 193, 198
Periorbital ecchymosis 130
Peristalsis 88
absence of 88
Peritoneal carcinomatosis 49
Peritoneal cavity 45, 51, 513
Peritoneal dialysis 164
Peritoneal irritation, indicative of 8
Peritoneal tuberculosis 49
Peritonitis, signs of 7
Periumbilical pain 14
severe 5
Permethrin 609
Pernicious anemia 29
Peroneal tendon syndromes 41
Persistent hiccups 374
Person's overall posture 95
Personal protective equipment 258, 339
Perth-Dundee technique 551
Pertussis 414
Petechiae, presence of 57
Petechial rashes 301
Peyronie's disease 554
Pharmacologic antagonists 559
Pharmacologic therapy 377
Pharyngitis 242, 625
chronic 625
management of 629fc
Pharynx 243
Phenazopyridine 182
Phenylbutazone 598
Phenytoin 149, 318, 598
Pheochromocytoma 237
Phimosis 545
causes 545
clinical presentation 546
etiology 545
evaluation 546
management of 547
pathological 545
physiological 545
secondary 548
techniques 548
treatment 547
Photophobia 19, 598
Phthiraptera 423
Phyllodes tumor 80
Physical activities, decreased 137
Physical hemolysis 68
Physiologic causes 286
Physiologic fatigue 284
Physiological discharge 78
Pierre-Robin syndrome 558
Pigmentation, disorders of 574
Pigments, types of 182t
Pioglitazone 469
Pituitary adenoma 78
Pityrosporum 572
Plantar fascia 343
Plantar flexion 36, 43
Plantar heel pain 344fc
Plasma 513, 519
enzymes 505
normal levels of 64
pooled 59
Plasmapheresis 69, 600
Plasminogen activator inhibitor-1 59
Plasmodium
falciparum 294
malariae 294
Platelet 63, 64, 513, 519
count 61, 62
normal 205
derived growth factor 111
disorder 56
congenital 54
dysfunction 54, 56
function disorders 66
plug, consolidation of 53
Pleural effusion 45, 184, 240
Pleuritic chest pain 101
Pleuritis 103, 237
Plummer-Vinson syndrome 231
Pneumatic balloon dilation 26
Pneumatosis intestinalis 15, 17
Pneumococcal conjugate vaccine 392
Pneumococcal disease 391
Pneumococcal pneumonia 298
Pneumococcal polysaccharide vaccine 392, 412, 418
Pneumococcal vaccine 414
Pneumococcus 391
Pneumonia 14, 16, 19, 103, 168, 183, 236, 238, 357, 388, 583
Pneumoperitoneum 15, 17, 89
Pneumothorax 119, 122, 175, 184, 236, 238
Polio 399
vaccine, inactivated 399
Poliomyelitis 300
Poliovirus
inactivated 422
vaccine
fractional inactivated 417
inactivated 409
Polyarteritis nodosa 19, 300
Polychondritis, relapsing 295
Polycystic ovary syndrome 670
Polycythemia 181, 183
Polyethylene glycol 22, 138
Polymerase chain reaction 72, 297, 393, 402, 404, 528
real-time 395
Polymorphonuclear leukocyte 472
Polymyalgia rheumatica 95
Polymyositis 295, 320
Polymyxin 246
Polyostotic fibrous dysplasia 576
Polyvinyl alcohol foam 362
Pons tumor 74
Pontine tegmental hemorrhage 74
Porphyria 19
Portal hypertension, initial phase of 47
Port-wine stain 570, 578
Posaconazole 524
Post-concussion
symptom scale 124
syndrome 126
Postextubation stridor 637
Post-laparotomy adhesions 6
Postmyringotomy tube 253
Postnasal drip 163
Postpartum hemorrhage, history of 58
Post-thrombolytic therapy 61
Pradaxa 61
Precise neurological examination 371
Preeclampsia 281
Pre-endoscopy barium esophagogram 232
Prefreeze 605
Pregabalin 469
Pregnancy
and children, immunization in 407
test 21
vaccination in 409
Prehepatic jaundice 443
Pressure ulcers, treatment of 480
Primary lump, extent of 80
Prinzmetal angina 100
Procalcitonin 171
Proctoscopy 25
Profile sign 113
Profound symptoms, absence of 184
Progestin-only pill 278
Projectile vomiting 666
Prolactinemia 78
Promethazine hydrochloride 655
Properdin 411
Prophylaxis
postexposure 402, 403, 403t, 405, 568
pre-exposure 403, 569
Propofol 160, 562, 563
Prostacyclins 45
Prostaglandin 18, 112
Prostatic hypertrophy 351
Prostatitis 351
Proteus mirabilis 586
Proteus vulgaris 245
Prothrombin complex concentrate 63, 66
Proton pump inhibitor 22, 346
Proven phyllodes tumors 81
Pruritic eruptions 175
Pruritus 114, 252
Pseudogout 458
Pseudogynecomastia 82
Pseudohemoptysis 355
Pseudo-locking, causes of 466
Pseudomonas
aeruginosa 245
species 604
Pseudoseizures 156
Psoas sign 21
Psoriasis 245
Psoriatic arthritis 455
Psychiatric causes 530
Psychiatric disorder, diagnosis of 530
Psychiatric features 145
Psychiatric origin 530
Psychiatry diseases 675
Psychogenic dysphagia 231
Psychogenic unresponsiveness 132
Psychological stress 100
Psyllium 25
Puberphonia 657, 659, 660
Pulmonary angiogram 185
Pulmonary arteriovenous 112
malformation 237, 357
Pulmonary artery
catheterization 358
pseudoaneurysm 357
Pulmonary conditions 101
Pulmonary contusion 239
Pulmonary disease 162
chronic obstructive 104, 236238
Pulmonary edema 134, 238
Pulmonary embolism 102, 109, 110, 144, 184, 236, 238, 357
Pulmonary fibrosis 163
Pulmonary hemosiderosis, idiopathic 358
Pulmonary hypertension 101, 102, 357
Pulmonary infections 114
Pulmonary injuries 119
Pulmonary interstitial disease 168
Pulmonary renal syndrome 358
Pulmonary thromboembolism 385
chronic 237
Pulmonary tuberculosis 112, 164, 168, 679
Pulmonary tumors 237
Pulmonary vascular diseases 357
Pulmonary veno-occlusive disease 357
Pulp 196
lacerations 313
Pulpitis
irreversible 195
reversible 194
Pulsatile mass 9
Pulse
oximeter measures 185
oximetry 133, 136, 239, 560
peripheral 105
Pupillary presentations 131
Pupillary responses 131
Purpura 443
Purpuric rash 130
Purulent 252
debris 245
expectoration, presence of 169
Pyelonephritis 2, 351
Pyloric stenosis 177
Pyrazinamide 394
Pyrexia 362
Pyruvate kinase deficiency 28
Q
QT prolongation 667
Quadriceps muscle weakness 505
Quartan fever 294
Quinidine 231
Quinine 500
R
Rabies 565
dumb 402
encephalitic 402
exposure categories 568t
immunoglobulin 568
paralytic 402, 566
pathophysiology of 566, 566fc
prevention of 568
prophylaxis 565
etiology 565
host factors 565
vaccine 412, 421
virus 569
Radiculopathy 95
Rading system 37
Ramsay-Hunt syndrome 74, 607
Range of motion 36, 95, 456
Raynaud's disease 282
Raynaud's phenomenon 183
Rectal diazepam 160
Rectal examination, digital 25, 366
Rectal gas, paucity of 15, 17
Rectal prolapse 139
Rectorrhagia 3
Rectosigmoid tumors 84
Rectum 137
collapse of 163
lower, examination of 139
Recurrent intrahepatic cholestasis, benign 441, 443
Red blood cell 63, 205, 348, 513, 519, 620
packed 63, 67
Red cell
aplasia, pure 29
destruction 28, 32
indices 31
infections of 28
production, decreased 28
progenitors, infections of 29
total circulating 27
Red currant jelly stools 15
Red eye, acute 371
Red flag signs 180
Reflex sympathetic dystrophy 43
Reflux esophagitis 374
Refractory ascites 49
treatment of 49
Reiter's syndrome 454, 455
Remittent fever 300
Renal cell carcinoma 295
Renal colic, diagnosis of 10
Renal disease 52, 56, 82
signs of end-stage 57
Renal failure 29
acute 49, 494
chronic 237
Renal function test 145, 297, 376
Renal impairment, severe 11
Renin-angiotensin-aldosterone 46
Respiration, normal 579
Respiratory distress syndrome, acute 236, 183, 238, 619
Respiratory examination 170
Respiratory failure 583
hypercarbia 537
Respiratory manifestations 399
Respiratory rate 477
Respiratory system 167, 543
specific 170
Respiratory tract infection
acute 168
upper 167
Respiratory viruses 171
Restlessness 126
Restrictive lung disease 163
Resuscitation, secondary survey with 516b
Reticular activating system 128
Reticulocyte count 31
Retinal injuries 270
Retinal vein occlusion, branch 274, 276
Retroareolar area 82
Retrognathia 558
Retroperitoneal injuries 518
Retroperitoneum 513
Reye's syndrome 306
Rhabdoviridae family virus 565
Rheumatoid arthritis 29, 295, 300, 455, 458
Rheumatoid factor 460
Rhinorrhea 130
Rhinoscopy, anterior 259
Rib fracture 119, 579
causes 579
clinical presentation 580
complications 582
evaluation and management 582fc
lower 579
management 581
multiple 579
right-sided 581f
pathophysiology 579
red flag signs 580
single 579
Ribonucleic acid 395, 565
mumps virus 395
Rickettsia prowazeki 437
Rickettsial diseases 303
Rickettsiosis 295
Rifampicin 445
Rifampin 394
Rifapentine 394
Rigler's sign 15, 17
Rituximab 69
Road traffic
accident 276
injuries 264
Rockall scoring 346b
Rolling sign 553
Romberg's sign 318
Rosiglitazone 469
Rotation test, external 38, 39, 40f
Rotatory nystagmus 653
Rotavirus 415, 422
vaccine 409, 415
Roth spots 114
Rotor's syndrome 441
Rubber band ligation 367
Rubella 395, 410
syndrome, congenital 416
vaccine 416
Rubivirus 395
Ruling out fracture 38
Runny nose 387
Rupture Baker's cyst 468
S
Saline 22
Saliva 565
Salmon patch 577
Salmonella
enterica 400
species 400
typhi 400, 420
Sarcoidosis 75, 164, 295, 302, 303, 442, 455, 679
Sarcopenia geriatric syndrome 674
Sarcoptes scabiei 438, 573
Scabies 608
clinical features 609
diagnosis 609
etiopathogenesis 608
infantile 573, 575f
treatment of 609, 609t
Schamroth's sign 113
Schistosoma haematobium 351
Scleroderma 138, 231, 303
Sclerosis, multiple 137, 231, 317, 318, 375, 657
Sclerotherapy 366
Scrotum
acute 584
anatomy of 585f
Scrub typhus 295
Seborrheic dermatitis 245, 572, 572f
Second-line therapy 160
Sedation
airway assessment procedures for 557
and analgesia, emergency equipment for 559b
completion of 561
management 561
pharmacologic agents for 562t
procedural 556
types of 557t
Sedative overdose 130
Sedoanalgesia 474
Seizure 95, 141, 147, 155, 161, 183
active 148t
attack 156
causes of drug-induced 151
classification of 141
differential diagnosis of 145t
episode of 141
family history of 143, 155
generalized 142
motor 142
nonmotor 143, 147
manifestations 157
neonatal 155
post-traumatic 151
precipitants 143
provoked 152t
stop 161
treatment of neonatal 158
types of 142f, 155
unprovoked 152t
worsening 157
Sensorium, altered 183
Sensory
ataxia 318
gait 320, 322
Sepsis 129
Septic arthritis 454, 455, 458, 463, 470, 474
Septic fever 300
Septic shock 15
Serial seizures 150
Serious life-threatening signs 14
Serogroup B meningococcal vaccines 411
Serological testing 445, 505, 628
Seronegative spondyloarthritis 455
Seronegative spondyloarthropathies 459
Serotonin 18
reuptake inhibitor, selective 665
Serous 252
Sertaconazole 612
Serum
amylase 376
ascites albumin gradient 48
differential diagnosis of 49t
biochemical tests 445, 628
blood sugar levels 146
calcium 146, 376, 667
electrolytes 146, 376
iron, determination of 31
lactate 88
magnesium 146
prolactin test 146
Sexually transmitted
disease 411
infections 24
Shallow breathing 380
Shallow mandibular fossa 449
Shock, signs of 7
Shoulder
girdle 502
joint 593
spica 595
Shoulder dislocation 593
anterior 593
inferior 593
mechanism of injury 593
nonoperative treatment 594
post reduction care 595
posterior 593
radiologic studies 594
signs 593
symptoms 593
types of 593
Shunt
anatomic 183
right-to-left 183
Sickle cell
anemia 32
beta thalassemia 32
crisis 16
disease 19, 28, 175, 412
trait 32
Sickness, decompression 383
Sideroblastic anemia 29, 32
Sigmoid colon, examination of 139
Sigmoid volvulus 84
Sigmoidoscopy 139
Sinus hyperplasia 486
Sinusitis 242, 279, 626
Siphonaptera 423
Sjögren's syndrome 74, 455, 457
Skin
and excreta, contact between 602
and mucosa, parts of 184
attachment 424
changes 20
clammy 31
color
evaluate 8
normal 181
coloration, blue 181
darkening 443
dry 326
examination 144
necrosis 555
pigmentation 442
problems 596
splitting 546
tests 171
thickening 79
Skinfold thickness 676, 677t
Sleep
apnea, obstructive 164, 237, 669
disturb 442
Sleep deprivation 670
and fatigue 143
Sleep disorders 284, 286
specific treatment for 292
Small bowel
obstruction 83, 85t, 89
red flags of 86b
red flags of 86
Smallpox 404
Smoke
inhalation of 618
poisoning 624
Smoking cessation 670
Snake
bites 283
venom 28
Sodium restriction 51
Sodium tetradecyl sulphate 366
Sodium valproate 149
Soft tissue traumas 474
Solbiati index 491, 492
Solitary nodule 324
Somnolence 126
Sorbitol 22
Sore throat 395, 625
causes 625
complications 628
etiology 625
investigations 628
red flags 627
treatment 629
Sounds, abnormal 105
Spasmodic dysphonia 657659, 661, 663
Spasmodic jerks 644
Spasms 502
Spastic esophageal disease 231
Speech issues 146
Spermatic cord torsion 586
Sphenopalatine artery 256
Spherocytosis 300
Sphincter tone 15
Sphincterotomy
chemical 25, 26
partial 26
Spider angioma 496
Spinal cord injuries 137
Spinal infarct 317
Spinal nerve roots 503
Spinal spondylosis 317
Spinal stenosis 482
Spinal tumor 317
Spinocerebellar ataxia 318
Splanchnic vasodilation 47
Splenectomy 68, 412
Splenic dysfunction 412
Sporadic crying 176
Sport concussion assessment tool 125
Sport-related injuries 93
Sprain, symptoms for 500
Sputum 171
Squamous cell cancer 436
Squeeze test 38, 39, 40f
Stable angina 100
Stapedius muscle fibers 73
Staphylococcal scalded skin syndrome 608
Staphylococcus 4, 357
aureus 245, 247, 416, 462, 474, 664
Status epilepticus 141, 150, 154
protocol of 150
treatment of 150, 159
Steatorrhea, cause of 66
Sternocleidomastoid 641
Steroids 279, 469
topical 547
Stevens-Johnson syndrome, risk of 598t
Stevens-Johnson syndrome 598, 599, 599t
clinical approach 597
etiopathogenesis 597
management 599
prognosis 599
treatment 599
Stiff neck 126
Stilbestrol 554
Stool guaiac test 21
Stool softeners 25, 366
Stork bite 577
Strain, symptoms for 500
Strawberry hemangioma 578f
Strenuous physical activity 43
Streptococcal pharyngitis 14, 172, 626f
Streptococcus 4, 462
pneumoniae 247, 305, 391
pyogenes 607, 627
Streptokinase 554
Stress 143
risk of 94
Stricturing diseases 233
Stridor 631, 638fc
acquired 633
causes of 633t
causes 632
congenital 633
causes of 633t
investigations 635
pathophysiology 631
treatment 636
types of 632t
Stroke 231, 647
diagnosis of 655
ST-segment elevation myocardial infarction 105, 109
Stye 280
Subclavian steal syndrome 652
Subconjunctival hemorrhage 268, 268f
Subdural hematoma 129
Subhyaloid hemorrhage 131
Submandibular glands autonomic system 73
Submucosal hemorrhoids 367
Subtalar joint, chronic instability of 42
Subungual ecchymosis 311
Subungual hematoma 311
Sulfadiazine 598
Sulfamethoxazole 475, 476
Sulfasalazine 182, 598
SulfHb
forms 182
produces cyanosis 183
Sulfhemoglobin 181, 186
Sulfhemoglobinemia 181, 184
Sulfonamides 182
Sumatriptan overdose 182
Superior vena cava syndrome 494
Supraclavicular lymphadenopathy 489
Supraclavicular node 80
Supraglottic growth 242
Suprapubic tenderness 20
Sweat test 171
Sweating, excessive 326
Swelling 37, 95
Swimmer's ear 245
Sydenham's chorea 321
Sympathetic nervous system 46
Symptomatology, complicated 90
Syncopal attack 25
Syncope 58, 101, 156, 163
Syndesmotic ligament 37
Synovial fluid analysis 460, 461t
Syphillis 74
Syringomyelia 317, 375
Systemic antibiotics 480
Systemic corticosteroids 600, 607
Systemic disease 138, 320, 371, 591
Systemic disorders 183, 502
Systemic embolization 362
Systemic fever 470
Systemic illness, signs of 144
Systemic infection 471
history of 143
Systemic inflammatory response syndrome 88
Systemic lupus erythematosus 29, 54, 56, 74, 286, 300, 358, 455
Systemic neuromuscular diseases 162
Systemic toxic syndrome 5
Systemic toxicity of inhaled gases 620
Systolic dysfunction 106
T
T cell lymphoma 609
Tabes dorsalis 320
Tachycardia 666
bleeding causes 8
supraventricular 533f, 538
ventricular 534f, 538
Tachyphylaxis 25
Tachypnea 183
Taghaandan maneuver 552
Takayasu arteritis 295
Talar tilt test 38, 39f
Talofibular ligament
anterior 37
injury, posterior 37
Tamoxifen 82
Tardive dyskinesia 667
Tau protein 125
Tecovirimat 404
Temperature variation, normal 294
Temporomandibular joint 193, 448
Tendon reflexes, deep 132, 144
Tendonitis 41
Tensile limits 36
Tension 14
pneumothorax 512
Terbinafine 612
Terminal duct, excision of 79
Testicular artery 584
Testicular parenchyma 589
Testicular perfusion 588
Testicular torsion 13, 15, 16, 175, 588, 589
neonatal 590
pathophysiology of 586f
Testicular tumors hypothyroidism 82
Tetanospasmin 639
Tetanus 237, 390
boosters 640
high-risk 639
neonatal 410
prone wound 639, 640
prophylaxis 639, 640t
toxoid 410, 414, 417
vaccine 410
Tetracycline 231, 388, 475
Tetralogy of Fallot 184
Thalassemia 29, 204206
syndromes 28
Theophylline 675
Therapeutic bronchoscopy 168
Therapeutic endoscopy 498
Therapeutic paracentesis 49
Thermoregulatory disorders 296
Thiacetazone 598
Thiazolidinediones 469
Third nerve palsy 371
Thoracic cavity 513
Thoracic trauma 518
Thorax 177
Throat
culture 628
pain 243
Thrombocytopenia 48, 53, 69, 257, 358
heparin-induced 63
Thrombocytopenic purpura, idiopathic 68
Thromboembolic occlusion, acute 5
Thrombogenic foams 260
Thrombolytic therapy 474
Thrombophlebitis 470
Thrombotic thrombocytopenic purpura 28, 54, 56, 62, 65, 68, 237
Thyroid
acropathy 112
autoantibodies 327
cytopathology 327t
disorders 237, 282, 499
dysfunction 342
gland 326
position of 323f
neoplasm 324
nodules, management of 329fc
nuclear scan 327
stimulating hormone 323
ultrasound 327
Thyroiditis 242
subacute 324
Thyroxine, free 21
Tibial arteries, posterior 41
Tibiofibular ligaments 39
Ticlopidine 474
Tinea corporis 611
clinical features 612
etiopathogenesis 611
management 612
treatment 612
Tinea cruris 612
clinical features 613
etiology 612
treatment 613
Tinea pedis 613, 614t
etiopathogenesis 613
Tinnitus 94, 249, 252, 254
Tissue
diagnosis 81, 492
Doppler 110
extraction 182
of oxygen 182
Tobacco 104
exposure 170
Todd's paralysis 144
Toe nail avulsion 310
Tongue 522
Tonic component 644
Tonic seizures 156
Tonic-clonic seizures 150
Tonsillar enlargement, chronic 164
Tonsillitis 242
Tonsils, inflamed 243
Tooth extraction, single 204
Toothache 193
Torsion 589
Torticollis 95, 641
acquired 643
causes 642
congenital 642, 643, 644
differential diagnosis 645
etiology 642
investigations 644
nondystonic 642
physical examination 644
physical therapy 645
primary 642, 643
secondary 642, 643
treatment of 645, 646fc
types of presentations of 641f
Toxic epidermal necrolysis 598
Toxic ingestion 154, 175
Toxic nodular goiter 326
Toxic substance ingestion 143
Toxicology screen 146, 160
Toxin 666
and drugs 144
Toxocarosis 74
Toxoplasmosis 303
Trachea 122
position of 105
Tracheitis 636
Tracheobronchial tree injury 512
Tracheobronchitis 165
Tracheomalacia 164
Traffic accident, neck injury after 511f
Tragal tenderness 245, 254
Tragulizers, large dose of 79
Tranexamic acid 66
Transbronchial lung biopsy 358
Transbronchial needle aspiration 358, 492
Transcoelomic spread 46
Transfusing platelet, indications for 65b
Transfusion reaction 28
symptoms 68
Transfusion therapy 66
Transient pustular melanosis 571, 572f
Transjugular intrahepatic shunt 49
Transthoracic needle aspiration 358
Transverse myelitis 317
Trauma 13, 16, 154, 174, 469, 481, 591
abdominal 518
crepitation, history of 471
deaths, timing distribution of 509f
history of 155
mechanical 28
pain to 193, 195
repetitive physical 28
Traumatic brain injury, mild 123
Traumatic injuries, evidence of 144
Tremor 647
classification 647
clinical features 647
drug-induced 648
drugs useful in essential 649
dystonic 648
epidemiology 647
essential 647, 649t
etiological classification 647
evaluation of 648
flapping 443
intention 647
intentional 318
kinetic 647
neurological cause of 648
neuropathic 648
orthostatic 648
Parkinson's 648
postural 647
psychogenic 648
resting 647
treatment 649
Wilson's 648
Trendelenburg's sign positive 320
Treponema pallidum 626
Trichophyton
mentagrophytes 611
rubrum 611
Tricuspid endocarditis 357
Triglyceride 297
Trimethoprim 475, 476
Trismus 449, 558
presence of 177
Troponin elevation, causes of 107f
Troponin, high-sensitivity 106
Trypsin 554
Tuberculin sensitivity 171
Tuberculin test 297
Tuberculosis 114, 165, 171, 286, 295, 300, 302, 303, 394
infection, latent 394
Tuberculous meningitis 74
Tumor 6
benign 78
diagnosis
of benign 473
of malignant 473
necrosis factor-α 300, 501, 590
Tunica albuginea 553, 584
Tympanic membrane 243
Typhoid 400
conjugate vaccine 420
fever 295
vaccination for 298
vaccine 419
Tzanck smear 528
U
Ubiquitin-proteasome system 501
Ulcer 468, 471
bacterial corneal 272
corneal 272
diabetic neuropathic 478
duodenal 374
gastric 104
multiple superficial 24
pressure 478
syphilitic 24
Unbound bilirubin 442f
Unknown origin, fever of 295, 299
Upper airway
cough syndrome 163, 164
viral infection of 163
Upper gastrointestinal
bleeding 345b, 497f
malignancy 495
Urate-lowering therapy 461
Urea 96, 335
breath test 21
Ureaplasma urealyticum 586
Uremia 129, 130, 666
Ureteral trauma 519
Ureteropelvic junction obstruction 19, 351
Urethra 552
posterior 519
Urethral injury 553
Uric acid nephropathy 494
Uridine-diphosphate glucuronosyltransferase 441
Urinary catheter 11
Urinary incontinence 139
Urinary retention 139
Urinary stool incontinence 470
Urinary symptoms 20
Urinary tract
anomalies, congenital 549
congenital 549
infection 10, 11, 14, 16, 178, 546, 591
symptoms, lower 591
Urine
analysis 146, 360
causes
of brown color 350t
of red color 350t
cola-colored 442, 443
culture 304
routine 297
Urolithiasis 19
Urticaria 614
acute 616
causes of 615, 615t
chronic 616
classification 614
clinical features 615
contact 617
ordinary spontaneous 614
physical 614, 615, 617
pigmentosa 576, 576f
treatment of 617, 617fc
types
of acute 616t
of chronic 616t
vasculitis 616, 617
Uveitis 272
V
Vaccination, historical aspect of 408
Vaccine
and immunization, global alliance for 409
inactivated 397
vial monitor 422
Vaccinia virus vaccine 404
Vagina, collapse of 163
Valacyclovir 529
Valsalva maneuver 231
Valvular heart disease 236, 237
Vancomycin 475
linezolid-tigecycline-colistin 280
Variceal hemorrhage 45
Varicella 393, 410
vaccine 421
zoster virus 303, 421
Varicoceles 585
Variola 404
Vascular abnormalities 53
Vascular ectasias 345
Vascular emergencies 274
Vascular endothelial growth factor 111
Vascular ischemia 73
Vascular malformations 577
Vascular stasis 605
Vasculitis 19
Vaso-occlusive crisis 175
Venous blood gas 135
Venous insufficiency 470
Venous thromboembolism 385
Venous ulcers, treatment of 479
Ventilation
monitoring 560
perfusion
mismatch 183
scan 241f
Ventricular extrasytolic bigeminism 533f
Vertigo 94, 254, 650
causes of 650t, 654, 656
central 652t
etiology 650
evaluation 651
management 655
pathophysiology 650
peripheral 652t
red flags 651
severe 132
Vessels bleeding, large 61
Vestibulo-ocular reflex 651
Veterinary surgeon 424, 438
Vibrio cholerae 420
Vigorous sexual intercourse 554
Viral arthritis 455
Viral conjunctivitis 262
Viral diseases 597
Viral fever 295
Viral hepatitis 295
Virchow's node 231, 489
Virus isolation 567
Viscera, abdominal 1
Visceral pain
fibers 14
occurs 14
Visceral peritoneum 45, 51
Visible injury 95
Visible internal sphincter muscles 24
Vision
blurred 371
doubling of 265
Visual disturbances 384
Visual field test 274
Vital signs 244
abnormal 3
assess 158
Vitamin
B complex 500
B12 291, 623, 673
E 500
supplements 78
K 66, 362, 445
antagonists 261
deficiency 52, 54, 56
malabsorption 62
Vitreous hemorrhage 270, 276
Vocal cord
carcinoma 658, 660, 661, 663
cyst 658f
dysfunction 237, 637
lesion, benign 657660, 662
leukoplakia 659f
nodule 660
papilloma 659f
paralysis 636, 657659, 661, 663
polyp 658f, 660
Vodder technique 476
Voice
hoarseness of 326, 627
professional 657, 659
Voice disorders 657
etiology 657
pathophysiology 657
red flags 660
treatment 662
Voice therapy
direct 662
indirect 662
Voluntary functions 128
Volvulus 178
Vomit, subjective feeling to 664
Vomiting 19, 38, 95, 126, 130, 664, 666
chronic 667
etiology of 664t
management of acute 667
Vomitus
old blood in 231
prevent aspiration of 17
von Willebrand
disease 5254, 56, 204, 205, 358
factor 59
Voriconazole 524
W
Wakefulness, absence of 128
Wallerian degeneration 73
Warfarin 62, 474
ingestion 62
therapy 66
Warts 610
clinical approach 610
common 610
etiology 610
management 611
plantar 610
Wax
impaction 251
visualization of 251
Wegener's granulomatosis 358
Weight gain 669
behavior modification 672
complications 670
dietary therapy 672
drug therapy 672
etiology 669
investigations 671
pathophysiology 669
red flags 671
treatment 672
Weight loss 231, 375, 674, 679fc
assessment of 677
causes of 675t, 679t
clinical feature 676
drugs 675
etiology 674
investigations 678
involuntary 19
medications leading to 675b
pathophysiology 675
red flag signs 677
treatment 678
Wernicke encephalopathy 129, 130
Westermark's sign 106
Whiplash associated disorder 93, 97t
Whiplash injury 93, 94, 98fc
acute 94
chronic 94
subacute 94
Whirlpool sign 17, 89
White blood cell 4, 304, 436
White papules 233
Whitehead's hemorrhoidectomy 368
Wilms tumor 300
Wilson's disease 321, 441, 445
Wisdom tooth eruption, pain to 193, 197
Wiskott-Aldrich syndrome 56
World Health Organization 27, 262, 277, 325, 369, 407
Worm infestation 680
Worsening pain, rapidly 95
Wound
management of 568
types of 640t
Wrist pivot method 452f
Wryneck 641
Wuchereria bancrofti 604
X
Xanthoma 105, 443
Y
Yellow fever 398, 437
vaccine 412
virus 398
Z
Zenker's diverticulum 232, 233
Zika virus 437
×
Chapter Notes

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Abdominal Pain (Adult)CHAPTER 1

Roberta Petrino,
Aldo Tua
 
INTRODUCTION
Abdominal pain is a very common symptom of presentation for patients admitted to the emergency department (ED) and represents a strong challenge for physicians and nurses involved in diagnosis and treatment. Incidence and clinical manifestations are both influenced by many demographic variables (age, gender, geography, etc.).
Although in most of the cases, it is not related to a serious disease, in some cases, it can be the only symptom of a potential rapidly evolved situation.
 
ETIOLOGY/CAUSES
Many intra-abdominal disorders cause abdominal pain and also several extra-abdominal diseases can present with abdominal pain. Some of these are immediately life-threatening, requiring rapid diagnosis and surgery. The knowledge of abdominal anatomy and its innervation helps for differential diagnosis, however, a systematic and logic approach, with a careful medical history and clinical evaluation, is fundamental. Focused clinical history and physical examination are able to place a right diagnostic hypothesis in 80% of patients with abdominal pain (Table 1). There are some alert signs and symptoms that must always be taken into careful consideration, because they probably underlie a serious condition (Table 2). Often a definitive diagnosis is impossible in the ED but the emergency physician has always to identify and rule out life-threatening clinical conditions. These include ruptured abdominal aortic aneurysm (AAA), perforated viscus, mesenteric ischemia, and ruptured ectopic pregnancy. Other diseases (e.g. acute appendicitis, acute diverticulitis, severe acute pancreatitis, and intestinal obstruction) are also serious and nearly as urgent.
 
PATHOPHYSIOLOGY OF THE CONDITION
The abdominal viscera are innervated by nociceptive fibers on the mesenteric surface and inside the wall of the hollow organs. These fibers are sensitive both to mechanical, mainly stretching, and chemical stimuli. They can produce deaf, subcontinuous, crampy, or violent pain.2
Table 1   Correlation between anatomical site of abdominal pain and the differential diagnosis.
RIGHT HYPOCHONDRIUM PAIN
Biliar: cholecystitis, cholangitis, cholelitiasis
Colic: colitis, diverticulitis, ileitis, retrocecal appendicitis, perforated duodenal ulcer
Haepatic: abscess, haepatitis, masses, haepatic congestion
Pulmonary: pneumonia, pulmonary embolism
Renal: nephrolithiasis, pyelonephritis
EPIGASTRIC PAIN
Biliar: cholecystitis, cholangitis, cholelitiasis
Cardiac: acute myocardial infarction, angina, pericarditis
Gastric: esophagitis, gastritis, peptic ulcer
Pancreatic: pancreatitis or tumors
Vascular: aortic dissection, mesenteric ischemia
LEFT HYPOCHONDRIUM PAIN
Cardiac: acute myocardial infarction, angina, pericarditis
Gastric: esophagitis, gastritis, peptic ulcer
Pancreatic: pancreatitis or tumors
Pulmonar: pneumonia, pulmonary embolism
Renal: nephrolithiasis, pyelonephritis
Splenic: rupture/infarction/distension
Vascular: aortic dissection, mesenteric ischemia
RIGHT LUMBAR PAIN
Colic: colitis, diverticulitis, ileitis, appendicitis, constipation
Haepatic: abscess, haepatitis, masses, haepatic congestion
Renal: nephrolithiasis, pyelonephritis, ureteral calculi
Fitz-Hugh-Curtis syndrome
UMBLICAL PAIN
Colic: appendicitis
Gastric: esophagitis, gastritis, peptic ulcer, small bowel obstruction
Vascular: aortic dissection, mesenteric ischemia
Cardiac: acute myocardial infarction
LEFT LUMBAR PAIN
Colic: colitis, diverticulitis, constipation
Splenic: abscess, rupture/infarction/distension
Renal: nephrolithiasis, pyelonephritis, ureteral calculi
RIGHT ILLIAC FOSSA PAIN
Colic: appendicitis, colitis, diverticulitis, Inflammatory bowel disease, irritable bowel syndrome, regional enteritis, epiploic appendagitis, Meckel's diverticulum, Chron's disease, inguinal hernia
Gynecological: pelvic inflammatory disease, ectopic pregnancy, endometriosis, mittelschmerz, ovarian torsion
Muscolar: Psoas abscess
Renal/Urinary: nephrolithiasis, pyelonephritis. Testicular torsion, ureteral calculi
Vascular: aortic aneurysm (leaking, ruptured)
HYPOGASTRIC PAIN
Colic: appendicitis, colitis, diverticulitis, Inflammatory bowel disease, irritable bowel syndrome
Gynecological: pelvic inflammatory disease, ectopic pregnancy, endometriosis, Mittelschmerz
Renal/Urinary: cystitis, nephrolithiasis, pyelonephritis
LEFT ILLIAC FOSSA PAIN
Colic: appendicitis, colitis, diverticulitis, Inflammatory bowel disease, irritable bowel syndrome, regional enteritis, epiploic appendagitis, inguinal hernia
Gynecological: pelvic inflammatory disease, ectopic pregnancy, endometriosis, mittelschmerz, ovarian torsion
Muscolar: psoas abscess
Renal/Urinary: nephrolithiasis, pyelonephritis. Testicular torsion, ureteral calculi
Vascular: aortic aneurysm (leaking, ruptured)
DIFFUSE ABDOMINAL PAIN
Vascular: aortic aneurysm, aortic dissection
Intestinal: appendicitis (early), bowel obstruction, peritonitis (all causes), perforated bowel, mesenteric ischemia.
Volvulus, gastroenteritis, peritonitis. Inflammatory bowel disease, strangulated, incarcerated hernia
Miscellaneous: herpes zoster (any single localization, not diffuse), muscular, diabetic gastric paresis, familial Mediterranean fever, sickle cell crisis, narcotic withdrawal, heavy metal poisoning, metabolic disorders (diabetic ketoacidosis, porphyria), hereditary angioedema, malaria
3
Table 2   Alarm signs and symptoms in abdominal pain.
History:
  • Extreme ages
  • Impossibility to feed
  • Vomiting in jet
  • Hematemesis
  • Syncope
  • Pregnancy
  • Recent surgical or endoscopic treatment
  • Fever
  • Severe pain of rapid onset
  • Caustic ingestion or foreign bodies
Physical examination:
  • Abnormal vital signs
  • Rectorrhagia and melena
  • Incarcerated or strangulated hernia
  • Mental deterioration
Laboratory testing:
  • Renal insufficiency
  • Metabolic acidosis, ABG lactates
  • Hyper-hypoglycemia
  • Anemia, leukocytosis, polyglobulia
  • High levels of lipases and amylases
  • High levels of bilirubin, alkaline phosphatase and transaminases
Imaging:
  • Free air in the abdomen
  • Thickening of the walls of the gallbladder and pericholecystic fluid
  • Dilatation of the biliary tract
  • Hydro-air levels
  • Intra-abdominal abscess
  • Air in the portal venous system
The abdominal pain is divided into:
  • Visceral: Usually secondary to stretching of hollow organs, twist or spastic contraction. It can be dull and continuous or colic, often located in the median site, as visceral innervation is bilateral, and it corresponds to the dermatome relative to the involved organ. Therefore, for the organs located above the Treitz ligament, it will be epigastric, for those between the Treitz and the hepatic flexure of the colon, it will be umbilical, and for the most distal organs, it will be hypogastric.
  • Parietal: It is usually acute, due to direct irritation of peritoneum located above the involved organ. The parietal innervation is monolateral, so the pain will be well localized. Only when there is a widespread involvement of peritoneum, as for leak of gastric contents, blood, pus, or other, the pain will be extended to all the abdomen. The peritoneal irritation may cause a reflex contracture of abdominal muscles whereby the abdomen will become stiff and untreatable. The irritant reaction to organic or chemical substances is different, so that the peritonitic pain will be much more striking during gastric perforation with spreading of gastric acid than during colic perforation, with leaking of stool or blood.4
  • Referred: Appears when the afferent fibers from an injured abdominal organ enter the spinal cord at the same level of somatic fibers coming from distant regions (for example, the gallbladder pain can be referred to the right shoulder).
 
CLINICAL PRESENTATION
Major diseases that cause acute abdomen of immediate surgical interest.
 
Acute Appendicitis
The inflammatory process is due to appendicular lumen obstruction, which can cause an increase in pressure within the lumen with consequent local circulatory dysfunction with ischemia of the wall (catarrhal or phlegmonous form) and necrosis. If perforation of the necrotic bowel wall occurs, appendicitis becomes complicated by perforative peritonitis, localized or diffuse (gangrenous or perforated form), generally caused by aerobic (Escherichia coli, Streptococcus, and Staphylococcus) and anaerobic (Bacteroides) bacteria superinfection.
In case of acute inflammation, there will be spontaneous, dull pain, which arises in the epi-mesogastric or periumbilical area. Later, when serosa involvement and peritoneal irritation develop, the pain is localized in the right lower abdominal quadrant. In addition, the pain is exacerbated by the cough and is not modified by body position changes. Vomiting is sometimes present and a low-grade fever (37–38°C) can be detected. Steadily, the patient loses appetite, so that the evaluation of this data is very important for diagnostic exclusion of appendicitis. At the physical examination, pain is evoked by palpating the right lower quadrant (RLQ), or more commonly, Blumberg's sign can be present, but Markle's sign is more sensitive to define a peritoneal irritation. Markle's sign, or jar tenderness, consists in the evocation of pain in RLQ by dropping from standing on the toes to the heels with a jarring landing. In case of suspicion, a white blood cell (WBC) count and C-reactive protein (CRP) detection should be tested since the concomitance of neutrophilic leukocytosis and elevated CRP significantly increases the possible diagnosis of appendicitis.
In the presence of a striking clinical picture, no further tests are necessary, but surgical advice must be activated as soon as possible. In less obvious cases, it is necessary to study the diagnosis more in depth. With an expert operator, ultrasonography (US) has a good specificity, but if this examination is not diagnostic or not reliable, a computed tomography (CT) scan of the abdomen and pelvis must be performed. Then, based on the evidence of direct examination, the radiologist will decide whether to complete CT using intravenous or oral contrast agent.
 
Intestinal Ischemia
Intestinal ischemia can present itself with three distinct syndromes, of which the first two generally have a favorable prognosis. The first syndrome is chronic mesenteric ischemia, determined by gradual reduction of blood supply to the affected intestinal tract, generally due to mesenteric vessels atherosclerosis. This condition is present with postprandial intermittent 5abdominal pain (angina abdominis). The patient is ill when he eats and consequently tends to reduce food intake and may appear debilitated to medical examination, also considering that elderly subjects are the most affected by the disease.
Ischemic colitis is caused by inadequate vascularization of some colon fragments, not necessarily on atherosclerotic basis, and generally starts as rectorrhagia rather than abdominal pain.
Acute mesenteric ischemia is due to acute thromboembolic occlusion of the celiac tripod, superior or inferior mesenteric artery, which leads to rapid necrosis of a no longer vascularized intestinal region, with subsequent development of a systemic toxic syndrome and exitus if not operated immediately.
The syndrome occurs more often in the presence of risk factors for ischemia. Most frequently, the symptom of onset is a severe periumbilical pain with an abdominal physical examination not proportional to the pain described by the patient. When the intestinal infarction has already been established, signs of peritoneal involvement are present. Rectal bleeding is rare.
Blood tests show signs of dehydration, metabolic acidosis, and multiorgan involvement when the situation is advanced, while in earlier stages, it is possible to detect leukocytosis or increase in D-dimer, but with little specificity. It is important to consider the risk factors and the onset symptoms, as the mortality once the intestinal infarction has been established is approximately 90%.
 
Acute Diverticulitis
About 30% of people over 50 years and 60% of those over 80 years of age have a diverticular disease that mainly affects the sigmoid colon. Diverticulitis is caused by the inflammation and perforation of the diverticulum, which can be circumscribed and buffered by the mesentery or can be opened with abscess formation or frank peritonitis. The patient presents with cramping abdominal pain, more frequently located in the left lower quadrant (LLQ), but in case of dolichocolon or diverticulosis of the ascending colon, the RLQ can also be affected. Nausea, vomiting, and anorexia are frequently associated. The diagnostic workup, in case of clinical suspicion of diverticular disease, involves a CT scan with intravenous or oral contrast medium (Fig. 1), while the colonoscopy is contraindicated when diverticular perforation is suspected. Uncomplicated diverticulitis can be managed at home with antibiotic therapy and liquid diet, while perforation with abscess or peritonitis requires immediate surgical evaluation.
 
Bowel Obstruction
Intestinal occlusion occurs when a mechanical block prevents progression of intestinal contents. This causes a bowel distension upstream from the obstruction due to the ingested air, the gases produced by the bacteria, and the endoluminal secretions. If the occlusion is not recognized and treated rapidly, ischemia and subsequent necrosis of the intestinal tract will develop. Table 3 lists the main causes of intestinal obstruction.6
zoom view
Fig. 1: Contrast enhancement CT scan that highlights the presence of loose ileal loops and with hydroaerial levels, thickening of the wall of the sigma with air bubbles in its context, the surrounding liquid flap. The findings are compatible with a perforated diverticulitis.
Table 3   Main causes of intestinal occlusion*.
  • Post laparotomy adhesions
  • Incarcerated or strangulated hernia
  • Tumors
  • Crohn's disease
  • Volvulus
  • Intussusception
  • Calculations
  • Ischemia
* The most common causes of obstruction, is constipation with fecalomas.
The abdominal pain is widespread and intermittent, the passage of feces and gases is absent but in the initial stages, diarrhea may be present, caused by the irritation of the mucosa. In advanced stages, vomiting will occur, which may be fecaloid due to bacterial activity.
At the physical examination, the abdomen is distended and painful and the bowel sounds could be increased with metallic sound, reduced or absent. If peritonitis occurs, the abdomen will be rigid with rebound tenderness present. Laboratory tests show hemoconcentration with possible electrolytic imbalances and renal insufficiency. The abdominal plain X-ray makes evident the presence of hydro-air levels, intestinal distention, and absence of air in the rectum (Figs. 2 and 3). The diagnostics can be completed with a CT-scan if the clinical condition allows it, which can identify the cause of the occlusion with an approximate sensitivity of 100%. In the event of intestinal obstruction, the surgical evaluation must be timely; however, it is essential to correct fluids and electrolytes imbalances and to decompress the bowel with a nasogastric tube.7
zoom view
FIGS. 2A AND B: Plain X- ray of the chest and of the abdomen with evidence of perforation, with typical free gas between the hemidiaphragm and the bowel wall, and hydro-air levels.
zoom view
Fig. 3: Plain X-ray of the abdomen with evidence of the classic signs of intestinal occlusion distension of ileal loops, presence of hydro-air levels, absence of air in the rectum.
 
RED FLAGS
  • Signs of shock (e.g. tachycardia, hypotension, diaphoresis, and confusion)
  • Severe pain
  • Signs of peritonitis
  • Abdominal distention
  • Attention to nonabdominal diseases that present with abdominal pain (see Table 1)8
 
EVALUATION
Evaluation of mild and severe pain follows the same process, although with severe abdominal pain or important systemic impairment, therapy must precede the other steps, and includes early surgical consultation. Life-threatening conditions should always be ruled out before focusing on less serious diagnoses. In seriously ill patients with severe abdominal pain, an early surgical exploration may be appropriate. In less critical patients, observation and a diagnostic workup are generally the right choice.
 
History
A thorough history usually suggests the diagnosis. It is necessary to promptly investigate the symptomatology in particular with regard to onset, quality, duration, intensity, radiation, and relationship with meals, causes triggering or attenuating the symptomatology. Of particular importance are characteristics and pain location, associated symptoms, and duration. Concomitant symptoms such as fever, melena, mucus or blood in the stools, hematuria, vomiting, hematemesis, heartburn, nausea, diarrhea, constipation, jaundice, and weight loss help direct subsequent evaluation. Past medical history and medications are essential, taking care that anticoagulants can increase the chances of bleeding and hematoma formation and alcohol predisposes to pancreatitis. Use of nonsteroidal anti-inflammatory drugs is also associated to epigastric pain. Recent antibiotic use if patient experiencing diarrhea. Collect information on the known allergies, on the date and time of the last meal, on any travel and activity employment, and on the use of drugs of abuse.
It is necessary to consider that while in most of cases, an acute abdominal inflammatory process, so as an acute bleeding causes tachycardia, if the process affects the diaphragm wall and therefore, the terminations of the vagus nerve, the patient may have a normal or bradycardic heart rate.
 
Physical Examination
Vitals signs must be evaluated in all patients as well as level of consciousness. General appearance is important: a sick patient is anxious, pale, diaphoretic, or in obvious pain. The abdomen must be evaluated starting with inspection to evaluate skin color, palpation to check distention of obvious masses, and auscultation of bowel sounds. Decreased bowel sounds suggest functional ileus or mesenteric infarction while hyperactive bowel sounds are present in small bowel obstruction. Palpation starts gently, away from the area of referred pain, detecting areas of particular tenderness, as well as the presence of guarding, rigidity, and rebound (all suggesting peritoneal irritation) and any masses. Voluntary guarding can be diminished by asking patients to flex the knees. Distracting the patient with conversation may divert attention from the examination. The inguinal area and all surgical scars should be palpated for hernias. It is important to look for typical signs like Murphy sign, or stopping the breathing because of the intense pain evoked by palpation of the gallbladder; rebound, or Blumberg sign, indicative of peritoneal irritation, which consists in evoking release pain after 9deep palpation; the characteristics of the bowel signs. There are controversial opinions on the indication in literature to perform rectal exploration routinely in the patient with abdominal pain. In fact, sensitivity and the specificity of this maneuver are rather low, but the presence of blood in ampoule can suggest diagnosis such as diverticulitis, tumor, and intestinal ischemia, while rectal tenderness poses in differential diagnosis anal fissures, perirectal abscess, and prostatitis.
Table 4   Extra-abdominal diseases that can present with abdominal pain.
Cardiac:
  • Acute myocardial infarction
  • Aortic aneurysm
  • Aortic dissection
Dermatological:
  • Herpes zoster
Endocrinological and metabolic:
  • Diabetic ketoacidosis
  • Other acidosis
  • Addison crisis
  • Porphyria
Gynecological and obstetric:
  • Ectopic pregnancy
  • PID
  • Ovarian cyst rupture
  • Ovarian torsion
Hematologic
  • Familiar mediterranean fever
  • Sickle cell crisis
It is important to consider all the extra-abdominal conditions that can present with abdominal pain (Table 4).
 
INTERPRETATION OF FINDING
Abdominal distention, vomiting, dullness at percussion, and high-pitched peristalsis strongly suggests bowel obstruction.
Severe pain in a patient with a silent abdomen who is lying as still as possible suggests peritonitis; whereas a patient who cannot sit or stand still suggests renal colic.
Back pain and migrant pain with shock suggests ruptured AAA, particularly if there is a tender, pulsatile mass.
Previous abdominal surgery makes obstruction caused by adhesions more likely. Advanced age, generalized atherosclerosis, and hypertension increases the possibility of myocardial infarction, aortic abdominal aneurysm, and mesenteric ischemia.
Shock and vaginal bleeding in a pregnant woman suggest ruptured ectopic pregnancy.10
 
INVESTIGATIONS
 
Laboratory Tests
Blood tests in abdominal pain should be focused according to clinical evaluation, keeping in mind that specificity and diagnostic accuracy are low.
Among laboratory tests, it is important to include glucose, electrolytes, creatinine, and liver function tests.
A dangerous approach is to rely on “normal” blood test rather than to clinical evidence and avoid observation and reevaluation.
In case of women of childbearing age, pregnancy must be considered, both as cause of the pain (ectopic pregnancy) and for the treatment to use.
Finally, urinalysis, tested by multitask or laboratory, is a routine test: it provides data in suspicion of renal colic, urinary tract infections, or porphyria, to test ketonuria and glycosuria, and to define urine specific gravity.
Arterial blood gas analysis is essential for critically ill patients with abdominal pain: metabolic acidosis and hyperlactatemia, if combined with high levels of creatine phosphokinase and creatinine, must create the suspicion of a systemic involvement, a widespread and advanced pathologic process.
 
Role of Abdominal X-ray
A standing chest radiograph remains the primary investigation of choice for the detection of free intraperitoneal gas, and may detect lower lobar pneumonia.
Plain abdominal radiography should be used selectively in the event of suspected intestinal obstruction or perforation (see Figs. 2A and B).
In several studies, the use of abdominal X-ray as first diagnostic step for abdominal pain has shown a very low diagnostic power, being significant only for intestinal obstruction (see Figs. 2 and 3). In this situation, the sensitivity of abdominal X-ray is 65–90% while specificity is 50–80%. Therefore, even if the CT scan sensitivity and specificity are higher, in the suspicion of intestinal obstruction, the abdomen X-ray is a first level test.
Ingestion of foreign body is another indication for abdomen X-ray, that allows to evaluate the shape, the size, and the position in order to establish the subsequent procedures.
Several studies have shown a higher sensitivity of ultrasound in the suspicion of hollow organ perforation (US 90% vs abdominal X-ray 70%). The only limit is the operator skill.
 
Role of Ultrasonography and Computed Tomography
Abdominal, contrast enhancement CT scan is the examination with the highest specificity and sensitivity, but bedside ultrasound is now considered the first diagnostic approach in the ED. In most cases, the ultrasound abdominal examination is sufficient to diagnose diseases of the upper right abdominal quadrant (cholecystitis, cholangitis) and in the diagnosis of renal colic, urinary tract infections, and ectopic pregnancy. It is also the fundamental in the 11diagnosis of aortic syndrome, it is also the fundamental in diagnosis of aortic syndrome and also in diagnosing perforation and intestinal obstruction.
If the ultrasound examination is negative or nondiagnostic but the clinical presentation is persistently altered, it is necessary to perform an abdominal CT scan, generally with the contrast medium, except there are absolute contraindications (history of anaphylactic shock or severe renal impairment). In literature, it is shown that using this method of approach (CT execution to patients with nonconclusive ultrasound), it is possible to reduce the number of CT scan to less than 50%.
 
TREATMENT
It is still not uncommon to think that treating abdominal pain with analgesic can mask the clinical evidence. On the contrary, it has been widely demonstrated that a correct analgesia facilitates clinical evaluation because it makes the patient better and more collaborative to examination, thus reducing possible complications, increasing the sensitivity of instrumental investigations, without altering the objective framework.
The class of drugs most indicated in the treatment of acute abdominal pain is that are effective, almost without side effects and have an antidote if necessary. Nonsteroidal anti-inflammatory drugs, used extensively in past because considered “safer,” are actually burdened from important cardiovascular, gastrointestinal, and renal side effects, particularly in elderly patients. In mild-moderate abdominal pain can be used paracetamol as a first-choice drug.
Antibiotics are indicated in diseases such as peritonitis and abdominal sepsis, urinary tract infections, and pelvic inflammatory disease (PID). Particular attention must be reserved for spontaneous bacterial peritonitis due for gram-positive aerobes.
Remember two nonpharmacologic treatments: (1) nasogastric tube to decompress a bowel obstruction or to confirm a gastrointestinal bleeding and (2) urinary catheter in presence of bladder obstruction or to monitor urinary output in critically ill patient.
 
SUMMARY
Although patients with abdominal pain in most cases do not have a severe pathology, the symptom may accompany very serious and potentially deadly clinical conditions, if not recognized promptly. Approach to patient with abdominal pain is summarized in Flowchart 1.
The knowledge of abdominal anatomy and the careful evaluation of clinical signs and symptoms, together with a precise focused medical history, allows to correctly orient in the diagnosis in 80% of cases.
There are no specific laboratory tests for the various morbid conditions, but the laboratory investigation serves mainly to quantify the degree of systemic involvement of the disease.
The most cost-effective diagnostic-instrumental approach in terms of cost/benefit is represented by the execution of an abdominal focused ultrasound in all patients; abdominal CT scan must be performed only in case of nonconclusive ultrasound.12
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Flowchart 1: Summary of approach to patient with abdominal pain.
Abdominal pain must be treated even before diagnosis, and the use of opioids is safe and recommended.
Also, fluids and electrolytes imbalance must be treated promptly while making the diagnostic workup.
When the diagnosis is uncertain but the patient is still symptomatic, it is often advisable and safe to keep patients under observation to evaluate the possible evolution. Keeping in mind that normal examinations do not exclude an abdominal serious process.
A plain X-ray of the abdomen, which is significant only in the suspicion of intestinal obstruction or perforation.