419 OTHER CAUSES OF RASH Table 14.3 Common skin manifestations in systemic disease Diabetes mellitus (b p328) Candidiasis, necrobiosis lipoidica (non-itchy yellow maculopapular lesions on the shins), f olliculitis (infected hair follicles), skin infections Dermatitis herpetiformis (itchy papu les and vesicles on knees, elbows, back and buttocks) Coeliac disease (b p308) IBD (b p309) Rheumatoid arthritis (b p454) Erythema nodosum, pyoderma gangrenosum Rheumatoid nodules (fi rm nodules either loose or at tached to deep structures over extensor surfaces, classically the elbows), vasculitis, pyod erma gangrenosum Facial butterfl y rash, photosensitivity, red scaly rashes, diff use alope cia (hair loss) SLE (b p457) Hyperthyroidism (b p326) Hypothyroidism (b p334) Neoplasia Pre-tibial myxoedema (non-pitting plaques and nodules, classically on the shins), clubbing, alopecia Sparse coarse hair, dry skin, asteatotic eczema (pruritic, dry, cracked skin) Acanthosis nigricans (velvety, brown pigmented plaques, often around the neck), dermatomyos itis, ichthyosis (scaly skin), pruritus Maculopapular rash ( fever and eosinophilia); urti caria; erythema multiforme, Stevens-Johnson syndrome Palpable purpuric rash typically on sh ins; wide range of other pathologies including telangiectasia, urticaria, ulcers (see b p59 3 for autoantibodies in diagnosis) Infections (oropharyngeal candida, facial/genital mollus cum contagiosum, herpes simplex, varicella zoster \200\223 b p414); seborrhoeic dermatitis or psoriasis (b p417); Kaposi sarcoma (enlarging purple patches or plaques seen on feet, a rms, legs or oral mucosa) Drug eruptions (OHCS8 b p609) Vasculitis HIV (b p490) _OHFP.indb 419 _OHFP.indb 419 30/05/2014 16:18 30/05/2014 16:18 420 CHAPTER 14 Skin and eyes Skin lumps Worrying features weight loss, night sweats, hard irregular lump, isize. Think about serious skin cancer, sarcoma, lymphoma, TB; common lipoma, sebaceous cyst, absc ess, boil, carbuncle, ganglion, fi broma, lymph node, naevi, skin tags, keratocanthoma, kel oid scarring. Ask about location, speed and duration of onset, change with time, pain, othe r lumps, trauma, bites, infections, skin changes, systemic symptoms (eg weight loss, vomiti ng, fever); PMH previous lumps, cancer, radiotherapy; SH foreign travel, sun exposure, occu pation; FH skin cancer. Look for site, size, shape, consistency (hard, fi rm, soft, fl uctu ant), ten- derness, temperature, surface, association with skin (moves with skin \200\223 intradermal, skin moves over it \200\223 subcutaneous), overlying skin (color, punctum, ul cerated), edges, mobility/tethering, pulsatility, transillumination, relationship to nearby structures, lymphadenopathy, splenomegaly. Investigations blds consider FBC, U+E, LFT, CRP , ESR; imaging CXR, USS, CT/MRI; biopsy FNA, punch biopsy, excision biopsy. Lipoma Common, benign tumor of mature fat cells. Symptoms single or multiple, non-painful, can cause press ure eff ects, common on the trunk and neck, never found on palms/soles of feet. Signs smoot h, well-defi ned, soft, subcutaneous, mobile, no skin changes. Management can be surgically excised if causing distress. Epidermoid cyst (sebaceous cyst) Proliferation of epidermal c ells within dermis. Symptoms single or multiple, painful if infected, common on the trunk, neck and face, almost never found on palms/soles of feet. Signs fi rm, well-defi ned, intra dermal, mobile; overlying punctum is common; may discharge white/cheesy material; can becom e infl amed. Management consider fl ucloxacillin 500mg/6h PO if infl amed/tender, may also require incision and drainage; surgical excision once non-infl amed. Ganglion cyst Cystic l esion of joint or synovial sheath of tendon. Symptoms single, non-painful; 80% occur at wri st. Signs smooth, well-defi ned, subcutaneous, transilluminable. Management conservative; c an be aspirated or excised, but 740% recur. Fibroma Benign tumor of connective tissue; can occur in any organ. Symptoms and signs vary according to tissue aff ected, usually slow gro wing with no overlying skin changes. Management biopsy/imaging if any doubt; excision often possible. Sarcoma Rare, but devastating malignant tumor of connective tissue. Symptoms sin gle, painful, progressive enlargement, weight loss. Signs fi rm/hard, tethered, regional ly mphadenopathy. Management combination of surgery, radiotherapy and chemotherapy. OHFP.indb 420 OHFP.indb 420 30/05/2014 16:18 30/05/2014 16:18 421 SKIN LUMPS Melanocytic naevi (moles) Benign proliferation of melanocytes. Worrying signs isize, change in pigmentation, irregular outline, bleeding, itching, infl ammation (may suggest transfor mation to melanoma, b p422). Symptoms and signs most common are acquired naevi that develop during childhood as small, fl at pigmented areas and may progress to pale, raised, fl eshy naevi with age; congenital melanocytic naevi are larger, present from birth and carry a hi gher risk of transformation to melanoma. Management refer to specialist if worrying signs a re present. Lymphadenopathy Worrying signs non-tender, >3wk, >1cm, hard, irregular surface, teth- ering, weight loss, night sweats, fatigue, absence of infection. Causes isolated loc al/regional infection; multiple see b p397. Symptoms lump usually in the neck, axilla or gr oin. Signs fi rm, subcutaneous; usually mobile, well-defi ned, smooth surface. Management e nlarged lymph nodes can often be treated by \200\230watchful waiting \200\231 however, bio psy or image if worrying signs are present. Abscess Accumulation of pus within cavity due t o infection or foreign body. Symptoms typically single, painful, onset over days, may be fe brile/unwell. Signs fl uctuant, well-defi ned, under the skin; tender, infl amed (red, hot) ; may spontaneously discharge; common on neck, axilla, groin, perineum. Management incision and drainage antibiotics eg fl ucloxacillin 1g/6h PO. Boil (furuncle) Abscess forming in infl amed hair follicle, typically with S. aureus infection. Symptoms single, painful, com mon on neck, axilla, groin, perineum. Signs red, tender, hot, central punctum, may discharg e pus. Management often discharges spontaneously, otherwise treat as abscess; multiple furu ncles may coalesce into a carbuncle which requires drainage and extended antibiotic therapy . Warts Benign proliferation of epidermis associated with infection with human papillomavir us (HPV); can occur in various sites. Common warts are papular lesions with a rough surface with black dots within them, often on the hands and feet. Spread is by direct contact. Pla ntar warts (veruccas) are usually fl at or inward growing with black dots ( \200\230heads \200\231). Often painful if over pressure areas. Plane warts are small, fl esh-colored, fl at-topped lesions usually on the face or backs of the hands without black dots. Anogenital warts are transmitted sexually and associated with diff erent HPV subtypes from non-genital warts; subtypes 16 and 18 are strongly associated with cervical carcinoma, so ensure recen t cervical smear in any 5 with genital warts (or in 5 partner, of any aff ected individual) . Treating warts is often diffi cult. Topical keratolytic agents (such as salicylic acid or trichloracetic acid) is usually fi rst-line treatment, and cryotherapy (freezing) is under taken by many general practitioners as well as in dermatology clinics. Non-genital warts of ten resolve spontaneously over 72 \200\2233yr. Actinic keratosis Scaly lesions seen on sun- exposed skin of fair skinned individuals. Can progress to skin cancer; can be surgically re moved or topically treated. _OHFP.indb 421 _OHFP.indb 421 30/05/2014 16:18 30/05/2014 16:18 422 CHAPTER 14 Skin and eyes Skin cancers Basal-cell carcinoma (BCC) Commonest form of skin cancer, accounting for 775% of diagnoses. Risk factors exposure to UV light (sunlight and sunbeds), PMH or FH of BCC, e xposure to arsenic. Appearance slow growing sore on sun-exposed skin; most are nodular (wax y appearance, rolled pearly edges and central ulceration \200\224 \200\230rodent ulcer \200 \231 typically found on face); other variants include super \201 cial (fl at, red, scaly p atches \200\223 found on trunk) and pigmented. Investigation biopsy and histology if large , followed by surgical excision; usually fully excised initially if small and sent for hist ological analysis. Treatment excision (including Mohs \200\231 surgery), topical chemothera py, radiotherapy, cryosurgery. Prognosis BCC rarely metastasise but can cause local tissue destruction ( g (eg ear, lip) and very infrequently cause death. p) y q y Mohs \200\231 surgery involves surgical removal of the obvious tumor and a thin layer of ti ssue from the site. This layer is frozen and stained then examined under a microscope. If t here are tumor cells present, a further (deeper) layer of tissue is removed, and the proces s is repeated until the layer is tumor-free. This procedure minimizes the need for large sk in excisions and gives the best cosmetic outcome. Squamous-cell carcinomas (SCC) These account for approximately 20% of cutaneous malignancie s. Risk factors exposure to UV light (sunlight and sunbeds) or to industrial car- cinogens (eg arsenic, tar), chronic ulcer infl ammation, immunosuppression, premalignant conditions (eg Bowen \200\231s disease, actinic keratosis). Appearance variable; typically fl eshy pla que or papule arising on sun- exposed skin (770% on head and neck), often with bleeding, sc aling or ulceration; other forms include Marjolin ulcer (new area of induration at edge of leg ulcer); keratoacanthoma is a rapidly growing nodule with central ulceration that usuall y spontaneously regresses and is considered by most as a variant of SCC. Investigation usua lly none, may be biopsied. Treatment surgical excision or radiotherapy; topical chemotherap y, photo- dynamic therapy and immunomodulators used if unsuitable for surgery. Prognosis if localized disease, excision gives 95% cure rate but SCC can metastasise rapidly via local lymph nodes with poor outcome. metastasise rapidly via local lymph nodes with poor outcome. Malignant melanoma Accounts for 74% of all skin cancers, but majority of skin cancer deaths . Risk factors pale-skin, sun exposure, sunburn, multiple/congenital naevi. Symptoms/signs A new, or changing mole, as assessed by ABCDE criteria:1 Asymmetry, Border irregularity, Co lor variation, Diameter increasing or >6mm, Evolving over time. Management surgical excisio n, lymph node removal, chemotherapy. Prognosis depends upon completeness of excision, l ymph node involve ment, presence of ulceration and tumor thickness; these are combined to g ive a stage (stage I: 5yr survival 85-99%; stage IV: 10%). 1 Abbasi, N.R. et al. JAMA 2004 292:2771 available free at (cid:27)jama.ama-assn.org OHFP.indb 422 OHFP.indb 422 30/05/2014 16:18 30/05/2014 16:18 423 BREAST LUMPS Breast lumpsp Worrying features >50yr, fi xed, hard, enlarging lesion with skin tethering, breast eczema, new nipple inversion or bloody nipple discharge; PMH or FH breast cancer. Think about serious breast cancer; common fi broadenoma, fi broad- enosis, abscess, isolate d cyst, seroma, trauma (fat necrosis). Ask about onset, duration, change with menstrual cyc le, pain, trauma, skin changes, nipple changes, nipple discharge; PMH previous lumps, breas t cancer, breastfeeding, pregnancy; DH OCP, HRT; FH breast cancer. Look for see b p141 for breast examination Management breast lumps require a triple assessment of clinical examinat ion, imaging (mammography USS) and histology (FNA) or core biopsy); these should be off e red via a \200\2301-stop \200\231 breast clinic. Fibroadenoma Symptoms and signs young wom en (<40yr) with highly mobile, non- tender, well-defi ned, and small lump (breast mouse), o therwise well. Management refer to breast surgeon; usually not excised unless >40yr, suspic ious USS appearance or >4cm. Fibroadenosis ( \201 brocystic change) Symptoms and signs 35 \200\22350yr, single or multiple, painful and tender lumps, size and pain vary with menstru al cycle. Management refer to breast surgeon; often assessed with USS and aspi- ration, but may require mammography and excision. Abscess Risk factors breastfeeding, DM, smoking, ste roids, trauma. Symptoms and signs single, red, hot, tender lump, fl uctuant, may discharge pus from the nipple, fever. Management refer to surgeon for incision and drainage with anti biotics. Breast seromas Collections of serous fl uid; common after breast surgery. Symptoms and signs may discharge fl uid, non-tender, fl uctuant. Management refer to surgeon for pe rcutaneous drainage. Breast cancer1 Most common non-skin cancer in UK; women aged 50 \200 \22370yr are off ered 3yrly screening mammography; overall 5yr survival is 80%. Risk factor s age, family history, estrogen exposure (early menarche, late menopause, nulliparity, obes ity), previous breast cancer. Symptoms fi nding on screening (mammography), breast lump, ni pple inversion or bloody discharge, skin changes, weight loss, bone pain. Signs palpable, n on-tender mass (often hard, poorly defi ned), skin dimpling, peau d \200\231orange (promine nt pores), nipple eczema (Paget \200\231s), lymphadenopathy. Investigations mammography U SS (for women <35yr with dense breasts); biopsy/FNA for histological evidence of cancer; st aging may require LFT, Ca2+, USS liver axilla, CT, bone scan. Treatment varies with tumor stage, tumor markers, grade and the patient \200\231s wishes. Options will include combina tions of surgery, chemotherapy, radio- therapy, hormonal modulation, and monoclonal antibod ies. Complications metastases (bones, lung, liver, brain), recurrence, lymphoe- dema, serom a, cosmetic appearance, psychological. 1 NICE guidelines available at (cid:27)guidance.nice .org.uk/CG80 and (cid:27)guidance.nice.org.uk/CG81 _OHFP.indb 423 _OHFP.indb 423 30/05/2014 16:18 30/05/2014 16:18 424 CHAPTER 14 Skin and eyes Leg ulcers Loss of epithelial integrity with failure to heal. Think about venous insuffi ci ency, peripheral vascular disease, neuro- pathic (eg DM), pressure ulcers, trauma, infectio n, pyoderma gangrenosum (b p418), vasculitides, skin cancer, steroids. Ask about onset, dur ation, pain, trauma, claudication; PMH peripheral vascular disease, iBP, CVA, MI, angina, v aricose veins, DVT, DM; DH steroids; SH smoking, alcohol. Look for number, site, size, base , edge, depth, shape, color, oedema, eczema, vascular disease (peripheral pulses, hair loss , cold), neuropathy (sensation), infection (discharge, lymphadenopathy). Investigations bld s FBC, CRP, fasting glucose (if not known DM; HbA1c if known DM); consider ESR, complement, RhF, ANA, ANCA; ankle brachial pressure index (ABPI, b p448) duplex USS or CT angiogram if ABPI abnormal; wound swab ( X-ray if osteomyelitis suspected); biopsy atypical areas. Table 14.4 Clinical assessment of leg ulcers Venous (780%) Arterial (710%) Intermittent claudication, HTN, DM, IHD, smoker Shiny, hairless, cold Neuropathic (710%) Numbness, DM, family history Joint destruction History Obesity, immobility, varicose veins, DVT Pigmented, varicose veins, swollen, hot Me dial aspect of legs Leg Site Lateral malleolus, toes, dorsum of foot Usually small Deep with a dark, dry base, few signs of healing Well defi ned, often circular Heel, metatarsal head, pressure points Usually small Can be very deep (extend to bone) Surr ounded by thickened skin Size Base Can be very large Usually superfi cial with sloughy exudate Irregular, areas of repeated he aling and exacerbation Edge Sensation Painful Painful Relatively painless Management Ensure good nutrition and treat the cause, where pos- sible. Healing often takes weeks to months and is commonly managed by community nurses, with ulcer clinic visits wher e appropriate: \200 Venous provided ABPI is >0.8 apply compression bandaging (eg 4-layer \200\230Charing Cross \200\231) with absorbable dressings to dry out the slough. Emollient s and steroid creams also help; may need debridement/grafting \200 Arterial avoid compres sion bandages; address vascular risk factors and refer to a vascular surgeon for considerat ion for bypass or angioplasty Neuropathic careful footcare to avoid repeated injury, often needs surgical debridement and antibiotics; osteomyelitis is common; assess for and treat coexist ent vascular disease; specialist diabetic foot team if DM Infection ulcers usually have bacteria present; infection or cellulitis should be suspected if there is pus, excessive pain, surrounding erythema or pyrexia. Swab the ulcer and treat as for cellulitis (b p412). No improvement consider other diagnoses (including TB and cancer) or dermatitis from therap eutic agents. Ensure swabs sent; discuss with dermatology and consider biopsy. May need cur ettage or skin grafting. OHFP.indb 424 OHFP.indb 424 30/05/2014 16:18 30/05/2014 16:18 This page intentionally left blank 426 CHAPTER 14 Skin and eyes Acute red eye emergency 3Call for senior help or speak to on-call ophthalmologist urgently if patient has new onset dvisual acuity (VA) in aff ected eye. Yes No Yes Foreign body sensation? Sudden onset? KERATITIS b p427 Photophobia? No No Yes FOREIGN BODY b p428 CONJUNCTIVITIS b p428 No No SUBCONJUNCTIVAL hemorrhage b p428 Engorged vessels? Pain? Yes Yes EPISCLERITIS/ SCLERITIS b p427 Altered or blurred vision? No Yes Small (constricted) ACUTE ANTERIOR UVEITIS b p427 Pupil size? Large (dilated) ACUTE ANGLE CLOSURE GLAUCOMA b p427 Fig. 14.2 Determining the likely cause of the acute red eye. OHFP.indb 426 OHFP.indb 426 30/05/2014 16:18 30/05/2014 16:18 427 ACUTE RED EYE EMERGENCY 3Keratitis (OHCS8 b p432) Corneal infl ammation with white slough on cornea; may ulcerate. Symptoms eye irritation/foreign body sensation often on background of chronic gritty/irrita ted eyes or in contact lens wearers. If ulceration occurs, pain, photophobia, and altered v isual acuity may develop. Signs mild localized redness, often only in one sector of the cor nea (unlike conjunctivitis which is usually bilateral and diff use with a discharge); norma l visual acuity unless ulceration. Fluorescein with a blue light may show corneal ulceratio n with corneal haze. Management if ulceration present or suspected, refer urgently for opht hal- mologist to consider infectious or autoimmune causes and for defi nitive care. This is likely to include corneal swabs/scrapes and antibiotic eye- drops under close supervision. 3Episcleritis and scleritis (OHCS8 b p432) Infl ammation of white outer coating; often und erlying autoimmune disorder. Symptoms mild eye ache and tenderness; pain, photophobia and a ltered visual acuity are uncommon in episcleritis, but may feature in scleritis. Signs mild localized redness (often involving just one sector, but occasionally diff use); normal vis ual acuity; otherwise normal examination in episcleritis. In scleritis the globe may be ten der to touch and there may be dvisual acuity. Management urgent ophthalmology review to con sider scleritis. Likely ophthalmic management topical steroids or non-steroidal agents for episcleritis, potentially oral immunosuppressants for scleritis. 3Acute anterior uveitis (i ritis) (OHCS8 b p430) Infl ammation of pigmented parts of eye; associated with systemic dis ease (eg IBD, arthropathies, sarcoid); pain on pupillary constriction. Symptoms blurred vis ion, photophobia, and pain if severe. Signs red eye, dvisual acuity, cornea usually clear, pupil may be irregular and small, hypopyon (pus in the anterior chamber). Management refe r urgently to ophthalmologist. Likely ophthalmic management intensive topical steroids, dil ating agents. 3Acute angle closure glaucoma (OHCS8 b p430) iIntraocular pressure due to blo ckage of anterior chamber drainage. Symptoms aching eye pain (usually unilateral and severe ), often associated with N+V; blurred vision and haloes around lights are common. Signs red eye, dvisual acuity, hazy cornea (if severe); pupil often mid- dilated, can be unreactive to light and oval shaped (rugby ball-like); globe tender and fi rm to touch. iintraocular p ressure; usually >40 mmHg. Management emergency referral to ophthalmologist; antiemetics an d IV opioids may be needed for symptoms but should not delay referral. Likely ophthalmic ma nagement constrict the pupil (miosis) with pilocar- pine drops, and reduce aqueous formatio n with acetazolamide PO/ IV. Mannitol IV is also sometimes used to reduce intraocular press ure. Defi nitive care achieved with peripheral iridectomy to allow constant drainage of aqu eous even when pupil dilated. _OHFP.indb 427 _OHFP.indb 427 30/05/2014 16:18 30/05/2014 16:18 428 CHAPTER 14 Skin and eyes Super \201 cial foreign body (FB) and corneal abrasions Symptoms sudden onset discomfort/f oreign body sensation; lacrimation and redness; occurs, eg whilst hammering or chiseling wi thout eye pro- tection or following minor trauma to the eye. A contact lens may some- times have been \200\230lost \200\231 and cause FB sensation. Signs red, watering eye; FB may b e visible. Always evert both top and bottom lids to check for FBs here as well; visual acui ty is usually normal. Fluorescein with a blue light may show corneal ulceration/abrasion(s) . Treatment may need to anesthetize the eye with topical local anesthetic (proxymetacaine, tetracaine, or oxybuprocaine) to allow examination and treatment. Gently pick up FB with co tton bud, or irrigate lavishly with sterile 0.9% saline. Re-examine eye afterwards to ensur e all FBs have gone. Protect the eye with an eye shield until local anesthetic has worn off and give chloramphenicol eye drops 0.5% 4h topical or ointment 1% 6h topical for 3d. If un able to remove FB or evidence of corneal abrasion speak to senior, or on-call ophthalmologi st. Conjunctivitis Symptoms eye discharge, FB sensation, itch, concurrent cold, hayfever. Sig ns red eye, discharge, normal visual acuity, clear cornea. Treatment can be highly contagio us so care should be taken with hand- washing. Bacterial topical antibiotics (eg chloramphe nicol drops 0.5%) to both eyes every 2h whilst awake for 2d, then 6h for 1wk; viral may nee d topical antibiotics to prevent secondary infections, but usually self-limiting; allergic identify allergen if possible and encourage avoidance; topical anti- histamine, (eg azelast ine), or mast-cell inhibitors (cromoglicate) may off er relief; artifi cial tears (eg Visco tears ) may help if dry eyes are a problem. Table 14.5 Determining the cause of a conjunctivitis Bacterial Viral Allergic Discharge Itch Recurrent Contagious Uni- or bilateral Other symptoms Sticky, pus-like Watery +/ \200\223 +/ \200\223 Yes One, then both One, then both Common co ld Often none Watery ++++ Often seasonal No Both Hay fever +/ \200\223 +/ \200\223 Yes Subconjunctival hemorrhage Symptoms often an incidental fi nding by the patient and usually benign; can sometimes initially cause mild FB sensation. Pain, photophobia, or altered vis ion should suggest an alternative diagnosis. Signs diff use area of bright red blood under the conjunctiva, very diff erent to infl amed blood vessels seen in other forms of red eye; normal VA. Treatment check BP, and if recurrent check FBC and clotting; may need eye prote ction (eg tape at night) if swollen and unable to close readily; discuss with ophthalmologi st only if recurrent or severe. OHFP.indb 428 OHFP.indb 428 30/05/2014 16:18 30/05/2014 16:18 429 SUDDEN VISUAL LOSS Sudden visual loss Worrying features severe defi cit, additional neurology, scalp pain. Think about retinal vein occlusion, retinal artery occlusion, giant-cell arteritis, retinal detachment, arteriosclerotic ischaemic optic neuropathy, vitreous hemorrhage; angle closur e glaucoma. Ask about loss of vision; often painless. Look for dvisual acuity or no vision in aff ected eye, pupil unresponsive to light (suggests optic nerve disorder); abnormal retina on fundo scopy. Check for other neurological signs, for scalp pain/tenderness and ECG for AF. Management immediate referral to on-call ophthalmologist. 3Giant-cell (temporal) arteritis (b p361); dvisual acuity in aff ected eye, typically with temporal headache/pain, may be re tinal splinter hemorrhages or disc oedema. 3Retinal artery occlusion (OHCS8 b p435) Symptom s sudden, painless and severe loss of vision. Signs relative aff erent pupillary defect; pa le retina with \200\230cherry spot \200\231 macula. Risk factors for vascular disease (DM, smoker, ilipids, IHD). Treatment if seen within 1h of onset, you may attempt to dislodge t he embolus by pressing hard on the globe, then suddenly releasing; most damage will be irre versible. 3Retinal vein occlusion (OHCS8 b p435) Symptoms sudden, painless and severe loss of vision; may be segmental. Signs relative aff erent pupillary defect; engorged, red retin a in aff ected area. Risk factors include age, chronic glaucoma, HTN, polycythaemia. Treatm ent supportive; laser photocoagulation may reduce macular oedema. 3Vitreous hemorrhage (OHC S8 b p434) Symptoms sudden painless loss of vision; fl oaters. Signs relative aff erent pup illary defect; loss of red refl ex; unable to see retina. Risk factors DM (proliferative re tinopathy), bleeding disorder, trauma. Treatment should resolve spontaneously; prevent furt her episodes by laser photocoagulation of proliferative vessels; vitrectomy if persistent. Optic neuritis may be associated with a sub-acute, painless, unilat- eral loss of vision, o ften with associated loss of color discrimination (best assessed by asking the patient to i dentify the color of a red Neurotip \204 ). Fundoscopy may reveal a swollen, bulging optic disc. Causes include demy- elinating disease (this may be a fi rst presentation of MS). Tre atment is sup- portive, with resolution occurring over a few weeks. _OHFP.indb 429 _OHFP.indb 429 30/05/2014 16:18 30/05/2014 16:18 430 CHAPTER 14 Skin and eyes Gradual visual loss Think about refractive error, cataracts, macular degeneration, chronic glaucoma, diabetic retinopathy, optic atrophy, drug toxicity, optic neuroma; inherited dise ase. Ask about painless loss of vision, symptoms of underlying disease. Look for dvisual ac uity or no vision in aff ected eye, pupil unresponsive to light or relative aff erent pupil lary defect (suggest optic nerve disorder), abnormal cornea, lens, retina, or optic disc on fundoscopy. Management needs full ophthalmic assessment. If in-patient try and arrange for review in eye clinic prior to discharge, or refer back to GP. Cataracts (OHCS8 b p442) Cau ses DM, steroids, trauma, eye surgery; congenital. Symptoms blurred vision (bilateral), poo r distance judgment (unilateral). Signs dvisual acuity, cataract visible in lens; retina an d red refl ex visible unless cataract is dense. Treatment cataract surgery is performed on a single eye at a time if the cataract(s) are interfering with lifestyle (eg reading or dri ving). They are usually done as a day-case procedure under local anesthetic; the lens is re moved (phaecoemulsion) and an artifi cial lens implanted. Age-related macular degeneration (OHCS8 b p438) Causes age related, smoking. Symptoms deterioration of central vision. Signs dvisual acuity, but normal visual fi elds; normal disc, but macula often pigmented or blee ding upon fundoscopy. Treatment is aimed at reducing further visual loss; \200\230wet \200 \231 (neovascular) forms can be treated with anti-angiogenic monoclonal antibodies (eg rani bizumab) or laser photocoagulation. Chronic (open angle) glaucoma results in peripheral vis ual fi eld loss in those with iintraocular pressure (IOP). Signs include cupping and atroph y of the optic disc. Treatment aims to dIOP by daqueous formation (topical b-blockers eg ti molol, or carbonic anhydrase inhibitors eg dor- zolamide) or ireabsorption (prostaglandin d rops, eg latanoprost); surgery involves trabeculectomy (allows aqueous drainage into subcon junctiva). Registration of visual impairment A consultant ophthalmologist can apply on behalf of a pat ient to register as blind or partially sighted; this is a voluntary not a statutory process . Registration entitles the individual to some tax allowances, benefi ts, and some concessi ons for public transportation and other public facilities. Generally acuity <3/60 (after co rrection) qualifi es as \200\230blind \200\231, whilst corrected vision <6/60 qualifi es a s \200\230partially sighted \200\231; restriction of visual fi elds or loss of central vis ion may also qualify. The Royal National Institute of Blind People advise on benefi t entit lements, aids for the house and independent living, and for guide dogs: Royal National Inst itute of Blind People 105 Judd Street, London, WC1H 9NE 0303 123 9999 (cid:27)www.rnib.org. uk OHFP.indb 430 OHFP.indb 430 30/05/2014 16:18 30/05/2014 16:18 431 OTHER VISUAL DISTURBANCES Other visual disturbances 3Photophobia Causes neurological meningitis, subarachnoid hemorrh age, migraine, encephalitis, hangover; ophthalmic glaucoma, scleritis, keratitis and cornea l injury, iritis, cataracts. Symptoms bright light causes discomfort or exacerbates pain (e specially painful having fundoscopy performed). Signs dislike of light; intolerant of fundo scopy. Check for signs of men- ingism (b p360) and for focal neurology; perform full eye ex amination. Treatment treat for likely cause(s); seek senior help urgently. Diplopia \200\223 double vision Causes extra-ocular muscle palsy, cranial nerve palsy, mya sthenia gravis, orbital fracture, multiple sclerosis. Symptoms double vision which is corre cted by closing one eye or at extremes of gaze is called binocular diplopia; monocular dipl opia is rarer and is not corrected by closing one eye, being caused by a structural abnorma lity within the eye. Signs double vision usually relieved by occluding vision in one eye (t he outer image will disappear when the aff ected eye is covered), loss of conjugate gaze, d ROM of eye when testing all movements in turn, fatigability of muscles, other evidence of a ssociated disease (MS, CVA, etc). Treatment discuss with senior; refer to neurologist/ophth almologist. Tunnel vision Causes glaucoma, severe cataracts, alcohol consumption, retinitis pig- mentos a, migraine. Symptoms loss of peripheral vision with preservation of central vision, as tho ugh looking through a tunnel. Signs check for visual fi eld defect, dvisual acuity, catarac ts, or abnormal retina; check BP and blood glucose. Treatment treat the cause. Haloes around lights Causes glaucoma, cataracts, post-corrective surgery, idiopathic. Sympt oms haloes and glare from lights, often more obvious at night. Signs look for dvisual acuit y, cataracts. Treatment treat the cause. Floaters and \202 ashing lights Causes retinal detachment, vitreous detachment, migraine, idiopathic (non-sinister). Symptoms dark fl ecks or webs which drift about in the line of vision; fl ashing lights, usually in the periphery of vision even when eye closed. Signs of ten very few signs if non-sinister cause; dvisual acuity, visual fi eld, or abnormal fundos copy may feature in retinal or vitreous detachment. Treatment often not necessary. If lots of new fl oaters have appeared quickly or there are associated fl ashing lights, haloes or newly impaired visual acuity refer urgently to ophthalmologist. _OHFP.indb 431 _OHFP.indb 431 30/05/2014 16:18 30/05/2014 16:18 This page intentionally left blank Chapter 15 Emergency department 433 Trauma 434 Head injury 438 Neck injury 440 Falls and collapse 442 Acutely painful limb emer gency 444 Acute limb pain 445 Chronic limb pain 448 Limb swelling 449 Joint pain 452 Neck l umps 458 ENT 460 Groin lumps 462 Burns emergency 466 Burns 468 Anaphylaxis in adults 470 Hy potension emergency 472 Hypotension 473 Shock 476 Pyrexia 482 Overdose emergency 492 Overdo se and deliberate self-harm 493 Vaginal bleeding 496 Gynecological causes of pain 500 Contr aception 501 Early pregnancy (1st trimester) 502 Later pregnancy (2nd/3rd trimester) 504 De livery 506 After delivery (post-partum) 507 _OHFP.indb 433 _OHFP.indb 433 30/05/2014 16:18 30/05/2014 16:18 434 CHAPTER 15 Emergency department Trauma Worrying features shock, tachypnoea, dGCS, signifi cant mechanism.1 Think about emergency severe trauma (b p232); common head injury, neck injury, concealed bl eeding, fractures, dislocations, sprains, strains, bruises, incisional wounds, lacerations, abrasions, foreign bodies. Ask about location at time of injury, activity prior to injury, cause/mecha- nism/direction of injury, ability to walk/move immediately after and now, exa cerbating/relieving actions, pain, associated symptoms, time of last meal; PMH all medical problems, clotting abnormalities, kidney problems, GI problems, surgery, admissions, psychi atric problems; DH tetanus status, allergies; SH occupation, dominant hand, normal mobility , help at home. Important questions to help assess RTAs Collision speed (both vehicles combined)? Wearing s eatbelt? Airbags deployed? Position front/back)? Injuries/fatalities of other vehicle occup ants? Patient trapped in car? What stopped the car? Was the car written off ? in car (driver/passenger side, Obs HR, BP, RR, GCS, blood glucose, temp. Look for (see b pp146 \200\223152 for specifi c j oint examinations); resting position, bruising, swelling, deformity, skin changes, active r ange of movement, tenderness (bony vs. soft tissue), passive range of move- ment, stability of joint, ability to use joint eg walking, always check: \200 Joints directly above and below the site of injury \200 Distal sensation/circulation (pulse, capillary refi ll) of aff ected limbs. Investigations X-ray if fracture/dislocation is possible or to exclude ) a radio-opaque foreign body (eg some glass, metal). g y ( g g Consequences of trauma covered elsewhere b p440 b p460 b p436 b p438 Wounds Head injury Neck injury Epistaxis Treatment Analgesia (b p86) should be given prior to examination and investigation to allow time for the drugs to act. The following injuries need senior review or referral: \200 W ounds with involvement of deep structures, eg tendons \200 Wounds in cosmetically sensiti ve areas, eg face \200 Wounds in functionally sensitive areas, eg hands, genitals \200 Wounds with loss of skin tissue \200 Displaced fractures \200 Unstable fractures \200 Open fractures \200 Fractures with skin tenting or associated dislocation \200 Disloca tion of major joints (ie hip, knee, ankle, shoulder, elbow) \200 Injuries with neurovascu lar compromise. 1 eg fall from >1m or 5 stairs; axial load to head \200\223 eg diving; hig h-speed motor vehicle collision; rollover motor accident; ejection from a motor vehicle; accident involving motorized recrea tional vehicles; bicycle collision. OHFP.indb 434 OHFP.indb 434 30/05/2014 16:18 30/05/2014 16:18 435 TRAUMA Soft tissue injuries (sprains, strains) A sprain is minor damage to a ligament while a stra in is caused by minor damage to a muscle. Both are managed the same way: \200 Rest initia lly, but weight-bear or exercise as soon as symptoms allow \200 Ice to reduce swelling ov er the fi rst 48h; keep the ice away from the skin (eg use a tea towel) and apply for 10 \200\22315min at a time Elevation reduces both swelling and pain. Prescribe adequate analgesia (eg paracetamol 1g/6 h PO and ibuprofen 400mg/6h PO) and give reassurance. Compression is not routinely recommen ded as it can delay regaining full mobility. Natural history symptoms often worsen over 24 \200\22348h then start to improve; they may t ake up to 6wk to resolve completely. Most heal completely, otherwise physiotherapy strength ening exercises can help. Dislocations \200 Provide adequate analgesia \200 Document defi cits in distal circulat ion and sensation and at-risk nerves \200 X-ray before and after reduction (except ankle dislocation which should be reduced urgently, with senior supervision) Recheck and document any defi cits in distal circulation and sensation and at-risk nerves. Appropriately immobilize/strap. Discharge with analgesia and orthopedic follow-up if necessary. Natural history symptoms im prove dramatically with reduction though some discomfort may be present for days/weeks. Fur ther dislocation is common and may need physiotherapy or surgical treatment. Fractures Types hairline very small fracture, no bony displacement; simple 2 bone sections; comminuted \211 3 bone sections; open/compound break in skin overlying a fracture. You should suspect a fracture if there is a history of high forces, bony tenderness, swelli ng or reduced range of movement (ROM). Treatment \200 Analgesia only eg single rib or coccyx fractures, these do not need imaging unless a complication is suspected (eg pneumothorax) Immobilization (eg backslab, sling) analgesia, fracture clinic follow-up for fractures that do not need an urgent orthopedic review Orthopedic referral if unstable, compound (open) or neurovascular compromise. Natural history pain worst after the injury with little improvement by day 3 \200\2235. Sim ple fractures should heal over 6wk with minimal complications; serious fractures may reduce range of movement permanently. 3Open/compound fractures resuscitate (b p472). Seek immedia te senior help, especially if distal sensation/circulation impaired or coexisting dislocati on. Give analgesia (eg IV morphine), take a digital/polaroid photo, cover the wound with io dine/saline-soaked swabs, start IV antibiotics (eg co-amoxiclav 1.2g/8h IV), review tetanus status, X-ray; refer urgently to orthopedics. _OHFP.indb 435 _OHFP.indb 435 30/05/2014 16:18 30/05/2014 16:18 436 CHAPTER 15 Emergency department Wounds Ask about mechanism of injury, paying particular attention to bites (animal or human ), foreign bodies (eg metal/broken glass), contamination with soil or manure and when the w ound occurred. Always ask about and document tetanus status. Look for record the site, size (measure) and type of the wound (see Table 15.1), check distal sensation, pulse/cap refi l l and movement, look and feel inside the wound (usually with local anesthetic) to assess de pth, pres- ence of foreign bodies and involvement of deep structures (eg tendons). Table 15.1 Types of wound Puncture Incisional wound Deep wound with a small skin defect, eg cat bite, nail Wound caused by sharp objects, eg kn ife/broken glass, often have straight edges and can be deep Wound following blunt trauma, e g banging head on sidewalk, edges are often ragged and bruised Graze Wound that fully penet rates the skin (epidermis and dermis) so that subcutaneous fat is visible Wound that does n ot fully penetrate the skin Laceration Abrasion Full thickness Superfi cial Cleaning all wounds should be thoroughly cleaned with sterile water or 0.9% saline. Abrasio ns may need to be scrubbed and deeper wounds may need cleaning with high-pressure 0.9% sali ne (use a syringe and green needle hub with the needle broken off ). Cleaning can be done a fter local anesthetic infi ltration. Important rules \200 X-ray all wounds involving brok en glass or metal foreign bodies \200 Wounds should not be closed if: \200 older than 1 2h (unless facial) \200 very dirty or infected foreign bodies present \200 bites Refer wounds that involve tendons or joints (to orthopedics), arteries (to vascular surgeons) or nerves (to orthopedics or plastics). Primary closure is closing the wound in ED; several options are available: \200 Glue for faces, children and small wounds (<2cm) if the edges are not gaping. The glue should just h old the edges together, not enter the wound. Be very careful not to get the glue in the eye