History-taking model
Kaji Sritharan, Vivian A Elwell, Sachi Sivananthan in Essential OSCE Topics for Medical and Surgical Finals, 2007
Hands Nails: clubbing, nicotine stains, cyanosis, vascular lesions, sphincter haemorrhages.Palms: pallor in palmar creases.Temperature.Capillary refill time: normal value is less than 2 seconds. Radial pulsesLook at both sides for synchrony (radial-radial), and radial femoral pulse.Rate and rhythm.Test for collapsing pulse (raise arm up). Allen’s test
Hematomas
Nilton Di Chiacchio, Antonella Tosti in Therapies for Nail Disorders, 2020
A complete dermatological examination is necessary in evaluating nail hematomas. The physical examination requires removal of nail cosmetics and artificial nails followed by an examination of the skin, hair, mucosa, and all 20 nails. Violaceous patches on the skin may indicate senile purpura, a bleeding disorder, or medication use such as prednisone or warfarin. The nails should be examined on a flat surface with the fingers and toes spread apart. A complete examination requires an evaluation of the patient while standing, as well as the gait to check for toe overlap, pressure on particular toes, or favoring one side of the body with weight. The nails, nail folds, and hyponychium are examined, as well as the degree of onycholysis when present. The digit is also examined for motor function, sensation, and circulation. Pressure is applied to the dorsal digit and strength of extension is evaluated. Capillary refill is employed to test circulation.
Haematology
Faye Hill, Sash Noor, Neel Sharma, Tiago Villanueva in Medical and Surgical Emergencies for Students and Junior Doctors, 2021
It is important to note how to recognise and manage sepsis as a general rule. Sepsis is regarded as a temperature >38°C, hypothermia, tachycardia, hypotension (typically a systolic blood pressure of <90 mmHg and mean arterial pressure of <70 mmHg), tachypnoea, confusion, significant oedema and hyperglycaemia. Blood investigations characteristically demonstrate a leukocytosis or leukopenia with a raised C-reactive protein and procalcitonin. Additional diagnostic criteria involve hypoxia, oliguria, a creatinine increase >0.5 mg/dL, disturbed coagulation (international normalised ratio >1.5), ileus, thrombocytopenia and hyperbilirubinaemia. There may also be hyperlactataemia with decreased capillary refill.
Degree of Soft Tissue Injury is a Major Determinant of Successful Arterial Repair in the Extremity: A New Classification of Extremity Arterial Injury?
Published in Journal of Investigative Surgery, 2022
Peijun Deng, Jiantao Yang, Jacques Henri Hacquebord, Bengang Qin, Honggang Wang, Ping Li, Liqiang Gu, Jian Qi, Qingtang Zhu
Following institutional review board approval (NO. 2021247), a retrospective study was conducted on data from all adult patients treated in our institution for traumatic extremity arterial injury of a major vessel between January 2013 and December 2020. The inclusion criteria were as follows: 1) single or multiple arterial injury in an extremity and resulting in 2) ipsilateral limb ischemia at the time of presentation. Limb ischemia was defined as 1) poor capillary refill or 2) weak pulse or pulselessness. The exclusion criteria were:1) age < 16 years, 2) injury below the wrist and ankle, 3) unstable vital signs, 4) polytrauma, 5) preexisting peripheral vascular disease, and 6) traumatic amputation. Finally, 106 patients were included in this study (Figure 1). The median age of patients was 36 years [interquartile range (IQR): 25.25-45], with 16 women and 90 men.
Aortic thrombosis in a neonate with COVID-19-related fetal inflammatory response syndrome requiring amputation of the leg: a case report
Published in Paediatrics and International Child Health, 2021
Priyanka S. Amonkar, Jeetendra B. Gavhane, Suhas N. Kharche, Sameer S. Kadam, Dattatray B. Bhusare
A full-term male neonate weighing 2400 g was born by normal vaginal delivery. There was no maternal history of COVID-19-like symptoms or any antenatal risk factors. At birth, the neonate was healthy and was discharged on Day 3 of life after an uneventful course in hospital. He was well until Day 6 of life when he developed irritability and progressive blackish discolouration of the toes of his right foot. On Day 10, he presented to MGM Hospital and Medical College, Navi Mumbai, India. On examination, he was irritable and afebrile but non-cyanotic. His heart rate was 144/min, respiratory rate 44/min, blood pressure 66/42 mmhg and SpO2 98% in room air, and capillary refill time was <3 seconds. There were no clinical signs of sepsis. Examination of other systems was normal. The right lower limb had gangrenous changes of the toes and discolouration was present up to 2 cm above the ankle (Figure 1). This extremity was cold and tender, pulses were absent and there was no capillary refill. The left lower limb also had a feeble pulse but no skin changes.
Anaphylaxis due to Hymenoptera sting progressing to thoracic aortic dissection
Published in Baylor University Medical Center Proceedings, 2022
On emergency department arrival, the patient was noted to be uncomfortable with a Glasgow Coma Scale score of 15. She was hypotensive and had an irregular heart rhythm with an aortic diastolic murmur. Her capillary refill was <2 seconds, and pulses were equal and 2+ in all extremities. The skin was diaphoretic with right-hand erythema. Her neurological exam was unremarkable. Initial laboratory results were significant for a hematocrit of 30.9%. The predominant initial concern was anaphylaxis due to persistent hypoxemia, hypotension, and nausea. Treatment was started with 0.3 mg intramuscular epinephrine, 1 L normal saline bolus, 125 mg methylprednisolone, 25 mg diphenhydramine, and 20 mg famotidine. An electrocardiogram revealed atrial fibrillation without acute ischemic changes.
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