3 results
22 - Fever in adults
- Swaminatha V. Mahadevan, Stanford University School of Medicine, California, Gus M. Garmel, Stanford University School of Medicine, California
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- Book:
- An Introduction to Clinical Emergency Medicine
- Published online:
- 27 October 2009
- Print publication:
- 26 May 2005, pp 333-352
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Summary
Scope of the problem
Accounting for 5–10% of all adult emergency department (ED) visits, fever is ubiquitous to the human experience. It is popularly felt to be either harmful in and of itself or a sign of an underlying serious disease. Most often young, previously healthy adults suffer self-limited illnesses that are well-tolerated and respond to symptomatic therapy. Morbidity and mortality from infectious causes of fever rise sharply with age. As opposed to children whose temperature elevations are overwhelmingly likely to be due to infection, adults have a broader differential of both infectious and noninfectious etiologies. Responses to elevated body temperature readings in the ED must first be taken in the context of the stability of the patient and then regarding the presumptive cause. Fever may not always be a component of initial concern but may be identified on measurement of the initial vital signs. Patients may also present with a history of feeling “feverish” that has resolved spontaneously or with home therapy. Disease entities that are being considered in febrile patients cannot be ruled out simply by the momentary absence of fever.
Pathophysiology
It is important to distinguish whether a high temperature is from a fever (defined as a deliberate hypothalamus-controlled reflex elevation of body temperature) or hyperpyrexia (an uncontrolled heat accumulation overwhelming compensatory mechanisms). This distinction is typically not difficult but has important immediate diagnostic and therapeutic implications.
10 - Abnormal behavior
- Swaminatha V. Mahadevan, Stanford University School of Medicine, California, Gus M. Garmel, Stanford University School of Medicine, California
-
- Book:
- An Introduction to Clinical Emergency Medicine
- Published online:
- 27 October 2009
- Print publication:
- 26 May 2005, pp 161-170
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- Chapter
- Export citation
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Summary
Scope of the problem
Patients manifesting abnormal behavior are common in emergency departments (EDs). They represent one of the most challenging classes of patients the emergency physician must treat. The causes of abnormal behavior are exceedingly diverse and require physicians to maintain a high level of vigilance to determine whether an underlying medical disorder exists. In 1998, it was estimated that nearly 4% of the approximately 100.4 million ED visits in the US were for behavioral problems. Many of these patients present “for medical clearance” prior to an intended psychiatric hospitalization. It is important that these patients be treated with the same sensitivity as every patient in the ED. “Medical clearance” should include a comprehensive medical evaluation to identify any potential underlying medical problem that may be responsible for the changes in behavior.
Pathophysiology
The physiology of behavior represents a complex interplay of human physiology and the environment in which it exists. Historically, changes in behavior have been classified as being of functional (psychiatric) or organic (medical) etiology. These classifications are dated, as neuropathophysiologic mechanisms of psychiatric disease have advanced over the past decades. Examples include aberrations in neurotransmitter transduction in depression (serotonin), schizophrenia (dopamine) and Alzheimer's disease (acetylcholine). Pharmacologic therapy directed at modulation of these neurotransmitters has greatly advanced the treatment and prognosis of patients suffering with these illnesses.
History
Prior to obtaining the history, the safety of the patient and staff should be ensured.
1 - Approach to the emergency patient
- Swaminatha V. Mahadevan, Stanford University School of Medicine, California, Gus M. Garmel, Stanford University School of Medicine, California
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- Book:
- An Introduction to Clinical Emergency Medicine
- Published online:
- 27 October 2009
- Print publication:
- 26 May 2005, pp 3-18
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- Chapter
- Export citation
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Summary
The emergency department (ED) is a challenging environment for patients, families, and medical personnel. Many challenges result from our practice's principles: available at any time for any patient with any complaint. Patients who come to the ED are not familiar with us personally, yet must feel confident about our abilities to help them during their time of greatest concern. Their needs may be as straightforward as an excuse note for work or a prescription refill in the middle of the night, or as complex as an acute illness or injury, an exacerbation of a chronic condition, or a cry for help if depressed or suicidal. Even providing reassurance about a child's fever to a concerned parent is a critical function of emergency physicians (EPs).
Qualities successful EPs exhibit include intelligence, sensitivity, humility, insight, proficiency making decisions with and acting on limited information, and the ability to multi-task. Being skillful negotiators, working well with individuals having different backgrounds and ethnicities, and advocating strongly for patients at all times are essential qualities. In addition to these traits, EPs must be experts in trauma and medical resuscitation of adults and children, and in sharing news with patients and family members about the outcomes of these events.
The majority of patients use the ED infrequently. Many may be experiencing this setting for the first time. Patients' lack of familiarity with this environment, fear, stress, waiting times, painful procedures, and overall discomfort often preclude them from having a positive experience.
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