Urgent Care A→Z Notes Review

Emergency Lecture Mod 1: Urgent Care A→Z Notes (Phyllis Wood Lecture)

Abdominal Pain

  • Triage Mindset:

    • Consider acute versus chronic conditions.

    • Distinguish between new onset pain versus pain ongoing for “2–3 days bothering them.”

  • Key Questions:

    • Last BM? (constipation question)

    • Always consider UA (urinalysis) for abdominal pain as UTI can mimic abdominal issues.

    • Typical presentation of UTI does not include "hunched over" appearance.

  • Red Flags for ED Referral:

    • Guarding

    • Right lower quadrant (RLQ) pain (likely appendicitis)

    • Very high blood pressure with concern for abdominal aortic aneurysm (AAA; check for pulsatile aorta).

  • Clues for Appendicitis:

    • Patient cannot jump off examination table due to pain

    • Low-grade fever

    • Possible increase in white blood cell count (↑WBC) if complete blood count (CBC) is available.

  • Exam Maneuvers:

    • Rebound tenderness

    • Heel-jar/heel tap test

    • Obturator sign (pain upon hip flexion/internal rotation).

Abrasions

  • Assessment:

    • Ask about mechanism of injury (important for potential fractures under abrasions).

Abscess / Cellulitis

  • Initial Assessment Classifications:

    • Early-stage = cellulitis (characterized by redness and firmness).

    • Late-stage = fluctuant abscess.

  • Cellulitis Strategy:

    • Outline the border of the cellulitis; recheck in 1–2 days; consider starting antibiotics.

  • Treatment Notes:

    • Do NOT perform incision and drainage (I&D) on a firm, non-fluctuant area. Use warm compresses instead to help the area declare itself.

    • When I&D is performed, note that the abscess may appear small but can yield a large amount of drainage; irrigate and pack to prevent tunneling.

  • Specific Cases:

    • Perianal abscess: Requires hospital/surgery due to risk of tunneling/sepsis.

    • Face/Eye Abscess/Cellulitis: Refer to ED due to high risk of serious complications.

    • Brown Recluse Bites: Often reported but frequently unconfirmed and complex for management.

Allergic Reactions / Anaphylaxis

  • Management Importance:

    • Allergic reactions can be fatal; treat with vigilance.

    • If significant reaction occurs: prescribe and teach EpiPen use; refer to allergist.

    • Possible labs include serum IgE and food allergen testing.

    • If emergency epinephrine is administered for anaphylaxis, call 911 even if the patient's condition improves.

Allergic Rhinitis

  • Overview:

    • Common condition; effectively treating rhinitis can improve overall allergy control and can reduce asthma triggers.

  • First-Line Treatment:

    • Intranasal medications such as azelastine (antihistamine spray), fluticasone.

  • Technique for Spraying:

    • Aim the spray while looking down to avoid a bad taste and improve delivery effectiveness.

Anemia

  • Differentiation of Types:

    • Distinguish between microcytic (small red blood cells) versus macrocytic (large red blood cells) anemia and find the root cause.

  • Special Note in Pediatrics:

    • Excessive milk/bottle feeding past 12 months can lead to iron deficiency due to low iron absorption from dairy.

  • Iron Absorption Notes:

    • Maximize absorption by taking iron supplements with vitamin C or orange juice.

    • Be wary of heavy menstrual cycles which can indicate an anemia risk.

    • Chronic diseases or cancers may also lead to anemia.

    • Side effects of iron supplements can include constipation and nausea, thus consider stool softeners and timing (take at bedtime if nausea is an issue).

Asthma

  • Nature of Condition:

    • Generally trigger-driven and can be fatal—emphasize prevention and rescue plans for exacerbations.

  • Control Assessment:

    • Frequency of rescue medication use reflects control level of asthma.

  • ACUTE Exacerbation Protocols:

    • Use SABA (short-acting beta agonist); consider oral steroids.

    • For severe cases, utilize IV steroids and magnesium; hospitalization may be warranted.

  • Monitoring Tools:

    • Peak flow meters should be used to determine personal bests and for action planning; their utility is often undervalued.

Bacterial Vaginosis

  • Characteristics:

    • Common condition that should be treated with metronidazole.

    • Note that BV is not classified as a sexually transmitted infection (STI), although its symptoms can mimic STIs.

    • Recommend avoiding scented hygiene products.

Bell's Palsy

  • Overview:

    • Presents as rapid unilateral facial weakness and can resemble a stroke.

    • Often associated with a viral trigger.

  • Treatment Protocols:

    • Administer steroids; sometimes valacyclovir is also indicated.

    • Eye care should include lubricating drops/ointment and taping the eye closed at night.

Biopsy (Skin)

  • General Guidance:

    • Urgent care facilities can perform skin biopsies to avoid extended waiting times with dermatology; ensure adequate depth and margins before sending for pathology.

Animal Bites

  • Key Actions:

    • Must report animal bites to appropriate authorities.

    • Manage punctures and bites with antibiotics, typically amoxicillin-clavulanate.

    • Evaluate tetanus and assess potential rabies risks.

  • Rabies Management:

    • Involves administering immune globulin around the wound and initiating a vaccination series; immunocompromised individuals follow a different regimen. Generally, rabies vaccines are administered at county health departments or in emergency departments.

Bleeding

  • Control Strategies:

    • Control all types of bleeding by utilizing pressure dressings, and apply a tourniquet if needed to manage severe cases.

    • For heavy vaginal bleeding, a pregnancy test and evaluation in the emergency department may be required.

    • GI bleeding with very low hemoglobin signifies need for emergency evaluation.

Burns

  • Best Practices:

    • Shift care from silver sulfadiazine to bacitracin in managing many minor burns.

    • Avoid using butter as it seals in heat and can cause infection.

    • Reassess wounds; once healed, recommend utilizing sunscreen for scar care.

    • Serious burns should prompt immediate hospitalization.

Bronchitis

  • Definition:

    • Often termed inflammatory cough syndrome, typically arising after approximately two weeks of cough; commonly viral in origin.

    • Note low oxygen levels suggest pneumonia instead of simple bronchitis.

    • Avoid the reflex response of prescribing Z-pak antibiotics without specific indications (e.g., in COPD exacerbation scenarios).

Bursitis

  • Condition Overview:

    • Characterized as inflammation of the bursa; aspiration may recur.

  • Treatment Options:

    • Initial management includes resting the area, using NSAIDs, and potentially corticosteroids; referral may be necessary if symptoms persist or worsen.

Cellulitis (Special Note)

  • Management Approaches:

    • Mark the borders of redness to track the spread of the condition.

    • Orbital cellulitis requires emergency department referral and often necessitates systemic therapy due to severity.

    • Understand that children can deteriorate more rapidly due to smaller body mass.

Chemical Dependence / Opioid Use Disorder

  • Treatment Concept:

    • Treat as a chronic disease with consideration that relapse may result in mortality.

    • Medication-assisted treatment (MAT) like buprenorphine/Suboxone has proven effective in saving lives.

    • Ensure patients have access to Narcan and provide counseling regarding safe usage (e.g., do not use alone, have someone present with Narcan, ensure that person is not using).

Chest Pain

  • Key Principles:

    • Chest pain signifies a myocardial infarction (MI) until proven otherwise.

    • Immediate ECG required; a STEMI is an emergency situation.

    • Patients must be prevented from driving themselves to a hospital during such events.

  • Epidemiological Notes:

    • Diabetics and women may present atypically with jaw/back/shoulder/arm pain.

Conjunctivitis / Eye Injury

  • Distinctions:

    • Educate how to differentiate between bacterial, viral, and allergic forms of conjunctivitis (bacterial requires antibiotics while viral/allergic do not).

  • Emergencies:

    • Eye injuries that can cause blindness require urgent care: employ fluorescein and Wood's lamp for abrasions and foreign bodies, sudden vision loss necessitates expeditious medical attention.

DVT (Deep Venous Thrombosis)

  • Management:

    • Often managed as an outpatient but can be grave; referral to vascular specialists should be considered before discharging patients.

Dental Pain

  • Expert Notes:

    • While not a dentist, provide medication bridges until dental care is available.

    • Recurrent “tooth pain” may be a referral pain hinting at serious underlying disease (e.g., can be cancerous); history review and possible imaging are warranted if symptoms are atypical or recurrent.