med 17: December 2023

Friday, December 29, 2023

nervous system infection, toxic ingestion, peripheral nervous system disease (eg, Guillain-Barre syndrome, myasthenia gravis, botulism), metabolic disorders ( eg, diabetic

ketoacidosis), hyperammonemia, and anemia.

CLINICAL PRESENTATION

..,._ History

Initial treatment may be required for stabilization before a

complete history and physical examination can be performed.

Ask for a description of respiratory problems, including

onset, duration, and progression of symptoms. Keep in

mind that respiratory distress can present as difficulty with

feedings in infants and decreased activity or feeding in toddlers. Inquire about precipitating or exacerbating factors.

Ask if there was any recent history of choking, as this may

be the only clue for a foreign body aspiration. Inquire if

they have ever had a similar presentation in the past.

Review all prior medications (chronic and acute) and note

time of administration. For example, how many times

albuterol was given per day in the past several days and the

last time given before coming to the ED. Ask if immunizations are up to date, as failure to do so could put the child

at risk for rare diseases (ie, epiglottitis, pertussis). Review

in detail all past medical history. Infants born prematurely

may have bronchopulmonary dysplasia (BPD), making

reactive airway disease, respiratory infections, hypoxia, and

hypercarbia more likely. When treating children with

asthma, ask about frequency of exacerbations, if they ever

required intubation or positive pressure ventilation, previous admissions (ED, general floor, intensive care unit) and

the last time they were on steroids. A history of chronic

cough or multiple previous episodes of pneumonias may

be suggestive of a congenital condition, undiagnosed reactive airway disease, or foreign body aspiration.

..,._ Physical Examination

The assessment should be conducted in a calm, efficient

manner, with assistance from parents. Agitating a child can

worsen symptoms and even precipitate acute decompensation, especially in suspected upper airway obstruction.

Allow the child to assume a position of comfort. Take extra

caution if the patient is presenting in the sniffing position

(head and chin are positioned slightly forward), as this may

indicate severe upper airway obstruction. Likewise, if the

patient is presenting in the tripod position (leaning forward

and supporting the upper body with their hands), this indicates severe lower airway obstruction, and this position will

optimize their accessory muscle use. Respiratory rate varies

in relation to age: newborn (30-60); 1-6 months (30-40);

6-12 months (25-30); 1-6 years (20-30); > 6 years (15-20).

Heart rate also varies with age: newborn ( 140-1 60),

6 months (120-160), 1 year (100-140), 2 years (90-140),

4 years (80-l lO), 6-14 years (75-100), > 14 years (60-90).

Keep in mind that tachycardia is typical with albuterol

treatment.

Skin exam can show diaphoresis, cyanosis (peripheral

or central), rash (eg, hives), bruising, or trauma and can be

a clue to the cause of respiratory distress. Make sure to fully

unclothe the patient, taking care not to worsen distress.

Stridor indicates upper airway obstruction, and the

phase of the respiratory cycle in which it occurs is a clue to

the location of obstruction. Inspiratory stridor is seen with

subglottic/glottis obstruction above the larynx ( eg, epiglottitis). Nasal flaring, dysphonia, and hoarseness also suggest

upper airway obstruction. Expiratory stridor is consistent

with obstruction below the larynx, in the bronchi or lower

trachea. Croup is the most common cause, but also consider foreign body, epiglottitis, anaphylaxis, angioedema,

peritonsillar abscess, retropharyngeal abscess, tracheomalacia, laryngomalacia, or obstructing mass.

Inspect the chest for depth, rhythm, and symmetry of

respirations. Retractions indicate accessory muscle use.

As the involved muscle groups move more superiorly (subcostal, intercostal, suprasternal, supraclavicular), airway

obstruction is more severe. Also examine the chest and

neck for any crepitus.

Lung exam is particularly important. Pneumothorax is

suggested by unilateral decreased or absent breath sounds,

but this finding is not always present. Wheezing and a prolonged expiratory phase indicate lower airway obstruction.

It is important to note that in patients with very severe

lower airway obstruction, wheezing may be absent as a

CHAPTER 49

result of poor aeration. Crackles, rhonchi, and decreased or

asymmetric breath sounds are found with alveolar disease.

Grunting prevents alveolar collapse and preserves func

tional residual capacity (FRC). Its presence implies severe

respiratory compromise.

When performing a procedure, attempts should be

made to minimize pain and suffering in children through

the use of anesthetic, sedative, and/or pain medications.

Not only will the patient be happier, but the parents will be

more satisfied with their child's care. Use of topical

anesthetics during laceration repair, suprapubic bladder

tap, lumbar puncture, or intravenous access is recommended. During complex laceration repair or fracture

reduction, consider using procedural sedation. These pro

tocols use stronger medications such as ketarnine, midazolam, morphine, or fentanyl. Adequate pain relief can

help reduce anxiety as well.

MEDICAL DECISION MAKING

In most pediatric cases, your history and physical exam

are sufficient to rule out serious pathology. However, if

more ominous diagnoses are suggested by the history and/

or physical, testing should move into laboratory, imaging,

and possibly procedures as necessary (Figure 47-2).

TREATMENT

Once treatment strategies are chosen or narrowed down to

a few alternatives, it is a good time to review the options or

plan with the parent(s). The parents can be very helpful in

supporting the clinician in explaining the plan to the

patient. If multiple alternatives are presented, the parents

can help choose an option most in line with their wishes,

preferences, and/or child's comfort.

Medication dosages and emergency equipment must be

appropriate for the patient's weight. Getting an accurate

weight as part of the initial vital signs can help speed

medication calculations at this stage of the ED visit. If a

directly measured weight is unavailable in an emergent

situation, using a resuscitation tape (previously called

Broselow tape) can be extremely helpful. The red arrow on

the tape is placed at the patient's head and the tape is

extended to his/her feet to measure length. There is an

CHAPTER 47

average weight listed on the tape for this length. It is this

weight that is used for medication dosing, etc. All

medication dosages must be calculated on a milligram per

kilogram basis. All treatment should be performed as

quickly and as gently as possible.

DISPOSITION

� Admission

Indications for admission in pediatric patients include

suspected or confirmed acute surgical diagnoses ( eg,

appendicitis), any medical condition requiring further

monitoring and treatment ( eg, asthma, dehydration with

intractable vomiting), and uncertain diagnoses requiring

further work-up. Also, patients with certain social issues,

including suspected abuse, neglect, and failure to thrive,

should be considered for admission pending social services

consultation.

� Discharge

Stable patients with good social supports and medical

follow-up are appropriate for discharge after medical

conditions have been diagnosed and treatment plans

initiated and/or completed. Chronic conditions and related

complex work-ups in otherwise stable patients can be completed by the patient's primary care provider. Because almost

all pediatric patients have regular primary care providers,

patients will benefit from contact between the emergency

medicine physician and the primary care provider to have

appropriate continuity of care after discharge from the ED.

The treatment of the pediatric patient presents unique

challenges and requires specialized training but is easily

achievable by maintaining good rapport and communica

tion and showing patience and empathy. These skills will

decrease the amount of anxiety for the patient and parent,

facilitate care, and improve compliance.

SUGGESTED READING

American Academy of Pediatrics Committee on Pediatric

Emergency Medicine, American College of Emergency

Physicians Pediatric Emergency Medicine Committee, O'Malley

P, Brown K, Mace SE. Patient- and family-centered care and the

role of the emergency physician providing care to a chlld in the

emergency department. Pediatrics. 2006;118:2242-2244.

Corrales 1\Y, Starr M. Assessment of the unwell chlld. Aust Pam

Physician. 201 0;39:270-275.

Goldman, RD, Meckler, GD. Pediatrics: Emergency care of children. In: Tintinalli JE, Stapczynski JS, Ma OJ, Cline DM,

Cydulka RK, Meckler GD. Tintinalli's Emergency Medicine: A

Comprehensive Study Guide. 7th ed. New York, NY: McGrawHill, 20 1 1, pp. 73 1-733.

Hamrn MP, Osmond M, Curran J, Scott S, Ali S, Hartling L,

One or more of the following additional criteria can

be used to enhance the specificity and s upport a diagnosis

of PID: oral temperature >101°F, abnormal cervical or

mucopurulent discharge, presence of abundant WBCs on

microscopy of vaginal fluid, elevated ESR, elevated CRP,

or laboratory documentation of cervical infection with

N. gonorrhoeae or C. trachomatis.

TREATMENT

The treatment of vaginitis, cervicitis, and PID is outlined

in Tables 44-1, 44-2, and 44-3. All regimens used to treat

cervicitis and PID should be effective against N. gonorrhoeae

and C. trachomatis. The need to treat anaerobes has not

been completely studied. Gardnerella (BV) has been

present in many patients with PID, so many recommend

treatment regimens that include anaerobic coverage (ie,

metronidazole). For women with mild to moderate severity PID, parenteral and oral regimens appear to have

similar efficacy.

DISPOSITION

.... Admission

In women with mild or moderate PID, outpatient therapy

yields similar short and long-term outcomes.

Hospitalization is recommended when the patient meets

any of the following criteria: surgical emergencies cannot

Table 44-3. Treatment of PID.

Option 1 Option 2

Outpatient Ceftriaxone 250 mg IM Cefoxitin 2 g IM WITH

treatment PLUS Probenecid 1 g PO

Doxycycline 1 00 mg PO PLUS

BID X 14 days Doxycycline 1 00 mg PO

± BID X 14 days

Metronidazole 500 mg ±

PO BID x 14 days Metronidazole PO BID x

14 days

Inpatient Cefotetan 2 g IV q12hrs Clindamycin 900 mg IV

treatment OR q8hrs

Cefoxitin 2 g IV q6hrs PLUS

PLUS Gentamicin 2 mg/kg IV

Doxycycline 1 00 mg PO followed by 1 .5 mg/

or IV q12 hrs kg q8hrs

be ruled out (eg, appendicitis, tubo-ovarian abscess), pregnancy, nonresponse to oral antimicrobial therapy, unable

to tolerate oral regimen.

.... Discharge

Patient with vaginitis and cervicitis can be safely discharged. When an STI is suspected, patients should be

instructed to notify their partners. For PID, outpatient

therapy is initiated in patients who do not have any of the

criteria listed previously, appear nontoxic, and have reliable follow-up.

SUGGESTED READING

Buckley RG, Knoop KJ. Gynecologic and obstetric conditions.

In: Knoop KJ, Stack LB, Storrow AB, Thurman RJ. The Atlas

of Emergency Medicine. 3rd ed. New York, NY: McGrawHill, 20 10.

Centers for Disease Control and Prevention. Sexually

Transmitted Diseases Treatment Guidelines, 20 10. http:// www.cdc.gov/std/treatrnent/20 10/toc.htm

Kuhn, JK, Wahl RP. Vulvovaginitis. In: Tintinalli JE, Stapczynski JS,

Ma OJ, Cline DM, Cydulka RK, Meckler GD. Tintinalli's

Emergency Medicine: A Comprehensive Study Guide. 7th ed.

New York, NY: McGraw-Hill, 20 11, pp. 71 1-16.

Shepherd SM, Shoff WH, Behrman AJ. Pelvic inflammatory

disease. ln: Tintinalli JE, Stapczynski JS, Ma OJ, Cline DM,

Cydulka RK, Meckler GD. Tintinalli's Emergency Medicine: A

Comprehensive Study Guide. 7th ed. New York, NY: McGrawHill, 20 1 1, pp. 716-720.

Sweet RL. Treatment of acute pelvic inflammatory disease. Infect

Dis Obstet Gyneco/ 20 1 1;56 1-909.

Preeclampsia

and Eclampsia

Kathleen A. Wittels, MD

Key Points

• Gestational hypertension, preeclampsia, and eclampsia

represent a spectrum of potentially life-threatening

diseases that must be diagnosed and treated aggressively.

• Consider preeclampsia in any pregnant patient with an

elevated blood pressure.

INTRODUCTION

Hypertension in pregnancy occurs in approximately 10%

of pregnancies and can be associated with significant

maternal and fetal morbidity and mortality. The spectrum

of disease is divided into 3 main categories: gestational

hypertension, preeclampsia, and eclampsia. Preeclampsia

affects 2-6% of pregnancies in the United States, with a

higher incidence globally. Eclampsia occurs in <1% of

patients with preeclampsia.

Gestational hypertension is defined as a blood pressure

> 140/90 mmHg in a pregnant patient without preexisting

hypertension. The hypertension will resolve within

12 weeks postpartum. When proteinuria is also present, it

is defined as preeclampsia. Preeclampsia typically occurs

after 20 weeks' gestation. A subset of patients will develop

severe preeclampsia, which is associated with one of more

of the following: severe hypertension (> 1 60/110 mmHg on

2 separate occasions >6 hours apart), large proteinuria,

neurologic symptoms, epigastric/right upper quadrant

(RUQ) pain, pulmonary edema, or thrombocytopenia.

Eclampsia is preeclampsia with seizures. HELLP syndrome

affects some patients with preeclampsia and eclampsia and

is associated with hemolysis, elevated liver enzymes, and

low platelets.

Although the exact etiology of preeclampsia is unknown,

there are several factors that are thought to contribute.

• The degree of hypertension does not correlate with the

severity of preeclampsia.

• Delivery of the fetus is the definitive treatment of

preeclampsia and eclampsia.

These include maternal immunologic intolerance, abnormal

placental implantation, endothelial dysfunction, and genetic

factors.

CLINICAL PRESENTATION

..... History

Patients with gestational hypertension and preeclampsia may

be asymptomatic. Some women will report facial or extremity

edema, epigastric or RUQ pain, headache, or visual disturbances. Seizures in a woman with preeclampsia is pathognomonic for eclampsia and may occur in the postpartum

period. Risk factors for preeclampsia that should be screened

for during the history include nulliparity, advanced maternal

age, a multiple gestation pregnancy, diabetes, obesity, and

previous preeclampsia.

..... Physical Examination

It is critical to pay careful attention to the vital signs,

particularly the blood pressure. Edema of the face or

extremities may be appreciated. Examination of the lungs

may reveal rales suggestive of pulmonary edema. The

abdominal exam is important to assess for tenderness as

well as to estimate the gestational age of the fetus

(Figure 45-1). Listen for fetal heart tones with a Doppler or

Epididymitis may be associated with dysuria, urgency,

and pyuria. Ultrasound will show preserved or increased

blood flow. A positive Prehn sign is helpful but is not always

present. Epididymitis can extend to become epididymoorchitis, which is more likely to be associated with signs of

systemic illness such as fever, nausea, and vomiting. Isolated

orchitis is rare and usually viral in origin. These infectious

processes are all more likely to be gradual in onset.

An incarcerated inguinal hernia is another diagnostic

consideration. However, the patient is likely to have a history of hernia or scrotal swelling before the episode of

incarceration. Similarly, a tumor is usually gradual in onset

and is often painless.

Direct testicular tramna can precipitate torsion or cause

testicular contusion or rupture. Ultrasound will demonstrate rupture and possibly a hematocele. Consider torsion

in any patient with testicular tramna who still has pain

1-2 hours after what seems like a relatively minor injury.

There is no single feature of the history, physical examination, or diagnostic studies that is completely reliable in

diagnosing or excluding testicular torsion. Because this is a

fertility-threatening diagnosis, high clinical suspicion mandates immediate urologic consultation (Figure 41-2). If

ultrasound is rapidly available, it may be helpful in confirming a diagnosis, but should not delay urologic consult.

TREATMENT

Most testicular torsions occur in the lateral to medial

direction. Manual detorsion should be performed by rotating the affected testis in the lateral direction 1.5 rotations

Acute scrotal pain

• I mmediate GU consult

• Attempt manual detorsion

• Diagnostic ultrasound

Definitive

surgical care

CHAPTER 41

Figure 41-2. Testicular torsion diagnostic algorithm.

(540 degrees). To remember the direction to detorse, think

of opening a book (Figure 41-3). The end point of the

maneuver is relief of pain. If pain becomes more severe,

attempt detorsion in the opposite direction. If manual

detorsion is successful (ie, relief of pain), emergent consultation with a urologist is still required.

Manual detorsion is a painful procedure. You should

warn your patient and consider administering intravenous

(IV) narcotics before the procedure. A single dose of IV

narcotics is not likely to ameliorate the pain of testicular

torsion or remove the clinical end point (ie, relief of pain)

of the detorsion maneuver.

When manual detorsion is unsuccessful, emergent s urgical exploration and detorsion is indicated. Patients usu

ally require surgical fixation of both the affected and the

unaffected testes to avoid future torsion.

.A. Figure 41-3. Manual detorsion of the testicle. Reprinted

with permission from Gausche-Hill M, Williams JW. Chapter 82.

Male Genitourinary Problems. In: Strange GR, Ahrens WR,

Schafermeyer RW, Wiebe RA, eds. Pediatric Emergency

Medicine. 3rd ed. New York: McGraw-Hill, 2009.

DISPOSITION

� Admission

Admission for operative urologic intervention is indicated

in testicular torsion or suspected torsion with an equivocal

ultrasound.

� Discharge

If no torsion is noted on ultrasound and an alternative

diagnosis is established, the patient may be discharged with

treatment as indicated (antibiotics for epididymitis, pain

medications for torsion of a testicular appendage) and

return precautions.

SUGGESTED READING

Cokkinos, DD, Antypa E, Tserotas P, et al. Emergency ultrasound

of the scrotum: A review of the commonest pathologic conditions. Curr Prob Diagnost Radial. 201 1 ;40: 1-14.

Davis JE, Silverman M. Scrotal emergencies. Emerg Med Clin

North Am. 20 1 1;29:469-484.

Sdmeider RE. Male genital problems. In: Tintinalli JE, Stapczynski JS,

Ma OJ, Cline DM, Cydulka RK, Meckler GD. Tintinalli's

Emergency Medicine: A Comprehensive Study Guide. 7th ed.

New York, NY: McGraw-Hill, 201 1, pp. 613--620.

Schmitz D, Safranek S. How useful is a physical exam in diagnosing testicular torsion? J Pam Pract. 2009;58:433-434.

Penile Disorders

S. Spencer Topp, MD

Key Points

• Priapism and paraphimosis are urologic emergencies.

• Prolonged priapism (>6 hours) may result in impotence.

• Paraphimosis may lead to glans ischemia and necrosis.

INTRODUCTION

Penile disorders are a relatively uncommon presentation to

the emergency department (ED); however, a few of these

conditions are truly emergent. The penis is composed of

3 external anatomic parts-the shaft, glans, and foreskin.

Penile disorders can be classified according to how these

anatomic areas are affected. This chapter focuses on priapism, phimosis and paraphimosis, and balanoposthitis.

..... Priapism

Priapism is a persistent, often times painful, erection in

which both sides of the corpus cavernosa are engorged with

blood.

These medications can be difficult to tolerate given

their side effect profile (headache, asthenia, and gastrointestinal intolerance). In addition to the dose administered

in the ED, the patient will require continued therapy for

1 month.

For potential HBV exposures, the health care worker's

vaccination status should first be determined. If the exposed

person is unvaccinated, treatment with hepatitis B immunoglobulin (HBIG) should be started as soon as possible

after exposure (preferably within 24 hours). If the exposed

person was vaccinated but didn't have an appropriate antibody response (HBsAb <10 miU/mL), then proceed as if

unvaccinated. If the exposed person has an appropriate

antibody response after vaccination, then no treatment is

needed, although a booster HBV vaccine can be considered.

CHAPTER 38

STEP 1: Determine the exposure code (EC)

Is the source material blood, bloody fluid, other potentially infectious material

(OPIM) or an instrument contami nated with one of these substances?

Large

(e.g., severa l drops,

major blood splash and/or

longer duration [i.e., severa l

STEP 2: Determine the HIV status code (HIV SC)

Lower titer exposure

(e.g., asymptomatic

and high CD4 count)

STEP 3: Determine the PEP recommendation

PEP recommendations

PEP may not be wa rra nted . Exposure type does not pose a known risk for HIV transmission.

Consider basic regimen. Exposure type poses a negligible risk for HIV transmission.

Recommend basic regimen. Most HIV exposures are in this category;

no increased risk for HIV tra nsmission has been observed but use of PEP is appropriate.

Recommend expanded regimen. Exposure type represents an increased HIV transmission risk.

If the source or, in the case of an unknown source, the setti ng where the exposure occurred

suggests a possible risk for HIV exposure and the EC is 2 or 3, consider PEP basic program .

..&. Figure 38-1 . Blood and body fluid exposure diag nostic algorithm. Reprinted with permission from Public

Health Service Guidel ines for the Management of Health-Care Worker Exposures to HIV and Recommendations

for Postexposure Prophylaxis. MMWR Recomm Rep. 1 998 May1 5;47(RR-7):1-33. Available at http:/ /wonder

.cdc.gov /wonder I prevguid/ m00 52 722/m0052722 .asp.

BLOOD AND BODY FLUID EXPOSU RE

For potential HCV exposures, baseline testing for antiHCV, HCV RNA, and ALT should occur with follow-up

testing for HCV RNA between 4 and 6 weeks after expo

sure and follow-up testing for anti-HCV, HCV RNA, and

ALT between 4 and 6 months after exposure. Currently

there is no proven effective postexposure prophylaxis treatment available. Immunoglobulins and antiviral agents are

not recommended.

All patients should be counseled on refraining from

unprotected sexual intercourse and blood donations.

Follow-up should be given with the institution's

employee health departments.

DISPOSITION

Health care workers exposed to blood or body fluids can be

discharged home with instructions to follow up with their

hospital's employee health offices the next business day.

SUGGESTED READING

Centers for Disease Control and Prevention. Basic and expanded

HIV postexposure prophylaxis regimens. http://www.cdc

.gov/mmwr/preview/mmwrhtml/rr5011a4.htm. Accessed

April 28, 2012.

Centers for Disease Control and Prevention. Management of

occupational blood exposures. http://www.cdc.gov/mmwr

/preview/mmwrhtrnl/rr50 1 1 a3.htm. Accessed April 28, 2012.

Centers for Disease Control and Prevention. Updated U.S.

Public Health Service Guidelines for the Management of

Occupational Exposures to HBV, HCV, and HIV and

Recommendations for Postexposure Prophylaxis http://www

.cdc.gov/mmwr/preview/mmwrhtrnl/rr50 1 1a1.htrn. Accessed

April 28, 2012.

Centers for Disease Control and Prevention. Updated U.S.

Public Health Service Guidelines for the Management of

Occupational Exposures to HIV and Recommendations

for Postexposure Prophylaxis. http://www.cdc.gov/mmwr

/preview/mmwrhtml/rr5409al .htm. Accessed April 28, 20 1 2.

Nephrolithiasis

jonatha n Ban koff, MD

Key Points

• Analgesic administration should not be delayed while

obtaining laboratory and radiology studies.

• Abdominal aortic aneurysm should be considered in

the differential of elderly patients being eval uated for

kidney stones.

INTRODUCTION

Kidney stones occur when urinary solutes precipitate out

of the urine and form crystalline stones in the

genitourinary (GU) tract. Nephrolithiasis is common in

the United States, with an estimated prevalence of 7% in

men and 3% in women. Kidney stones most often affect

people in the third to fifth decades of life, but can occur

at all ages.

DISPOSITION

..... Admission

Patients with cellulitis or abscesses should be admitted if

there is an extensive area of involvement or if they are

systemically ill, have significant comorbid illness, or are

immune-compromised. All patients with necrotizing

infections should be admitted to an intensive care unit

for broad-spectrum antibiotic therapy after surgical

debridement.

..... Discharge

Patients with cellulitis or a drained abscess with limited

area of involvement, no or minimal systemic symptoms,

and no significant comorbidities may be discharged.

SUGGESTED READING

Chambers HF, Moellering RC Jr, Kamitska P. Clincal decisions.

Management of skin and soft-tissue infection. N Eng! l Med.

2008;359: 1063.

Dewitz F. Soft tissue. In: Ma OJ, Mateer JR, Blaivas M. Emergency

Ultrasound. 2nd ed. New York, NY: McGraw-Hill, 2008,

pp. 441-444.

Infectious Diseases Society of America. Practice Guidelines for

the Diagnosis and Management of Skin and Soft-Tissue

Infections. http://www.idsociety.org/uploadedFiles/IDSN

Guidelines-Patient_ Care/PDF _Library I Skin o/o20and %20

Softo/o20Tissue.pdf. CID 2005:41.

Kelly EW, Magliner D. Soft tissue infections. In: Tintinalli JE,

Stapczynski JS, Ma OJ, Cline DM, Cydulka RK, Meckler GD.

Tintinalli's Emergency Medicine: A Comprehensive Study

Guide. 7th ed. New York, NY: McGraw-Hill, 20 1 1,

pp. 1014-1024.

Wang CH, Khin LW, Heng KS, Tan KC, Low CO. The

LRINEC ( Laboratory Risk Indicator for Necrotizing

Fasciitis) score: A tool for distinguishing necrotizing fasciitis from other soft tissue infections. Grit Care Med.

2004;32: 1 535-1541 .

H uman Imm unodeficiency

Virus

Sorabh Khandelwal, MD

john Davis, MD

Key Points

• A high index of suspicion is needed fo r the initial

diagnosis of human immu nodeficiency virus (H IV),

particula rly in the context of atypical presenting

symptoms. Consider acute HIV in the patient who

presents with a mononucleosis-like i nfection, but

with negative monos pot testing.

• CD4 T-cell count is correlated with risk for opportunistic

infection.