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RASH, ACUTE GENERALIZED SKIN ICD-10CM # R21 Rash and other nonspecific skin eruption 1769

ERUPTION

Full clinical assessment

Yes Urgent
1 >90% body surface area erythematous? Erythroderma
Dermatology input

No

2 Blisters present?

No Yes
Stevens-Johnson
Yes syndrome / toxic
Urgent
Mucous membrane involvement? epidermal necrolysis /
Dermatology input
acute pemphigus
No

Yes Consider bullous pemphigoid, erythema


Blisters ≥5 mm? multiforme, fixed drug eruption, acute
dermatitis, insect bite
No

Consider herpes simplex / zoster, dermatitis herpetiformis, chickenpox,


impetigo, acute dermatitis

3 Purpura present?

No Yes

Yes
Evidence of infection? Consider meningococcal sepsis / endocarditis

No
Coagulopathy, anticoagulant therapy,
Yes disseminated intravascular coagulation,
↓Platelets or ↑PT / APTT?
idiopathic thrombocytopenic purpura,

Algorithms
Clinical
thrombotic thrombocytopenic purpura
No

Consider vasculitis or drug reaction

4 Pustules present?
Yes
Likely pustular psoriasis or systemic infection III
No

Yes
5 Wheals present? Urticaria Seek precipitant

No

Yes
6 Underlying chronic dermatosis? Consider acute flare

No

7 Likely drug reaction or infective exanthem. Refer Dermatology if persistent or severe symptoms

FIG. 121  Rash: acute generalized skin eruption. (From Gawkrodger DJ: Dermatology ICT, ed 4, Edinburgh,
2008, Churchill Livingstone; Japp AG, Robertson C: Macleod’s clinical diagnosis, ed 2, Philadelphia, 2018,
Elsevier.)

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1770 Rectal Ulcer ICD-10CM # K62.6 Ulcer of anus and rectum

Endoscopic evidence of SRUS

Jumbo biopsy on proctosigmoidoscopy


or colonoscopy to exclude malignancy

Asymptomatic Symptomatic without Symptomatic with


full-thickness prolapse full-thickness prolapse

Observe
Endoscopic ultrasound ± Cystocolpoproctography
Anorectal manometry/EMG
Defecating proctogram or
Dynamic MR

Normal Paradoxical Internal or external Internal or external


puborectalis prolapse without pelvic prolapse with pelvic
contraction organ prolapse organ prolapse

Re-emphasize Rectopexy ± Multidisciplinary pelvic


Biofeedback
elimination of suppositories, sigmoid resection floor repair
botox?
digitations, etc. ± biofeedback ± biofeedback
Follow-up with further biopsies

Endoscopic evaluation
to assess healing

FIG. 122  Schematic for the management of solitary rectal ulcer syndrome (SRUS). EMG,
Electromyography; MR, magnetic resonance. (From Cameron JL, Cameron AM: Surgical therapy, ed 12,
Philadelphia, 2017, Elsevier.)

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RED EYE ICD-10CM # K62.6 Red eye 1770.e1

FIG. E126  Scleritis. (From Kanski JJ: Clinical diagnosis in ophthalmology, ed 1,


St Louis, 2006, Mosby.)

FIG. E123  Senile entropion of the lower lid. (From Douglas G, Nicol F,
Robertson C: MacLeod’s clinical examination, ed 13, Edinburgh, 2013, Churchill
Livingstone.)

FIG. E127  Acute angle-closure glaucoma. Arrows show dilated conjunctival


vessels at corneal edge. Note hazy cornea. (From Roberts JR, Hedges JR: Clinical
procedures in emergency medicine, ed 5, Philadelphia, 2010, Saunders.)
FIG. E124  Iritis (anterior uveitis). (From Schwartz MH: Textbook of physical
diagnosis: history and examination, ed 6, Philadelphia, 2009, Saunders.)

FIG. E125  Episcleritis. (From Rutter P: Community pharmacy, ed 2, Edinburgh,


2009, Churchill Livingstone.)

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Red Eye—cont’d ICD-10CM # H57.8 Other specified disorders of eye and adnexa 1771

Eye examination (see clinical tool)

1 Is eye redness bilateral?

No Yes

Yes Consider bilateral iritis / keratitis /


Photophobia or severe pain?
scleritis
No

Yes
Itchy? Likely allergic conjunctivitis

No

Likely infective conjunctivitis

Abnormality of eyelashes, eyelid Yes Ectropion / entropion (Fig. E123) /


2
or eye closure? blepharitis / trichiasis / Bell’s palsy

No
Yes
3 Does cornea stain with fluorescein? Keratitis / foreign body

No

Yes
4 Is pupil larger in the red eye? Acute angle-closure glaucoma (Fig. E127)

No

Yes
5 Is photophobia present? Likely iritis (Fig. E124)

No

Algorithms
Clinical
Yes
6 Severe pain / tenderness? Consider scleritis (Fig. E126)

No

7 Is the eye redness localised? III


No Yes

Yes
Asymptomatic + ‘quiet’ Subconjunctival haemorrhage
adjacent conjunctiva

No

Probable episcleritis (Fig. E125)

Consider unilateral conjunctivitis / extra-ocular causes of red eye


8 Episcleritis
Urgent ophthalmology review if decreased VA, severe pain or photophobia

FIG. 128  Red eye. (From Japp AG, Robertson C: Macleod’s clinical diagnosis, ed 2, Elsevier, 2018.)

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1772 RENAL MASS ICD-10CM # D41.10 Neoplasm of uncertain behavior
of unspecified renal pelvis

Cystic
Mass not identified
Smooth wall Renal ultrasound
(confirmed with CT scan)
No internal echoes

Solid/complex Hypoechoic mass suspicious


Observe Internal echoes for abscess (Fig. 130)
Irregular wall

Negative CT number
Fat density CT scan
Angiomyolipoma

Complex mass Solid Decreased


Suspected caval attenuation suspicious
Observe No contrast enhancement Contrast enhancement
thrombus for abscess
Indeterminate Vascular tumor
(Fig. 131)

Surgery MRI

IV antibiotic
Avascular
Renal arteriogram Neovascularity
Inconclusive

Needle aspiration Surgery

Malignant cells

Surgery

FIG. 129  Evaluation of a patient with a renal mass on renal ultrasound. CT, Computed tomography;
MRI, magnetic resonance imaging. (Modified from Williams RD: Tumors of the kidney, ureter, and bladder. In
Goldman L, Schafer AL [eds]: Cecil textbook of medicine, ed 23, Philadelphia, 2008, Saunders.)

FIG. 130  Acute renal abscess. Transverse ultrasound image of the right kidney FIG. 131  Acute renal abscess. Nonenhanced computed tomography scan
demonstrates a poorly marginated rounded focal hypoechoic mass (arrows) in the through the mid-pole of the right kidney demonstrates right renal enlargement
anterior portion of the kidney. CT, computed tomography. (From Wein AJ, Kavoussi and an area of decreased attenuation (arrows). After antimicrobial therapy, a
LR, Partin AW, Peters CA: Campbell-Walsh urology, ed 11, Philadelphia, 2016, follow-up scan showed complete regression of these findings. (From Wein AJ,
Elsevier.) Kavoussi LR, Partin AW, Peters CA: Campbell-Walsh urology, ed 11, Philadelphia,
2016, Elsevier.)

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Renal Trauma ICD-10CM # S37.009A Unspecified injury of unspecified kidney, initial encounter 1772.e1

1. Penetrating abdominal, pelvic trauma


2. Rapid decelerating scenarios
3. Polytraumatically injured patients
4. Gross hematuria
5. Microscopic hematuria with shock

Blood at meatus
Perineal hematoma
Positive for meatal blood
Clinically stable RGUG or flexible urethroscopy Clinically unstable

Consider FAST Consider single-phase CT

CT with delayed views Inability to void or Emergent surgery


gross hematuria and pelvic FX if renal exploration indicated and no CT
Single-shot IVP

Urinary extravasation CT cystogram Consider CT with delayed


No contrast in distal ureter Abd/pelvic CT with delay views when stable
Cystogram with retrograde studies

FIG. E132  Recommended evaluation protocol for patients with a medical history or physical find-
ings consistent with possible genitourinary injury. Abd, abdominal; CT, computed tomography; FAST,
focused assessment with sonography for trauma; FX, fracture; IVP, intravenous pyelography; RGUG, retrograde
urethrogram. (Wein AJ, Kavoussi LR, Partin AW, Peters CA: Campbell-Walsh urology, ed 11, Philadelphia, 2016,
Elsevier.)

TABLE E49  Consensus Recommendations for Management of Renal Trauma


Clinical Findings and/or Grade of Renal Injury Recommended Treatment
Grade 1 or 2 renal injury irrespective of traumatic etiology* Nonoperative
Isolated grade 3, grade 4, and hemodynamically stable grade 5 renal injuries Nonoperative
Uncontrollable renal hemorrhage/vascular instability; occasionally grade 4 “shat- Absolute requirement for surgical intervention
tered” kidneys and a high percentage of grade 5 injuries
Persistent or delayed hemorrhage not responding to angiographic embolization Absolute requirement for surgical intervention
Expanding pulsatile retroperitoneal mass found on surgical exploration for coexist- Absolute requirement for surgical intervention (verify contralateral renal func-
ing intraabdominal injuries tion prior to exploration)
Penetrating trauma, inadequate preoperative radiographic staging because of vas- Retroperitoneal (renal) exploration recommended (verify contralateral renal
cular instability of patient, retroperitoneal hemorrhage found on exploration function prior to exploration)
Blunt trauma; inadequate preoperative radiographic staging because of vascular Observation—if FAST with bilateral blood flow. If no FAST obtained, consider
instability of patient; no duodenal, pancreatic, or colonic injuries with retroperi- intraoperative single-shot IVP/US with renal blood flow assessment or CT
toneal hemorrhage found on exploration immediately following stabilization of patient
Blunt trauma; inadequate preoperative radiographic staging because of vascular Surgical interventions with renorrhaphy an option (verify contralateral
instability of patient; duodenal, pancreatic, or colonic injuries with retroperito- renal function prior to exploration) or Drain intra-abdominal injuries.
neal hemorrhage found on exploration Observation—if FAST with bilateral blood flow. If no FAST obtained, consider
intraoperative single-shot IVP/US with renal blood flow assessment or CT
immediately following stabilization of patient
Blunt/penetrating trauma; radiographic screening studies reveal grade 3 renal Retroperitoneal (renal) exploration with renorrhaphy and repair recommended
injury with devitalized renal fragments, grade 4 or 5 renal injury, coexisting
intraabdominal injuries—especially duodenum, pancreas, and colon

CT, Computed tomography; FAST, focused assessment with sonography for trauma; IVP, intravenous pyelography; US, ultrasound.
*Blunt or penetrating trauma.
From Wein AJ, Kavoussi LR, Partin AW, Peters CA: Campbell-Walsh urology, ed 11, Philadelphia, 2016, Elsevier.

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