Rash, Acute Generalized Skin Eruption: Full Clinical Assessment

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

Full clinical assessment

Yes Consider bullous pemphigoid, erythema

Consider herpes simplex / zoster, dermatitis herpetiformis, chickenpox,

Consider vasculitis or drug reaction

Endoscopic evidence of SRUS

Jumbo biopsy on proctosigmoidoscopy

Asymptomatic Symptomatic without Symptomatic with

Normal Paradoxical Internal or external Internal or external

Re-emphasize Rectopexy ± Multidisciplinary pelvic

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

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

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

Eye examination (see clinical tool)

1 Is eye redness bilateral?

Yes Consider bilateral iritis / keratitis /

Likely infective conjunctivitis

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

7 Is the eye redness localised? III

Probable episcleritis (Fig. E125)

Consider unilateral conjunctivitis / extra-ocular causes of red eye

Solid/complex Hypoechoic mass suspicious

Complex mass Solid Decreased

Needle aspiration Surgery

1. Penetrating abdominal, pelvic trauma

Consider FAST Consider single-phase CT

CT with delayed views Inability to void or Emergent surgery

Urinary extravasation CT cystogram Consider CT with delayed

TABLE E49 Consensus Recommendations for Management of Renal Trauma

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