A patient presents with an upper respiratory illness and wants antibiotics. She points out that she always gets antibiotics, and that she always gets better, therefore the antibiotics must be needed. Is this bacterial sinusitis?


The preferred term today is acute rhinosinusitis, which reflects the fact that the mucosa of the nasal and sinus mucosa are continuous and both affected. Upper respiratory infection is common, happening 6 times a year in children and 2-3 times per year in adults. The cause is initially viral in most cases. Bacteria superinfection is rare, occurring in 2-10% of cases. Nonetheless, antibiotics are prescribed in 81% of patients.


Imaging, whether radiographic or CT, does not differentiate bacterial from viral illness. With an ordinary cold, 87% of patients have abnormalities on CT.


Recent IDSA guidelines emphasize knowledge of the natural history of acute viral rhinosinusitis as a means of diagnosing bacterial superinfection. Fever and constitutional symptoms abate within 24-48 hours. Clear mucus becoming thick is normal and expected after about 3-4 days. The illness has peaked by day 5-6 and is starting to get better, even if not fully resolved.


Traditional signs of bacterial infection were a list of major criteria, but essentially they were indicators that the sinuses were either full of purulence or plugged (anterior or posterior purulent drainage, sinus fullness or pain, hyposmia).


To keep it simple, indications for antibiotics would be if the illness is:

-severe (for 3-4 days)

-prolonged (more than 10 days – 61% of taps at this time show bacteria)




Take Home Points:

-Viral acute rhinosinusitis is by far the most common cause

-Imaging does not reliably differentiate bacterial from viral causes

-Antibiotics are indicated when there is inappropriate worsening, severity, or duration


References: Chow, IDSA Guidelines, Clin Infect Dis, 2012



A patient presents with pruritus and excoriations.  He has a poor social situation and appears disheveled.  Could this be scabies?


Although some diagnostic algorithms are as simple as finding itching in 2 areas of the body (Mahé Trans R Soc Trop Med Hyg 2005) a closer look may prove rewarding.


Distribution: Infection is spread by direct contact, so regardless of where the infection started, the hands and wrists tend eventually to become infected.(Fathy J Egypt Soc Parasitol 2010) Other prominently affected areas include extensor surfaces, the genitalia, and axillary skin. The head and neck generally are spared.



The lesions eventually just look like excoriations. However, in earlier stages they are papulovesicular or nodular.


A closer look

Burrows are pathognomonic.  The term burrow seems to imply that the mites go deep.  They do not. These are just epidermal tunnels. The mite makes a serpiginous run through the stratum corneum, chewing up dead skin cells along the way.  A silvery burrow can sometimes be seen on close examination with a 0.3mm mite at the very end. They look like a tiny splinter hemorrhage.


Burrow ink test

The original burrow ink test was intended to reveal occult burrows. Rub low viscosity ink on the affected area, wipe off with alcohol, and the tract might be revealed. Tetracycline is used if you intend to cover a large area.  The tracts are then visible in ultraviolet light.


Diagnosis can be confirmed with scraping and slide review.  The diagnosis is made by finding eggs, mites, or feces. Dermatologists can do this at the bedside using dermoscopy.  Generally though this is a clinical diagnosis and such studies are not necessary in the emergency department.



-Scabies prominently affects the hands and avoids the head and neck

-Lesions can be nodular or papulovesicular before being excoriated

-Epidermal burrows are pathognomonic, and sometimes the mite is seen at the end

-The burrow ink test can be used to reveal occult burrows


A patient presents with left elbow pain after losing his balance and falling into a wall. The radiologist reads the x-ray as negative. But is there a fracture?


Physical diagnosis of orthopedic injuries receives little attention but is crucial to the practice of emergency medicine.


Check range of motion. The inability to extend the elbow is 73-100% sensitive for a fracture of the elbow. The patient can not fully extend the elbow.


Gently palpate the region. The entire region is tender but this appears to be maximal at the radial head. You palpate the radial head and put the radius through supination and pronation back and forth. This elicits the patient’s pain.


You diagnose a radial head fracture in spite of the negative x-rays. The patient follows up with orthopedic surgery and the radial head fracture is later confirmed.


Take home points:

-Elbow fractures typically restrict range of motion

-The radial head is stressed through supination and pronation

-Gentle palpation can help localize the fracture site