Beruflich Dokumente
Kultur Dokumente
May 2013 1) Syncope is a pain and I will not rail on more about how much we hate it, although I am positive you have already seen the first word of this paragraph and skipped the rest of the paragraph. Here they say that folks without CHF who are under the age of 60 will have little risk of death in 30 days, so send them home. (AEM 19(5)488). Let us look a little closer at this study. First of all it was a retrospective study based on ICD 9 codes; although that shouldn't be much of an issue here, as syncope doesn't have many imitators. But it will miss those who syncopized and had a good reason- like hypoglycemia which wouldn't kill most people, but also v tach, and MI so we cannot know true mortality. However, if we go by their numbers- they had almost 24000 ED visits and found only 307 deaths within 30 days. Again, we cannot be sure that they found everyone who died but the mortality was about 1% which I believe is probably true. Now they found higher hazard ratios with DM, and CHF. However, the hazard ratio will be higher in the above 60 group simply because they have more of a preponderance of these illnesses. Basically you can
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comes from TAKE HOME MESSAGE: Use Hisotacryl for anchoring in those IVs. Works well for diarrhea too! 3) America is now being overrun with new drug issues- it used to be herion, then it was designer drugs and I am not saying that these have disappeared but now it is prescription drugs. Oh, I know you were shocked to find out that those 450,678 pills of Percocet that you prescribed for Mr. Handley for his renal colic fell into the hands of other law abiding folks but be carefulthe swallowing of whole fentanyl patches is now on the upswing. (JEM 42(5) 549). They saw 76 patients in their series
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Cephalosporin allergies. What was thought to be a 10% cross reactivity is probably less than 1% and only with those cephalosporins that have an R1 chain- and even then- the allergy is to Amoxicillin or Ampicillin whom also have an R1 chain. Now I know you know which cephalosporins have an R1
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kind of like philosophy class-at the end of the day what are you left with? In any case they crunched the studies and found that Amoxicillin in early pregnancy increases your risk
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Probably is that R1 chain 6) Maybe this is just a problem in Israel, but I doubt it. We have been railing about (aren't I always railing about something? Well, you know there is a haloperidol shortage) catheter overuse that is finally now getting attention. There is pressure to reduce the amount of patients walking around with these awful contraptions, and in this study they found that in the hospital, the place were most catheters were inserted was the
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in your
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pants: 7) OK clinical quiz time. This old disease is making a comeback and is as angry as a ferret in your pants. If the disease progresses you can commonly see Higoumenakis sign (unilateral enlargement of the sternoclavicular joint), mulberry molars (extra cusps on the molars), Olympian brow (frontal bossing) and less commonly clutton joints (sterile
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8) I guess this information may help someone- birds are often pets (although who wants to deal with Q fever and psittacosisdon't you detest words that have a silent p? You should see a psychiatrist) and yes, you do have to know microbiology. Parakeet bites can inoculate salmonella and the ever popular Staph Aureaus- you will need Cipro and TMP/SMZ to cover them. They also have E coli. Cockatoos carry bacillus species and their bites will require clinda coverage. Parrots pass on Pasturella and Pseudomonas so consider Cipro and Augmentin. Conures require cipro. This information was passed on to me from a presentation at the International Virtual conference of Veterinary Medicine by Dr. Jesus- whom I do not know, but I am sure Father Greg does. (J Hand Surgery (am) 37 (9)1925) TAKE HOME MESSAGE: Bird bites are not innocuous and require serious antibiotics especially to the
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the anterior chamber) and a macular lesion on the palm in a lady with mitral valve prolapse, obesity and hypertension.
(JACC 60(12)e21)
Kind of easy, no? I Wouldn't Take Her To A Dog Fight, Cause I'm Afraid She'd Win. I'm So Miserable
Without You; It's Like Having You Here. 11) I don't know when you will use this information- maybe to
treat a bird bite- but Tramadol can be used as a local anesthetic and aside from local irritation works just as well (J Cut Med Surgery 16(2)101) Maybe- the p values verus
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then sending them home with antibiotics. They then returned much later for the elective procedure of removing the tract. True this was a small study but we have been trumpeting for a while the idea of just needling abscesses and not opening them. (Dis Colon Rectum 55(6)640) My question is- did they really need the antibiotics?? The abscesses were needled until dry. TAKE HOME MESSAGE: a Pilonidal abscess can also be needled and discharged for a definitive procedure later on. She
Got The Ring and I Got The Finger 13) A little twist on ultrasound for our geeks: ultrasound can break
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(AJC 110:761) I would enjoy Father's input on some of the finer wines available in Flint Michigan (actually I have hit up on Flint enough- let's hit up on the Day glo plaid jacket capital of the world- nearby Ypsilanti Michigan) including those tried and true favoritesThunderbird, Ripple and Sterno. Now while I think Risk Management Monthly is a great way to learn how to practice medicine in the ED and not in the courtroom, I want to point out that each issue ends with Father Greg's Wine of the
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Who are these guys? 15) We spoke about syncope above and now on to another favorite subject: Vertigo. There are two choices here- either its BPPV or its a stroke. But there is a third option and that is vestibular neuritis which is an inflammation of the vestibular nerve. They state in this article that it is missed 85% of the time (how do they know this? There is no gold standard) but there are some hints to it. VN is a single event with rotational vertigo. Vomiting occurs and it doesn't get better when you stand still. There is a loss of the vertibulo ocular reflex and there is usually nystagmus when they look forward. On the other side, stroke is when people can't walk at all (VN- they
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more than odds ratio 21) Don't you just love neonates? You know, those cute little creatures that just come out the oven all looking the same? Well, there are some changes as to dealing with these little adults if they need resuscitation that go beyond just APGAR and calling in the pediatricians. Temperature control,
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"I
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Well, that's from Ken Iserson. Ken, thanks for writing- and the information has been passed on
Thanks again for the excellent EMU. I wanted to make a comment about the pediatric article on abscesses (Randomized trial comparing wound packing to no wound packing following incision and drainage of superficial skin abscesses in the pediatric emergency department) by Kessler. While I personally am unsure about the utility of packing, and have begun to do more loop drainage procedures, I don't think this study should be trusted to be good enough evidence to conclude that packing doesn't decrease morbidity. The following weaknesses in the study make any conclusions unclear:
Study was stopped early because they couldnt enroll enough patients. Only in age 1-25 (mostly teenagers)
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In summary, while there are some small studies that suggest that packing is painful and useless, I don't think this study should be used to support a specific approach. Just my opinion - most abscesses just need to be adequately drained to heal (but this study isnt' proof.) Thanks. Jeff Freeman MD
Jeff, that was excellent. I think that you may want to consider joining the EMU staff (currently consists of one guy, but we can find room for you). Truth be told, most abscesses will probably get better no matter what you do, and I always believe that doing less is better. But you are entirely correct, the evidence is lacking at least in this study. Unfortunately, the Kessler that wrote this article is not the one that is an EMU subscriber, but our Dr. Kessler is a prolific writer and one of articles that came out recently on TTP was excellent (JEM 43(3)538). We have spoken about TTP in the past but I will try to include
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28) Answer to number 2- The Mad adventures of Rabbi Jacob- which was and still is a pretty funny movie. And number 7 is of course tertiary syphilis- may have helped to mention saddle nose but that would have given it away. Do get yourself checked out for this before you read another EMU. And number 10 was easy it was an article in JACC so it had to do with cardiology- it was infective endocarditis- Staph Aureaus to be exact. The lesions is of course a Janeway lesion but these are rare
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(About 5%(NEJM368:1425) And the friends of Father in 14 were Dean Martin- a comedian who teamed up with Jerry Lewis in the sixties, Boris Yeltsin who was the Premier of Russia and Billy Carter who actually was a beer imbiber who was President Jimmy Carter's brother and was
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This is a problem of entrapment of the median nerve. 2) I know that this conjures up thoughts of fibromyalgia, RSD, TMJ, Mitral Valve prolapse and all sorts of nebulous diseases that the modern day personality disorder patient has at 3 AM. However there is some rhyme and reason to this condition. The epidemiology of Carpal Tunnel Syndrome is that it is most common in females who have a smaller carpal tunnel and occurs mostly in patients between the ages of 45 and 65. This entrapment is caused by tendon thickening, synovitis, fluids, or lesions
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like this.
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the parasthesias will be different although there will be pain and parastesias in the hand. 6) Treatment: Steroid injections (easy to do- a little proximal to the wrist crease) are unlikely to do damage and these injections and cock up splints are effective. Physiotherapy can help to, but all of these work for only about two months. Surgery is the ultimate treatment and can be done under local, in the office and takes a few minutes. Oral steroids and oral NSAIDs do not work. There is now a mini release surgery which has a smaller incision. Endoscopic techniques also exist. Sensitivity in
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problem is more difficult. Eye Cases- Pain Here are the five cases- pretty basic but let's see how you do. A). 74 year old with left eye pain that stared when he turned off the light to take a nap. He has a headache, blurred vision, pain and nausea. There is corneal haziness and the eye is dilated and reacts poorly to light. B) A 20 year old guy wearing contacts during a game of volleyball. He sustained no trauma. He feels all of the sudden stinging in his right eye
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