Category: Misc
Keywords: Frostbite, treatment (PubMed Search)
Posted: 1/24/2009 by Michael Bond, MD
(Updated: 8/31/2024)
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FrostBite
Now that we are in the cold winter months, we are more likely to see patient with frostbite and hypothermia. Here are some tips for treating frostbite.
Adapted from Frostbite: Treatment and Medication by C. Crawfor Mechem, MD, MS, FACEP as posted on eMedicine.com.
Category: ENT
Keywords: Iritis, diagnosis (PubMed Search)
Posted: 1/17/2009 by Michael Bond, MD
(Updated: 8/31/2024)
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Patient with iritis will typically present with a painful red eye and it can sometimes be difficult to tell if it is due to conjunctivitis or a corneal abrasion. Some tips that can help differentiate iritis from other causes of painful red are:
Finally, ensure you document:
Adapted from Pfaff J and Moore G. Eye, Ear, Nose and Throat. Emergency Medicine Clinics of North America. Volume 15, Issue 2 (May 1997)
Category: ENT
Keywords: Conjunctivitis (PubMed Search)
Posted: 1/11/2009 by Michael Bond, MD
(Updated: 8/31/2024)
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Conjunctivitis:
Patient presenting to the Emergency Department complaining of "Pink Eye" is very common but how can you be sure that they do not have a bacterial conjunctivitis and absolutely need antibiotics or are they just suffering from a viral or allergic conjunctivitis.
Category: ENT
Keywords: Otitis Externa, Malginant (PubMed Search)
Posted: 1/4/2009 by Michael Bond, MD
(Updated: 8/31/2024)
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Otitis Externa:
Infections of the external ear canal are common and can typically be treated with topical antibiotic solutions (Cortisporin Otic, Cipro Otic, etc...) or antibiotic solutions mixed with topical steroids (Cortisporin HC Otic, Cipro HC Otic, etc...). Most patients should not require PO or IV antibiotics.
However, you need to always be on the look out for malginant otitis externa (MOE) which is a more deep seated infeciton extending into the temporal bone and can have a mortality rate as high as 50%. Patients that are diabetic, immunospressed, or have had radiation therapy to the base of the skull are at increased risk. Patients with MOE typically have pain out of proportion to clinical findings and granulation tissue may be present in the ear canal. Suspect this diagnosis in patients that have cellulitis or extreme tenderness over the mastoid process.
If you suspect MOE the patient should be started on antibiotics that cover pseudomonas. Consider obtaining a CT scan with temporal bone cuts and an Otolaryngology consultation.
Category: Infectious Disease
Keywords: CA-MRSA, Treatment (PubMed Search)
Posted: 12/27/2008 by Michael Bond, MD
(Updated: 8/31/2024)
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It is almost impossible to get through a shift these days with out seeing an abscess that is caused by CA-MRSA. As of the 2007 Antibiotic nomogram (2008 data not yet available) at University of Maryland CA-MRSA was only 70% sensitive to clindamycin, and >98% sensitive to bactrim and > 96% sensitive to doxcycline. A local community hospital in Baltimore is showing only 55% sensitivity to clindamycin.
As a New Year's resolution to yourself I recommend that you check with your local hospital's Micrology department to see what the sensitivities are to bactrim, clindamycin, doxycycline. If sensitivities are less than 80% it would generally be recommended that these medications not be used as initial empiric treatment.
For Baltimore bactrim and doxycycline should probably be the preferred treatment options.
Have a Great New Year.
Category: Critical Care
Keywords: Critical Care, reimburshment, billing (PubMed Search)
Posted: 12/20/2008 by Michael Bond, MD
(Updated: 8/31/2024)
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Critical Care Billing Pearls:
Level | RVU | Medicare | Commerical |
99285 ED E/M, Level 5 | 4.71 | $170 | $304 |
99291 Critical Care, first hour | 5.84 | $211 | $363 |
As the table shows Critical Care billing will earn you approximately 25% more with no additional overhead. Critical care time must be at least 30 minutes, and the following procedures are included in the critical care code:
The following procedures are not bundled into critical care time, so they can be billed separately, therefore the time you spend doing these procedures can not be included in your total critical care time:
Remember critical care time does not need to be continuous but you need to be immediately available to the patient for the time to count. You can not count time going off the floor to review an xray or CT, but this time can be counted if you do it in the immediate vacinity of the patient.
FINAL CAVEAT To help your coders bill appropriately it helps to include a statement such as "Critical Care time XX minutes where I was directly involved in the care of this patient exclusive of all other separately billable procedures."
$2
Category: Obstetrics & Gynecology
Keywords: metronidazole, pregnancy, safety (PubMed Search)
Posted: 12/14/2008 by Michael Bond, MD
(Updated: 8/31/2024)
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It seems to come up about once or twice a month about the safety of metronidazole in pregnancy. This has been very controversial over the years, but the current stance is that it is safe in pregnancy. In fact, untreated vaginal infections, bacterial vaginosis and trichomonas, have been associated with miscarriages and preterm labor, so the benefits outweigh the risks.
Below are two good references to add to your file in case you get into a debate with somebody quoting old data.
Organization of Teratology Information Specialists Information on Flagyl and Pregnancy
Safety of metronidazole during pregnancy: a cohort study of risk of congenital abnormalities, preterm delivery and low birth weight in 124 women. J Antimicrob Chemother 1999; 44: 854-855 http://jac.oxfordjournals.org/cgi/content/full/44/6/854
Category: Hematology/Oncology
Keywords: Thrombotic thrombocytopenia Purpura, TTP (PubMed Search)
Posted: 12/6/2008 by Michael Bond, MD
(Updated: 8/31/2024)
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Just a quick remainder that Thrombotic thrombocytopenia Purpura, TTP, is typically described as a pentad of symptoms:
Not all symptoms need to be present and it would be rare for you to see the full pentad. Consider the diagnosis and request that the lab due a manual differentiation or blood smear. It is there that they will notice schistocytes, fragmented RBCs, that will help clinch the diagnosis.
Most cases of TTP are idiopathic (~60%) but secondary TTP is known to occur with cancer, pregnancy, HIV, bone marrow transplantation, immunospressive drugs like cyclosporin and tacrolimus, and platelet aggregation inhibitors such as cloperidol.
Treatment consists of plasmapheresis, plasma exchange, immunospression with steroids, Rituximab, and other chemotherapies.
Category: Obstetrics & Gynecology
Posted: 11/23/2008 by Michael Bond, MD
(Updated: 8/31/2024)
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Third Trimester Bleeding:
Category: Misc
Keywords: Glucometer, Accuracy (PubMed Search)
Posted: 11/15/2008 by Michael Bond, MD
(Updated: 8/31/2024)
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The glucometer is one of the devices that we quickly reach for in the management of our unresponsive patients, diabetics and in the critically ill. Recently, I noticed that our Roche Accu-Check has a big sticker on the case stating that results could be affected by therapies that alter the metabolism of galactose, maltose, and xylose. Since this was a big hole in my fund of knowledge I decided to look up what else affects the accuracy of glucometers.
Now, Dr. Winters already warned used about the inaccuracy of bedside glucometer readings in the critically ill, but what about the patient that is not septic and/or in shock.
Substances/Drugs that have been reported to affect the accuracy of glucometers are:
Anemia also results in higher values, and a capillary blood sample can differ from venous blood by as much as 70mg/dL.
Most errors are more significant when dealing with hypoglycemia.
So the moral of the story is be careful with a bedside glucometer when the reading is low, as the venous blood sample sent to the lab may return even lower. Error on the side of treating the patient with glucose.
Fahy BG, Coursin DB. Critical glucose control: the devil is in the details. Mayo Clin Proc. Apr 2008;83(4):394-397.
Category: Misc
Keywords: high altitude illness (PubMed Search)
Posted: 11/1/2008 by Michael Bond, MD
(Updated: 8/31/2024)
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High altitude illnesses is typically called Acute mountain sickness (AMS) and is associated with two major complications high altitude pulmonary edema (HAPE) and high altitude cerebral edema (HACE).
Symptoms associated with AMS are headache, fatigue, nausea and vomiting, anorexia and insomia. Cough, Cyanosis, hypoxia, and dyspnea are associated with HAPE. HACE is associated with progressive neurologic symptoms and can lead to ataxia and coma.
Factors that increase your risk for altitude illnesses are:
Category: Orthopedics
Keywords: felon, management, incision (PubMed Search)
Posted: 10/24/2008 by Michael Bond, MD
(Emailed: 10/25/2008)
(Updated: 8/31/2024)
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Management of Felons
For good photos of the incision technique please visit the reference article listed.
Clark, DC. Common Acute Hand Infections. Am Fam Physician 2003;68:2167-76
Category: Misc
Keywords: Hypothyroidism, Myxedema, Treatment (PubMed Search)
Posted: 10/11/2008 by Michael Bond, MD
(Updated: 8/31/2024)
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Severe Hypothyroidism or Myxedema Coma
Category: Orthopedics
Keywords: Mallet Finger, Extensor Tendon Injury (PubMed Search)
Posted: 10/5/2008 by Michael Bond, MD
(Updated: 8/31/2024)
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Mallet Finger:
A common injury resulting in a tear or avulsion of the extensor digitorium tendon inserting into the base of the distal phalanx. Occurs due to hyperflexion of the finger usually as of a esult of it getting jammed on a ball while playing sports. Most can be treated non-surgically.
The distal phalanx must be kept in full extension for 6 to 8 weeks. This is one of the few times that the finger should not be splinted in the position of function.
Make sure that patient is informed that if they remove the splint and flex their finger the 6 to 8 week healing window will be reset to day 0. These patients should not be doing ROM exercises and must wear the splint full time.
Category: Procedures
Keywords: paracentesis, ascites, analysis (PubMed Search)
Posted: 9/27/2008 by Michael Bond, MD
(Updated: 8/31/2024)
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Paracentesis Part II- Ascites Fluid Analysis:
See last weeks procedure pearl for some hints on doing a paracentesis..
Now that you have the fluid what should you send it for:
Now for the analysis:
** Corrected definition of SAAG as it was initially reversed. Thanks to Dr. McCurdy on his proof reading.
Category: Procedures
Keywords: Paracentesis (PubMed Search)
Posted: 9/21/2008 by Michael Bond, MD
(Updated: 8/31/2024)
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Paracentesis:
Since we have covered so many other procedures I though I would include paracentesis for completion.
A diagnostic paracentesis (typically 30-60 ml) is indicated to:
A therapeutic paracentesis (large volume >1L) is indicated in the emergency department for:
Remember large volume paracentesis can result in profound fluid shifts and subsequent hypotension.
Absolute Contraindications to paracentesis include: Acute abdomen requiring surgery
Relative contraindications are:
To view a video on how to do a paracentesis please visit the New England Journal of Medicine http://content.nejm.org/cgi/content/short/355/19/e21
Next I will address how to interpret the paracentesis fluid results.
Category: Procedures
Keywords: Dental Blocks (PubMed Search)
Posted: 9/13/2008 by Michael Bond, MD
(Updated: 8/31/2024)
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Dental Pain and Blocks:
I am sure that most of us have felt like we should have attended dental school when we see the fifth toothache of the day, but for those with true dental pain it can be severe and debilitating. For these patients the only way to truly get their paint under control is to perform a dental block. This will provide the patient with several hours of excellent pain relief, and may be all they need before seeing a dentist the next day.
For those that are not familiar with dental blocks, a great web page that I found that covers the advantages and disadvantages of the more common blocks is http://www.septodont.ca/Septodont/english/other/cea_di01.html
So for your next dental pain consider performing a dental block instead of just sending them home with a P&P pack (percocet and penicillin)
Category: Gastrointestional
Keywords: HIDA, narcotics, biliary colic (PubMed Search)
Posted: 8/30/2008 by Michael Bond, MD
(Updated: 8/31/2024)
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Biliary Colic and Narcotics:
It is common to give patients with biliary colic narcotics inorder to relieve their pain. It was common teaching in the past that Morphine should be avoided due to the fact that it could cause spasm of the spincter of Oddi. It is now known that all narcotics, even meperidine, can cause spasm or irritation of the spincter of Oddi.
So this weeks pearls are:
Category: Orthopedics
Keywords: Splint, Basic, Position (PubMed Search)
Posted: 8/23/2008 by Michael Bond, MD
(Updated: 8/31/2024)
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Splinting Pearls:
Category: Orthopedics
Keywords: olecranon, bursitiis, septic, treatment (PubMed Search)
Posted: 8/17/2008 by Michael Bond, MD
(Updated: 8/31/2024)
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Olecranon Bursitis is inflammation and swelling of the bursa overlying the olecranon process of the ulna. Can result from trauma, overuse, or infection.
Treatment can consist of:
Remember aspiration has some major risks that need to be explained to the paitent:
They also need to know that the fluid will likely reaccumulate. So aspiration is not a guaranteed cure.