Category: Endocrine
Keywords: DKA, Management (PubMed Search)
Posted: 7/31/2010 by Michael Bond, MD
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Diabetic Ketoacidosis Treatment:
Charfen MA, Fernadez-Frackelton M. Diabetic Ketoacidosis. EMCNA 2005:609-628.
Category: Procedures
Posted: 7/30/2010 by Rose Chasm, MD
(Updated: 7/16/2024)
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Category: Toxicology
Keywords: caustic (PubMed Search)
Posted: 7/29/2010 by Fermin Barrueto, MD
(Updated: 7/16/2024)
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Ingestion of caustics can lead to immediate burns to mouth, esophagus, stomach as well as possible perforation. Months and years later, further complications are esophageal stenosis and increased incidence of esophageal carcinoma. The main benefit to EGD is to determine extent of injury within the esophagus. The lesions are graded much like a burn:
Grade I: Mild burn, no risk for esophageal stenosis
Grade II: Moderate, if circumferential, patient is at risk for esophageal stenosis
Grade II: Eschar present, high risk of perforation as well as esophagel stenosis
You can make a case that all intentional-suicidal ingestions of caustics should undergo EGD since there should be some injury if ingestion truly occurred or at the least a higher probability. The difficult case is the pediatric unintentional ingestion. Utilizing clinical exam and history will assist with that determination - there is a little research to guide this decision (next pearl)
The attached picture is the post-mortem of a caustic injury showing grade II linear lesions in esophagus with eschar distally and in stomach (Grade III).
Category: Neurology
Keywords: migraine headache with aura, aura, headache (PubMed Search)
Posted: 7/28/2010 by Aisha Liferidge, MD
(Updated: 7/16/2024)
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A. At least two attacks with at least 3 of the following:
1. One or more fully reversible aura symptoms (indicates focal cerebral cortical and/or brain stem functions).
2. At least 1 aura symptom develops gradually over greater than 4 minutes, or 2 or more symptoms occur in succession.
3. No aura symptom lasts greater than 60 minutes.
4. Headache follows aura with free interval of at least 60 minutes.
B. At least 1 of the following aura features establishes a diagnosis of migraine with typical aura:
1. Homonymous visual disturbance.
2. Unilateral paresthesias and/or numbness.
3. Unilateral weakness.
4. Aphasia or speech difficulty.
Category: Critical Care
Posted: 7/27/2010 by Mike Winters, MBA, MD
(Updated: 7/16/2024)
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Drug-Induced Thrombocytopenia
Priziola JL, Smythe MA, Dager WE. Drug-induced thrombocytopenia in critically ill patients. Crit Care Med 2010; 38(S):S145-54.
Category: Cardiology
Posted: 7/25/2010 by Amal Mattu, MD
(Updated: 7/16/2024)
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Classic electrocardiographic findings for hypokalemia:
u-waves (produces appearance of long QT), especially in the precordial leads
ventricular ectopy (PVCs typically)
ST segment depression or downward sagging, especially in the precordial leads
note that the sagging ST segments that terminate in large U-waves end up producing biphasic T-waves; these have the mirror image appearance of Wellens waves
Category: Orthopedics
Posted: 7/24/2010 by Brian Corwell, MD
(Updated: 7/16/2024)
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History and Physical Examination Red Flags | |
Historical Red Flags | Physcial Red Flags |
Age under 18 or over 50 Pain lasting more than 6 weeks History of cancer Fever and chills Night sweats, unexplained weight loss Recent bacterial infection Unremitting pain despite rest and analgesics Night pain Intravenous drug users, immunocompromised Major trauma Minor trauma in the elder | Fever Writhing in pain Bowel or bladder incontinence Saddle anesthesia Decreased or absent anal sphincter tone erianal or perineal sensory loss Severe or progressive neurologic defect Major motor weakness |
Category: Toxicology
Keywords: anticholinergic, sympathomimetic, pupil (PubMed Search)
Posted: 7/22/2010 by Michael Bond, MD
(Updated: 7/24/2010)
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A patient arrives via EMS agitated with VS: P 140, BP 155/100, R 18, T 101F. There is an admitted drug exposure and you examine his eyes which are dilated. You shine the light in the eyes - if the pupil reacts, would that be consistent with anticholinergic or sympathomimetic toxidrome?
Answer: Anticholinergic exposure paralyzes pupillary constrictor muscles and causes dilated pupils that do not react to light. Think about when you go to the eye doctor's office. They put homoatropine in your eyes so that when they look with the slit lamp they can see the retina without interference from pupillary constriction. Sympathomimetic exposure like cocaine activates pupillary dilator muscles, the constrictors are still intact and will give a reflexive constriction to light. This patient has reactive pupils and by the mere fact is in Baltimore probability dictates a sympathomimetic exposure like cocaine.
Category: Neurology
Keywords: Migraine headache without aura, Headache, International Headache Society, International Headache Society Criteria for Migraine (PubMed Search)
Posted: 7/21/2010 by Aisha Liferidge, MD
(Updated: 7/16/2024)
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A.
1. Pulsatile or throbbing in quality
2. Unilateral in location
3. Moderate to severe in intensity
4. Aggravated by activity (i.e.climbing stairs, exertion), plus
B. at least 1 of the following 2 during the headache ("VP"):
1. Vomiting and/or nausea
2. Photophobia and/or phonophobia
Category: Critical Care
Posted: 7/19/2010 by Mike Winters, MBA, MD
(Emailed: 7/20/2010)
(Updated: 7/16/2024)
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ICU Acquired Weakness
Griffiths RD, Hall JB. Intensive care unit-acquired weakness. Crit Care Med 2010; 38:779-87.
Category: Cardiology
Keywords: ST segment elevation, myocardial infarction (PubMed Search)
Posted: 7/18/2010 by Amal Mattu, MD
(Updated: 7/16/2024)
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There are multiple reasons for ST-segment elevation, the most important of which is acute myocardial infarction. However, because the treatment difference between MI vs. other more benign causes is so important, one should keep in mind the following factors that strongly point toward the diagnosis of MI:
1. the presence of ST-segment depression in any lead aside from aVR or V1
2. ST elevation that is horizontal or convex upwards (like a tombstone)
3. ST or T-wave morphologies that change over time with serial testing
4. ST changes compared to old ECGs
5. the development of Q-waves
6. ST elevation that follows coronary anatomy (e.g. limited to inferior leads, anterior leads, or lateral leads)
Category: Orthopedics
Keywords: Salter Harris (PubMed Search)
Posted: 7/17/2010 by Michael Bond, MD
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The Salter Harris Classification System is used in pediatric epiphyseal fractures. The higher the type of fracture the poorer the prognosis
Some common exam facts about Salter Harris Fractures are:
The Classification system as listed by Type:
A image of the fractures can be found on FP Notebook at http://www.fpnotebook.com/_media/OrthoFractureSalterHarris.jpg
Category: Toxicology
Keywords: valproic acid, carnitine, ammonia (PubMed Search)
Posted: 7/15/2010 by Fermin Barrueto, MD
(Updated: 7/16/2024)
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Valproic Acid (Depakote) is a drug that uniquely has the ability to raise serum ammonia concentrations. It is able to do this without raising liver er enzymes and it can occur in overdose or at therapeutic levels. Do not think of this in the context of hepatic encephalopathy. This a metabolic derangement caused by VPA.
Perrott J, Murphy NG, Zed PJ. L-carnitine for acute valproic Acid overdose: a systematic review of published cases. Ann Pharmacother. 2010 Jul-Aug;44(7-8):1287-93. Epub 2010 Jun 29.
Category: Neurology
Keywords: stroke, lacunar infact, clumsy hand dysarthra syndrome, hemiparesis, ataxia (PubMed Search)
Posted: 7/14/2010 by Aisha Liferidge, MD
(Updated: 7/16/2024)
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Category: Critical Care
Posted: 7/13/2010 by Mike Winters, MBA, MD
(Updated: 7/16/2024)
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Drug-Drug Interactions in the Critically Ill
Papadopoulos J, Smithburger PL. Common drug interactions leading to adverse drug events in the intensive care unit: Management and pharmacokinetic considerations. Crit Care Med 2010;38(S):S126-S135.
Category: Misc
Keywords: Pneumoperitoneum, CXR, CT (PubMed Search)
Posted: 7/12/2010 by Rob Rogers, MD
(Updated: 7/16/2024)
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Category: Geriatrics
Keywords: infection, cellulitis, geriatric, elderly (PubMed Search)
Posted: 7/11/2010 by Amal Mattu, MD
(Updated: 7/16/2024)
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Elderly patients are at higher risk for skin infections for numerous reasons:
1. Blunted immune system response of skin to infections.
2. Slower wound repair after 3rd decade.
3. More frequent exposure to infections, especially drug resistant infections, especially if the patient is frequently hospitalized or in nursing homes.
4. Frequent portals of entry for skin infections: indwelling tubes and lines, leg ulcers, fissures and maceration on feet and between toes.
A key takeaway point is to always check the skin thoroughly of your elderly patients when searching for infections, especially the feet and toes!
Category: Orthopedics
Keywords: Spondylolysis (PubMed Search)
Posted: 7/10/2010 by Brian Corwell, MD
(Updated: 7/16/2024)
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http://www.gentili.net/signs/images/400/spinescottyparsdefectdrawing.JPG
The Scotty dog’s head (superior articular facet), nose (transverse process), eye (pedicle), neck (pars interarticularis), and body (lamina) should be easily identified on the oblique radiograph.
Category: Toxicology
Keywords: bradycardia, hypotension, beta blocker, calcium channel blocker, clonidine (PubMed Search)
Posted: 7/7/2010 by Bryan Hayes, PharmD
(Emailed: 7/8/2010)
(Updated: 7/16/2024)
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In a patient with toxin-induced bradycardia and hypotension, here is a quick differential to help identify the responsible substance:
Less commonly seen causes include: magnesium, propafenone, and plant toxins (aconitine, andromedotoxin, veratrine).
Category: Neurology
Keywords: stroke, brain CT (PubMed Search)
Posted: 7/7/2010 by Aisha Liferidge, MD
(Updated: 7/16/2024)
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