Professional Documents
Culture Documents
Emu Nov 2013
Emu Nov 2013
Nov 2013 1) Magnets are stronger than ever as they now contain neodymium. And they are around- magnetic earrings are simulations for those who have not yet pierced their ears who do not want to. wallowing magnets can !e devastating- they can cause perforation and ulceration if another magnet or another metallic o!"ect is concurrently ingested. A!dominal # ray is still used for diagnosis. $%ed &astro Nutr''$3)23(). )on*t wait for the + A guys to ma,e this diagnosis- +A./ 01M/ M/ A&/2 Magnet ingestion can !e dangerous. 2) A definite may!e. +his tiny study said that &a!apentin did help with post dural induced headaches. $Anest 3nten 4are 50$5)615) +hese headaches were tough ones as some failed !lood patch. 3t wor,ed in '07 of patients which actually is not that great. 8eing that &a!apentin is a ,nown pain reliever9 3 do not ,now if using a cheaper one may wor, "ust as well. +A./ 01M/ M/ A&/2 &a!apentin is another option in pain relief 3) 34: stuff- 3 really did not ,now this $c*mon cott- tell me you did). +hey present a case where they could not ventilate a patient who they intu!ated. +hey did all the )1%/ stuff $Dislodgement; O!struction; Pneumothora#; E<uipment failure) and nothing helped. +hey too, them off the vent and !agged = !ut no luc,. /ven the suction catheter did not advance. +hen they got a revelation. 3 was crushed. o was the /+ tu!e. eems that if you !low up the !alloon more than 10 cc you can occlude the tu!e. Now they went !ac, to the la! and tried this in vitro and discovered this can only happen in tu!es smaller
36 1
36 2
Reality continues to ruin my life. I'm not dumb. I just have a command of thoroughly useless information. 5) 3 can summariAe this fast and you pro!a!ly wish 3 would.
+oday*s wound care is2 moist; and do not distur!. &auAe macerates wounds so do not use it- use a petroleum !ased dressing or one that has a plastic side that doesn*t stic,. $C
36 3
Calvin !here's no "roblem so a#ful$ that you can't add some guilt to it and ma%e it even #orse. &) 0ere is a clinical <uiA. +he case is a man with
arcoid who presents with respiratory failure. 0e is tu!ed; put on a propofol drip and started on >ocephin and AAithromycin. 0e ta,es amlodipine and prednisone. 0e is !uc,ing the vent so the propofol is increased and fentanyl is added.5? hours later- his urine is green. 0e did not receive arsenic nor has the urine !ag !een filled with spinach $yu,). o what happenedE % urine porphyrins were negative $Neth C Med 60$@)2?2). +he two authors were from NF = one from :NF :pstate and one form
36 4
+his statue is in %rague. &ives new meaning to a pissing contest; right Gather ®E ') %eople can have a stro,e while ta,ing 4oumadin and giving +%A is complicated under such conditions. +hey gave this fellow with an elevated 3N> and a sign of a stro,e %44 and within 1' minutes the 3N> was 1H2 of what it was and he got his +%A. $4ere!ro )is 33$@)'(6). +his is pretty <uic, and 3 was unaware reversal could !e so <uic, !ut nevertheless; it is only a case report; and 3 am surprised they could get the 3N> $and the type and cross) results !ac, so fast as this is one of the la! tests from the /) that ta,es a while to do. +A./ 01M/ M/ A&/2
36 5
the loo!out" accordin# to the $a%anese& '(nt )ed 51'1*+2,-5+ .oo! ( !no/ 0ou 1mericans are all lau#hin# at me e ein# concerned a out this and since sanitation is #reat in 0our countr0 '( !no/" 0ou alread0 ou#ht the se/a#e mana#ement %lant 2or the cit0 o2 Detroit- and the %olice station as /ell+ ut this disease e3ists in the de4elo%ed /orld as /ell and ( thin! it is onl0 a matter o2 time until it hits 0our shores& 5o let me remind 0ou o2 the $ones criteria& Here it is co%ied 2rom 6i!i%edia
)odi2ied $ones criteria /ere 2irst %u lished in 1*44 0 7& Duc!ett $ones" )D& 839 7he0 ha4e een %eriodicall0 re4ised 0 the 1merican Heart 1ssociation in colla oration /ith other #rou%s&849 1ccordin# to re4ised $ones criteria" the dia#nosis o2 rheumatic 2e4er can e made /hen t/o o2 the ma:or criteria" or one ma:or criterion %lus t/o minor criteria" are %resent alon# /ith e4idence o2 stre%tococcal in2ection; ele4ated or risin# antistre%tol0sin < titre or D=1ase&819 >3ce%tions are chorea and indolent carditis" each o2 /hich 0 itsel2 can indicate rheumatic 2e4er& 8598698?9
Major criteria[ @ol0arthritis; 1 tem%orar0 mi#ratin# in2lammation o2 the lar#e :oints" usuall0 startin# in the le#s and mi#ratin# u%/ards& Aarditis; (n2lammation o2 the heart muscle 'm0ocarditis+ /hich can mani2est as con#esti4e heart 2ailure /ith shortness o2 reath" %ericarditis /ith a ru " or a ne/ heart murmur&
36 6
5u cutaneous nodules; @ainless" 2irm collections o2 colla#en 2i ers o4er ones or tendons& 7he0 commonl0 a%%ear on the ac! o2 the /rist" the outside el o/" and the 2ront o2 the !nees& >r0thema mar#inatum; 1 lon#-lastin# reddish rash that e#ins on the trun! or arms as macules" /hich s%read out/ard and clear in the middle to 2orm rin#s" /hich continue to s%read and coalesce /ith other rin#s" ultimatel0 ta!in# on a sna!e-li!e a%%earance& 7his rash t0%icall0 s%ares the 2ace and is made /orse /ith heat& 50denhamBs chorea '5t& CitusB dance+; 1 characteristic series o2 ra%id mo4ements /ithout %ur%ose o2 the 2ace and arms& 7his can occur 4er0 late in the disease 2or at least three months 2rom onset o2 in2ection&
Minor criteria[ De4er o2 3,&2E3,&* FA '1-1E1-2 FD+ 1rthral#ia; $oint %ain /ithout s/ellin# 'Aannot e included i2 %ol0arthritis is %resent as a ma:or s0m%tom+ Raised er0throc0te sedimentation rate or A reacti4e %rotein .eu!oc0tosis >AG sho/in# 2eatures o2 heart loc!" such as a %rolon#ed @R inter4al8,98*9 'Aannot e included i2 carditis is %resent as a ma:or s0m%tom+ @re4ious e%isode o2 rheumatic 2e4er or inacti4e heart disease Other signs and symptoms 1 dominal %ain =ose leeds
36 ?
@recedin# stre%tococcal in2ection; recent scarlet 2e4er raised antistre%tol0sin < or other stre%tococcal anti od0 titre" or %ositi4e throat culture& Gotta lo4e Dr& $ones 2irst name& 6hat did the0 call him
2or shortH Iou are ri#ht- the0 called him Dred '0ou didnBt reall0 thin! ( /ould sa0 Duc!0 /ould 0ouH+ 71J> H<)> )>551G>; RHD is around and can a22ect adults& Calvin: Moms and
reason are like oil and water. Calvin: That's one of the remarkable things about life. It's never so bad that it can't get worse. .) Beu,otriene receptor antagonists do not reduce asthma
admissions and there is not enough evidence to provide any !enefit in lung function +his is an /8M review $ %aed >esp >ev 13$5)22@) Nice com!ination of !oth a patient and disease oriented outcome. Are they steroid sparingE 3 really do not care as steroids are really not that dangerous that 3 would want to spend money on this med +A./ 01M/ M/ A&/2 Beu,otriene
36 ,
wea,ness parathesia and memory pro!lems. +his is !ecause the nerves are such good conductors. $C Neuro Neuro %sych ?3$() (33). +his reminds me of D4 Gields IMy Gather had a chair in applied electricity at the tate %enitentiaryI
Calvin: As far as I'm concerned if something is so complicated that you can't e%plain it in &' seconds then it's probably not worth knowing anyway.
36 *
affair with M>3 $while at the same time complaining a!out health care costs). 3n these patients with chest pain; elevated troponin and normal coronaries on %+4A- they then underwent M>3 as outpatients = much later- and 107 were found with evidence of myocarditis and 107 were found with an M3. $8C> ?'$101@)/5@1). +he ,ey point here is that M3 is still possi!le even with clean coronaries- pro!a!ly from spasm- an issue we have discussed !efore. 0owever; we also see the M>3 was not that useful most of the time. Now also there are cases of nursemaid*s el!ow that do not reduce and an M>3 can tell you the reason- in this case report for e#ample- full entrapment of the annular ligament. $C %ed 1rtho 32$')/20) 4ould 4+ or ultrasound have shown the sameE +A./ 01M/ M/ A&/2 M>3 can !e used for nursemaids el!ow and elevated troponin in the face of a %+4A that is negative ; !ut the <uestion is if it is cost effective. /1) 8ac, to you 34: guys- what can 3 do = 3 am a frustrated 34: guy-they have soooo much fun. Dell there are four psych emergencies in the 34: that you need to ,now how to handle. )elirium-lower the noise level; ma,e sure sleepHawa,e cycles are preserved; avoid !enAos = yes you heard me right- avoid !enAos- and anticholinergics; and give %+. 3f there is agitation; use antipsychotics and de3medetomidine- see last month*s /M:. NM - here you want to stop the medications causing it. Dhat to give is a <uestion; dantrolene; dompamine agonsists. !enAos or even /4+. erotonin syndrome- again discontinue meds and
36 1-
them selves it really isn*t necessary in the /). 3n this Gam %ract article- they here recommend it only in focal seiAures or those with developmental delay. 0owever they then say that those with no structural !rain disease do not need anti seiAure medswell how do you ,now with out the 4+E Naturally; if !leeding is suspected then 4+ should !e performed. $AG% ?@$5)335) 3 thin, the important point here is not doing the 4+ from the /) and truth !e told; 3 never found any surprises on 4+ after a first time seiAure in the /). +A./ 01M/ M/ A&/2 4+ after a first time seiAure- in the /) is not necessary if it wasn*t focal and the patient is normal now. 3n the clinic- pro!a!ly still need one.
36 11
di22erentl0 than
/omen however; things do go wrong with the mammary glands and you should ,now
36 12
a!out them. Masses; pain and discharge are the pro!lems. Masses- mammography is the standard !ut ultrasound is more sensitive in the under thirty group $since ultrasound has no radiation; 3 am not sure why they don*t "ust ultrasound everyone). %ain is usually not due to a malignancy and medications can !e common causes which include hormones; 14s; psych meds and some 4J meds. )ischarge is more complicated. 3f it is one sided; associated with a mass or is spontaneous- that is suspicious. 3f it is !ilateral; chec, out + 0 and prolactin $i!id p353) Note that they do not discuss trauma where fat necrosis can occur. 8y the way; the !irds a!ove are a tufted titmouse; and a !lue footed !oo!y !ird. +here; we got that past the censors. +he last !ird is a tunning Ginch it has nothing to do with our discussion and even 3 do not ,now what it is doing here. +A./ 01M/
36 13
that is very itchy and spreading. teroids creams did not help. 0e has no allergies and no sensitivities. +he rash has coalesced over the shins. +he rash is scaly. Fes it could !e tinea versicolor; !ut that has smaller and circular lesions. 3t could !e pityriasis rosea !ut this is usually asymptomatic. /#creta and tinea corporis are also good thoughts; !ut loo, differentecAema has a crac,ed appearance and tinea tends to !e more papular. 3t will help if 3 say this came after a strep throat. 1h;
36 14
/&) 3f you read /M: in the !athroom = and you should !e- then you
may fall asleep as this isn*t terri!ly useful. Bet me ma,e it <uic, so other people can use the lavatory- t wave inversions in the anterior and inferior leads can !e a sign of %/. 3t occurs a!out 117 of the time which is more than 1K333+333 !ut was less li,ely to !e pic,ed up. $C/M 53$2)22@) +hey then do .appa to see how people agreed on this finding; !ut this muddies the study !y trying to do two things in one study. Also; .appa is a hard thing to use- if the prevalence is low; the ,appa- a measure of agreement- loo,s !etter. 3 however included this study also !ecause 3 li,e Amal Mattu who is a !rilliant man and a great lecturer although he refused my offer $through his resident) for
36 15
Calvin: If you do the *ob badly enough sometimes you don't get asked to do it again. Calvin: "irls are like slugs + they probably serve some purpose but it's hard to imagine what
16) 1ne last clinical <uiA. o there was this young guy who had a fever and wasn*t !reathing too well. 0is D84 was only ?.? !ut his 8% was 100H60 and his creatinine went up to '.?. %latelets were only 25. 3f it helps; 3 first heard a!out this diagnosis when reading a National &eographic in a !ar!er shop on 8la,ely treet in )unmore right outside of cranton %A. Dhat was itE 1?) Fea 3 ,now 3 didn*t give you much to go on. Dell; the author*s name was 0ong and he was from .orea. Dhy would that !e importantE 1() 1h the reference is important also- C 4lin Jir ''$1)1. 3 have for sure made this too easy at this point
36 16
you got this case of a (3 year old man with a massive cere!ral !leed //& was unremar,a!le; !ut this guy is a vegeta!le and is going to stay this way. %1A is the caregiver who was appointed as such after the son- the previous %1A- was ousted over his alledged trying to admit the father to a nursing home. +he %1A wants aggressive treatment and the son does not. +he %1A says the son is only concerned a!out the inheritance; the son claims that the %1A will get paid for as long as the patient lives and so he is acting out of self interest. 3t is clear to the son the Gather would never have wanted his life prolonged li,e this. +hey as,ed for the perspectives of many people. +he lawyer says = the law is clear-the %1A is considered the voice of the patient and the family is powerless. 0owever the physicians caring for the patient do not have a legal o!ligation to provide futile care. +he lawyer and the ethicists recommended sending this to the ethics committee of the hospital and trying to get them to resolve the !ad !lood !etween son and %1A. After this they get the social wor,ers; nursing and physician*s perspective that raise further issues. $AC 0ospice and %alliative
36 1,
25) +he AA88 provided new practice guidelines for !lood transfusions which is !ased on a restrictive rather than a li!eral transfusion policy. +here is no hemoglo!in level which is for sure an indication for transfusion $although 3 assume that a level of 0.01 gramHdl may trigger a transfusion) and this means that people with a 6 or ? who are "ust fine than, you can stay that way. /ven more so; they admit that there is little evidence for that well accepted nut that all heart patients need to !e over 10mgHdl. $Ann 3nt Med 1'6$1)5(). 0owever; read the editorial. 3n many cases the dangers
36 1*
:tah; !ut dead sea water into#ication can happen and is dangerous- even a swig of '0 cc can elevate your magnesium and calcium significantly $%/4 2?$?)?1'). My hospital is the nearest to the )ead sea and we see a lot of these9 my director )r. 4armi was ,ind enough to allow me to interview him on how he treats this. 4alcium is generally easily treated with fluids and diuretics. Magnesium responds less well to diuretics. Girst aid includes fluids !ut then = if the level is eight or higher = or the patient is comatose you !etter consider dialysis. 3 thin, Gather ® can !e the first to tell you = you got to !e careful what you drin, +A./ 01M/ M/ A&/2 hypermagnesemia can result swallowing small amounts of )ead ea water. Calvin *ne of
my baby teeth came out7 I have to say$ I'm not entirely comfortable holding a "iece of my o#n head. Calvin Cigars are all the rage$ >ad. ?ou should smo%e cigars7 Calvin's Mom Clatulence could be all the rage$ but it #ould still be disgusting. Calvin I see. ,ad Dicely "ut$ dear
36 21
Mom will you drive me into town? Reply Why should I drive you, Calvin? Its a perfect day outside! What do you think people have feet for? To work the gas pedal. - Calvin and Hobbes
,now !ecause you may miss them on plain films. +his article s on perilunate dislocations. +hey are high energy outstretched hand things. +he can tether the median nerve and cause aseptic necrosis from compromised !lood supply so this is a dislocation that you want to deal with immediately. 1ften there will !e associated fractures such as of the scaphoid or the radial styloid. $8MC 35'2 e602@)
36 23
7he 2irst %icture is a %erilunate dislocation& 7he second is a lunate dislocation& +hese dislocations are !est seen on lateral films. +he last dislocation is a scaphoid lunate dislocation which you see !est on A% = there is a large hiatus !etween these two !ones- it can !e less pronounced than this picture
+A./ 01M/ M/ A&/2 )on*t miss dislocations in the hand. After Calvin nails Susie with a
snowball he walks up to her and says I must say, the stinging snow makes your cheeks look positively radiant. I have a hammer. I can put things together! I can knock things apart! I can alter my environment at will and make an incredible din all the while! Ah, its great to be male! - Calvin and Hobbes 36 24
+hat !oo, sounds very interesting. 3 will give it a plug and vouch for all of .en*s wor,; while not !e a!le to accept a free copy; since 3 can not accept any gifts. 0owever; if it was given to meN. 8y the way; that guy was serious a!out the chest e#am-3 stand in the middle- 3 am not going to diagnose any +> murmurs !ut it does help for wheeAing and the li,e. +han,s for writinginterested in ,nowing where you can get a good sandwich in MichiganE +ry Glint. 30) Num!er si# was a patient with respiratory al,alosis which causes propofol to !e meta!oliAed to pretty green urine. 0ere is the )) for green urine form the article "ust in case you wondered why you have a su!scription to /M:2 Aimetidine; @romethaKine" (ndomethacin" )etoclo%ramide" Dlutamide" )eth0lene lue; 1s%ara#us; Alorets 'chloro%h0ll+; 6ilisan %ills 'Ahinese her al medication+" Hartnu% disease" (ndicanuria" @seudomonas urinar0 tract in2ection" Lile 4ia 4esicoenteral 2istula" Green eer 'DatherH+" some #reen d0es& Num!er 15 was guttate psoriasis which will respond to higher potency steroids and :J8 treatments. 3 would have thought this was a fi#ed drug reaction !ut there was no
36 2?
aller#ies can cause this as /ell& Guess /hat- the th0roid can cause this also" ut that doesnMt other me- the th0roid seems to cause e4er0thin#& 7his /ill cause or ital s/ellin# as /ell& Do not 2or#et dermatom0ositis and lu%us& 6e /ill mention tumors" ut ( do not thin! that /ill e that hard to dia#nose& 4+ 7here is a /eird ird called le%harochalsis /hich is a disease o2 0oun# adults that comes and #oes 2or an a4era#e o2 t/o da0s& 5+ 7he article doesnBt sa0 this" ut ( use heat as hel%in# me ma!e the dia#nosis& 1ller#0 in onl0 one e0e is rarer" is usuall0 less hot and less red& (t ma0 e itch0& 6+ He0 /hat a out medsH (matini causes this o2ten ut /e use that onl0 2or A). and most o2 us /ill not see that& Li%hos%honates can cause this as /ell as scleritis and u4ietis& H0aluronidase is o2ten a 2iller in cosmetics and o2ten causes edema& =51(D5 and some anti%0shotics do it as /ell& ?+ @ost sur#ical causes can come 2rom the ears as /ell- cochlear trans%lants can do thisP
36 2*
.un# 7rans%lant >mer#encies; 1+ 7hese 5/iss docs are honest 2rom the outset- the0 sa0 this is /hat the0 do& Iou arenBt #oin# to see much science here" ut it at least ma!es some sense& Jee% in mind this article is not 2or %ost o% com%lications ur rather 2or the lun# trans%lant %atient
36 3-
remem er himH 2+ Ies" that is O 7hant" the 2ormer 5ecretar0 General o2 the O=& =ot Quite sure /hat %eo%le /ho didnBt !no/ his name said to him 'Rhe0" 0ouRRIesHR+ 3+ 6ell" 0ou #uessed it- the li2elon# ta!in# o2 sometimes three or more immunosu%rressi4es causes most o2 their %ro lems& (n2ection" #ra2t re:ection" and one marro/ su%%rsion& Lut do not sto% readin# 0et&
36 31
e2ore O 7hant& His name /as Da# Hammars!:old- #ood luc! tr0in# to %ronounce that one 'THe0 0ouU /ould %ro a l0 /or! here too+ ?+ A0to%enia is 2airl0 common #i4en the tonna#e o2 meds the0 ta!e& Do /atch the 6LA& 1nti iotics do this es%eciall0 7)V-5)W" and Dla#0l& 5ome anti 4irals can do it too& Iou ma0 ha4e to mi3 and match the meds ,+ 5o 0ou see this #u0 /ith a runn0 nose& 7he0 attac! him /ith nasal 4iral and acterial cultures and then start mo3i2lo3icin& (2 it
36 33
36 34
Ara%honso 7hor%e& ( am not #oin# to attem%t to %ronounce that one 11+ <steo%orosis and osteo%enia is 4er0 common amon# these %atients and most /ill e #ettin# calcium" 4itamin D and a i%hos%honate& 5till" 2ractures are Quite common& 1lso do not 2or#et that since man0 are ta!in# a res%irator0 Quinolone1chilles tendon %ain or transection ma0 e %resent& Ose lidocaine %atches" do not use =51(D5& 7he0 do use anti iotics as %ro%h0la3is Quite 2reQuentl0 'li!e 2or dental %rocedures+ ut a#ree the literature is s%arse& 12+ H7= is commonN the0 a4oid calcium channel loc!ers ecause o2 the edema the0 can cause& Remem er /ith the su%%ressant dru#s the0 ta!e" the0 can ha4e a ad )( or AHD and sho/ 2e/ si#ns& Ditto /ith %ulmonar0 em olism" so i2 there is a DC7 E chec! those lun#ers& Le2ore sur#er0- s%ea! to these #u0s- mortalit0 is hi#h
36 35
13+
Ies that is Ha Ha Alinton Di3a name onl0 ri4aled 0 the =e/ $erse0 7o/n
36 36