MKSAP: 76-year-old woman with a headache
Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.
A 76-year-old woman is evaluated for a 1-day history of headache, left eye pain, nausea and vomiting, seeing halos around lights, and decreased visual acuity of the left eye. She has type 2 diabetes mellitus, hypertension, and atrial fibrillation. Medications are metformin, digoxin, metoprolol, hydrochlorothiazide, and warfarin.
On physical examination, temperature is 36.8 °C (98.2 °F), blood pressure is 148/88 mm Hg, pulse rate is 104/min, and respiration rate is 16/min. Visual acuity wearing glasses is 20/40...
Source: Kevin, M.D. - Medical Weblog - December 20, 2014 Category: Journals (General) Authors: mksap Tags: Conditions Neurology Source Type: blogs
Wide Complex Tachycardia: Lewis Leads Do Not Differentiate VT from SVT with Aberrancy
An 83 yo complained of palpitations and dizziness and presyncope. He had a history of systolic heart failure with an EF of 40-45% and h/o coronary stents. He is on digoxin and coumadin for atrial fib. He denied chest pain or shortness of breath. EMS arrived and noted HR in the 170's. He was not in shock. There was no pulmonary edema. Mental status and blood pressure were normal.They recorded the following rhythm strips:V5A very wide complex regular tachycardia. By ECG alone (without considering pretest probability), the differential is VT vs. SVT with aberrancy vs. AVRT vs. ...
Source: Dr. Smith's ECG Blog - December 1, 2014 Category: Cardiology Authors: Steve Smith Source Type: blogs
Top stories in health and medicine, November 20, 2014
From MedPage Today:
No Benefit to CABG, Mitral Valve Repair Combo. A year after coronary artery bypass graft surgery (CABG) and mitral valve repair, patients with moderate ischemic mitral regurgitation did not seem to benefit from having the two procedures versus having only CABG.
Watchman Proves Long-Term Mettle in AFib. Left atrial appendage closure in atrial fibrillation patients using the Watchman device bested warfarin therapy for preventing the combined outcomes of stroke, systemic embolism, and cardiovascular death.
A Role for the Microbiome for Arthritis in Kids?. Children who were exposed to antibiotics had an i...
Source: Kevin, M.D. - Medical Weblog - November 20, 2014 Category: Journals (General) Authors: MedPage Today Tags: News Heart Neurology Source Type: blogs
LITFL Review 156
Welcome to the 156th LITFL Review. Your regular and reliable source for the highest highlights, sneakiest sneak peeks and loudest shout-outs from the webbed world of emergency medicine and critical care. Each week the LITFL team casts the spotlight on the blogosphere’s best and brightest and deliver a bite-sized chuck of FOAM.
The Most Fair Dinkum Ripper Beauts of the Week
Is clot retrieval in ischemic stroke the next development? Caution in allowing one marginally positive study to change practice. Rory Spiegel implores us to study our past mistakes (NINDS-2) so as to avoid repeating them. [AS]
Master your manageme...
Source: Life in the Fast Lane - November 17, 2014 Category: Emergency Medicine Authors: Marjorie Lazoff, MD Tags: Education LITFL review LITFL R/V Source Type: blogs
Destiny of a cardiac embolus !
One of my patients with atrial fibrillation recently developed a fairly moderate sized right MCA stroke that resulted in dense left sided hemiplegia .He was on warfarin , but the stroke was confirmed to be ischemic,the etiology was fixed as cardio embolic .After a smart recovery he asked this question.
Why did the clot from my heart preferred to enter the brain doctor ? Is there no other place for it to go ?
I told him in simple terms , “It is your destiny and the clot’s wish”. In fact , you are some what blessed as the clot did not enter the left side of the brain .If ...
Source: Dr.S.Venkatesan MD - October 31, 2014 Category: Cardiology Authors: dr s venkatesan Tags: Atrial fibrillation cardiac source of embolism stroke aortic arch type and embolic risk cardiac emboli carotid artery origin angle and risk of stroke clot deflection in stroke embolic stroke fate of clot from heart Ischemic stroke Source Type: blogs
Destiny of a cardiac embolus !
One of my patient with atrial fibrillation , recently developed a fairly moderate sized right MCA stroke that resulted in dense left sided hemiplegia . He was on warfarin , but the stroke was confirmed to be ischemic ,the etiology was fixed as cardio embolic .After a smart recovery he asked this question.
Why did the clot from my heart preferred to enter the brain doctor ? Is there no other place for it to go ?
I told him in simple terms , “It is your destiny and the clot’s wish”. In fact , you are some what blessed as the clot did not enter the left side of the brain ....
Source: Dr.S.Venkatesan MD - October 31, 2014 Category: Cardiology Authors: dr s venkatesan Tags: Atrial fibrillation cardiac source of embolism stroke aortic arch type and embolic risk cardiac emboli carotid artery origin angle and risk of stroke clot deflection in stroke embolic stroke fate of clot from heart Ischemic stroke Source Type: blogs
Split Decision
These days I divide my time between clinical and consulting work. in my consulting job I work as a medical command physician for ambulances, helicopters and airlines needing advice and direction on all sorts of medical emergencies.
For the past several months I have been fielding several calls a day regarding screening for *possible* Ebola patients wanting to board a plane or currently in the air and suddenly developing symptoms.
Of all of those phone calls…only one of them had recent travel in Liberia and originated from a West African airport. All of the rest were from random passengers that vomited, or had di...
Source: Mr. Hassle's Long Underpants - October 30, 2014 Category: Emergency Medicine Authors: Doc Shazam Tags: Uncategorized Ebola Source Type: blogs
The problems with evidence
We all want to practice “evidence based medicine”. Yet that phrase is so overused that one must always question the true meaning underlying the use of the phrase.
The first assumption that many make is that evidence is a solid structure without nuance. Yet we can have different experts look at the same evidence and develop different conclusions! Why else would we have competing guidelines. Consider this quote: There are no facts, only interpretations. – Nietzsche.
So what is evidence-based medicine. What proof do we need that a diagnostic strategy is the best, or a particular...
Source: DB's Medical Rants - October 29, 2014 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
The last visit: Turning off the defibrillator
He had called the other day to update me up on his condition. He did not sound upset, but resolute. “They offered me peritoneal dialysis,” he said, “but I decided against it and figured I’d just let nature take its course. The hospice people are so wonderful — I’ve got things all set here at home, but I have two questions. What should I do about my warfarin? You know, I just don’t want to have a stroke. And what I do about my defibrillator?”
Continue reading ...
Your patients are rating you online: How to respond. Manage your online reputation: A social media gu...
Source: Kevin, M.D. - Medical Weblog - October 9, 2014 Category: Journals (General) Authors: Wes Fisher, MD Tags: Physician Heart Palliative care Source Type: blogs
Novel Boston Scientific Device Headed For Another Rough FDA Panel
On Wednesday Boston Scientific’s Watchman device will once again appear before the FDA’s Circulatory System Devices advisory panel. The Watchman is a novel catheter-delivered left atrial appendage closure device which is intended to be used in place of chronic warfarin therapy to lower the risk of stroke in people with atrial fibrillation. It has been under development for more than a decade and its approval has twice been postponed by the FDA. Briefing documents released ahead of Wednesday’s panel suggest that the third time may not be the charm for Watchman, though close FDA watchers believe th...
Source: CardioBrief - October 7, 2014 Category: Cardiology Authors: Larry Husten Tags: Heart Rhythms Interventional Cardiology & Surgery People, Places & Events Policy & Ethics atrial fibrillation Boston Scientific FDA stroke Watchman Source Type: blogs
Less is more in atrial fibrillation stroke prevention — please, drop the aspirin
A recent study in the Journal of the American College of Cardiology shed more light on the commonly used drug combination of aspirin and a vitamin-K antagonist (such as warfarin). It was a small registry study from one region of France but I believe it offered confirmatory evidence against this dangerous practice.
Investigators followed patients with stable coronary artery disease (no recent events) for 2 years to assess the incidence and outcomes of major bleeding episodes. They found that overall rates of major bleeding were less than 1%, but those patients on the combination of aspirin and an anticoagulant drug were a...
Source: Dr John M - September 30, 2014 Category: Cardiology Authors: Dr John Source Type: blogs
The Last Reprogramming
He had called the other day to update me up on his condition. He did not sound upset, but resolute. "They offered me peritoneal dialysis," he said, "but I decided against it and figured I'd just let nature take its course. The hospice people are so wonderful - I've got things all set here at home, but I have two questions. What should I do about my warfarin? You know, I just don't want to (Source: Dr. Wes)
Source: Dr. Wes - September 25, 2014 Category: Cardiology Authors: Westby G. Fisher, MD Tags: defibrillator doctor-patient relationship Life medicine teaching Source Type: blogs
Prolonged (63 minutes) Ventricular Fibrillation, Followed by Unusual Cardiogenic Shock
In this study, 5% of VF arrest was due to PE: V fib is initial rhythm in PE in 3 of 60 cases. On the other hand, if the presenting rhythm is PEA, then pulmonary embolism is likely. When there is VF in PE, it is not the initial rhythm, but occurs after prolonged PEA renders the myocardium ischemic.--Another study by Courtney and Kline found that, of cases of arrest that had autopsy and found that a presenting rhythm of VF/VT had an odds ratio of 0.02 for massive pulmonary embolism as the etiology, vs 41.9 for PEA. (Source: Dr. Smith's ECG Blog)
Source: Dr. Smith's ECG Blog - September 19, 2014 Category: Cardiology Authors: Steve Smith Source Type: blogs
