An Ischemic ECG and Bedside Echo shows diffuse dysfunction but with Apical Sparing
An approximately 40 y.o. male was in jail when he reported dyspnea.  He was brought to a small local ED where a chest x-ray showed pulmonary infiltrates.  He was hypotensive and hypoxic, and a provisional diagnosis of sepsis from pneumonia was made.  He had CT pulmonary angiogram which was read as " no PE. "  His lactate was 4.6 mEq/L and WBC count 20,000.  He was given levofloxacin, thentransferred to a tertiary care center.Upon arrival, his vitals were HR 115, BP 87/53, RR 30, T 37.3, and O2 sat 91% on room air. Breathing was labored, tachypneic.  He had cool extremi...
Source: Dr. Smith's ECG Blog - September 4, 2018 Category: Cardiology Authors: Steve Smith Source Type: blogs

The double-edged power of the medications we prescribe
My patient, a rugged sixty year old with massively muscular forearms, gray chest hair at the V of his denim shirt, and a voice that suggested years of liquor and unfiltered cigarettes, lowered his voice and leaned forward. “I’m not usually scared of anything, but for three nights now, ever since I started taking the Levaquin for this pneumonia, I have had the most horrific nightmares. I can’t even talk about them, that’s how terrifying they are. I have never been so scared in my life. You’ve got to get me on a different antibiotic, or I would rather let the pneumonia run its course.” I h...
Source: Kevin, M.D. - Medical Weblog - July 30, 2018 Category: General Medicine Authors: < a href="https://www.kevinmd.com/blog/post-author/a-country-doctor" rel="tag" > A Country Doctor, MD < /a > Tags: Meds Infectious Disease Source Type: blogs

Tropical Travel Trouble 008 Total TB Extravaganza
LITFL • Life in the Fast Lane Medical Blog LITFL • Life in the Fast Lane Medical Blog - Emergency medicine and critical care medical education blog aka Tropical Travel Trouble 008 Peer Reviewer Dr McBride ID physician, Wisconsin TB affects 1/3rd of the population and one patient dies every 20 seconds from TB. Without treatment 50% of pulmonary TB patients will be dead in 5 years. In low to middle income countries both TB and HIV can be ubiquitous, poor compliance can lead to drug resistance and malnourished infants are highly susceptible. TB can be very complex and this post will hopefully give you the backbone t...
Source: Life in the Fast Lane - June 16, 2018 Category: Emergency Medicine Authors: Neil Long Tags: Clinical Cases Tropical Medicine Genexpert meningitis TB TB meningitis Tuberculosis Source Type: blogs

Longing for the QT
A 58-year-old man presented to the ED with a reported overdose of an unknown medication. The patient was agitated, combative, and altered. Initial vital signs included a heart rate of 115 beats/min, blood pressure of 154/93 mm Hg, respirations of 22/min, and temperature of 99.5°F. The patient was difficult to evaluate because he was agitated, and he was given 5 mg of haloperidol IV and 2 mg of lorazepam IV. The patient continued to be agitated, and was given another 10 mg of haloperidol IV, followed by a repeat dose of 10 mg IV 15 minutes later. The patient then became unresponsive, and his cardiac monitor demonstrated...
Source: The Tox Cave - March 1, 2016 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

The answer – hypokalemic metabolic alkalosis and hypocalcemia
To recap the story: 70+ year old man with recent admission for pneumonia.  Discharge on clindamycin and levofloxacin.  Now with progressive weakness, fatigue, tingling and confusion. 142 98 12 256 2.5 32 1.4 6.5 albumin 2.8 pH 7.53 pCO2 39 pO2 69 HCO3 32 What happened in the past 3 weeks?  What diagnostic tests do you want, and what questions do you want to ask? Answer: He had some loose stools, but negative C diff. I asked the question about his previous labs – they had been normal.  Hypokalemic metabolic alkalosis and hypocalcemia made me think of hypomagnesemia.  Then I wondered wh...
Source: DB's Medical Rants - January 24, 2016 Category: Internal Medicine Authors: rcentor Tags: Acid-Base & Lytes Attending Rounds Source Type: blogs

Tingling, weakness, fatigue and abnormal labs
70+ year old man with recent admission for pneumonia.  Discharge on clindamycin and levofloxacin.  Now with progressive weakness, fatigue, tingling and confusion. 142 98 12 256 2.5 32 1.4 6.5 albumin 2.8 pH 7.53 pCO2 39 pO2 69 HCO3 32 What happened in the past 3 weeks?  What diagnostic tests do you want, and what questions do you want to ask?   (Source: DB's Medical Rants)
Source: DB's Medical Rants - January 21, 2016 Category: Internal Medicine Authors: rcentor Tags: Acid-Base & Lytes Attending Rounds Source Type: blogs

Issues with Medicine
On the white coat.Everyone wears one. I wonder why. I think patients are starting to realize that it’s actually those of us *without* a white coat that are the doctors.On Customer Service.How stressful would it be if you actually gave a damn about patient satisfaction scores. Not because it’s not a worthy goal to be customer friendly; but because these scores are derived from so many factors that you, as a doctor, have absolutely no control over. Wait times, parking, whether or not you have access to old medical records. Think about it, if a patient in the ED waits 8 hours, cannot tell the difference between a ...
Source: EM Physician - Backstage Pass - September 8, 2015 Category: Emergency Medicine Authors: Taylor Source Type: blogs

Antibiotics for Appendicitis: Penny wise but pound foolish
By SAURABH JHA A Finnish group randomized patients with acute appendicitis to surgery and antibiotics and found that antibiotics were successful in 73 % of patients. Depending on how this is framed, you can celebrate a 70 % success or lament a 30 % failure. Much of the debate in healthcare is a battle of framing.The study has limitations. Finland is not just a land of the midnight sun but a land of fewer laparascopic surgeries than the USA. This is important because if done properly laparoscopic surgery has a lower morbidity than open surgery, as Skeptical Scalpel explains. Should we be excited that antibiotics c...
Source: The Health Care Blog - August 20, 2015 Category: Consumer Health News Authors: suchandan roy Tags: THCB Saurabh Jha Source Type: blogs

Antibiotics for appendicitis: What does a surgeon think about this?
Like many practicing general surgeons I read with interest the recent Finnish paper published in JAMA that attempted to challenge the long held surgical dogma that the best treatment of acute appendicitis is cold hard steel.  The paper itself, in terms of design, was beautiful.  This was no retrospective review of a series of case studies.  This was a rigorously conducted multi-center randomized controlled trial that assigned 530 patients over the course of 3 years into either surgical or non-surgical treatment arms: Interventions.  Patients randomized to antibiotic therapy received intravenous ert...
Source: Kevin, M.D. - Medical Weblog - August 7, 2015 Category: Journals (General) Authors: Tags: Conditions Surgery Source Type: blogs

The Good, the Bad, and the Ugly
The urine drug screen commonly utilized in the emergency department is an immunoassay that uses antibodies to detect specific drugs or their metabolites. This allows for rapid screening for drugs of abuse, but it has many limitations.   Gas chromatography-mass spectrometry (GC-MS) is the confirmatory test, but it is more costly, time-consuming, and generally can only be performed by outside laboratories. This confirmatory test is generally not useful in the emergency department, but has a role in cases of pediatric exposures, research, or occupational drug testing.     One of the limitations of a urine d...
Source: The Tox Cave - June 1, 2015 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

The Good, the Bad, and the Ugly
The urine drug screen commonly utilized in the emergency department is an immunoassay that uses antibodies to detect specific drugs or their metabolites. This allows for rapid screening for drugs of abuse, but it has many limitations.   Gas chromatography-mass spectrometry (GC-MS) is the confirmatory test, but it is more costly, time-consuming, and generally can only be performed by outside laboratories. This confirmatory test is generally not useful in the emergency department, but has a role in cases of pediatric exposures, research, or occupational drug testing.     One of the limitations of a ...
Source: The Tox Cave - June 1, 2015 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

24-Hour tPA Stroke Window Making Physician Lives So Much Better Now.
Dallas, TX - Twenty years of  physician suffering ended abruptly Monday after the American Stroke Association (ASA) announced a dramatically expanded 24-hour tPA stroke window protocol to better accommodate doctors' increasingly hectic schedules. "Recent apologies by the American Board of Internal Medicine forced us to reevaluate our priorities as an organization.  We now understand just how disruptive our three hour tPA window has been on doctors' lives and for that we are deeply sorry,"  said ASA President Dr. Jan Fleming. With the new 24-hour window, ASA officials are hoping to give doctors...
Source: The Happy Hospitalist - February 12, 2015 Category: Internal Medicine Authors: Tamer Mahrous Source Type: blogs

How Can You Be Sure?
“How can you be sure?” That question stopped our discussion for a second. During some down time, several nurses and I were talking about childhood coughs. Her 6 month old child had just started daycare 2 weeks ago and has been coughing ever since. The child was put on amoxicillin and then Zithromax by her pediatrician but … [GASP] … her cough wasn’t getting any better. The nurse thought her child had pneumonia. “What should she be taking now?” I was in a particularly snarky mood, so, with a smirk, I said “probably vancomycin … maybe add gentamycin just for the gram n...
Source: WhiteCoat's Call Room - January 13, 2015 Category: Emergency Medicine Authors: WhiteCoat Tags: Random Thoughts Source Type: blogs

Ebola Virus Mutates On Entry Into United States. Responds To Antibiotics
Atlanta, GA -  The Centers for Disease Control and Prevention (CDC) is reporting two American aid workers who contracted Ebola hemorrhagic fever while treating others in West Africa have started responding to treatment with antibiotics. "Never in my wildest dreams did I imagine Ebola would respond to antibiotics," Dr. Feldor Baldink, a public health physician with the CDC, said in a statement Sunday. Dr. Kent Brantley and Nancy Writebol were flown urgently back to the United States and transferred to Emory University, one of just a handful of American medical centers that are specially equipped to ...
Source: The Happy Hospitalist - August 3, 2014 Category: Internists and Doctors of Medicine Authors: Tamer Mahrous Source Type: blogs

Recovering at Home
They let me out of the hospital this noon, and I like being with my loved ones.  I feel a little better than yesterday, but the regimen is about the same at home as it has been in the hospital. Levaquin 750 mg once daily, probiotics to mediate the effect of the Levaquin on the stomach, lots of sleep. I'm pretty sure that the pneumonia is viral, not bacterial, because it has responded so slowly to three different antibiotics.  Nevertheless I'm taking the Levaquin, despite its risk to the Achilles tendon, in case it really is a virulent bacterium. Right now my temp is generally around normal, which is a definite...
Source: Myeloma Hope - August 2, 2014 Category: Cancer Tags: pneumonia Source Type: blogs

Feeling a Little Better
Still in the hospital.  My temperature seems to have stabilized near normal, I'm coughing a little less, and blood oxygen (without supplemental oxygen) is up in the 94% range.  However, pulse rate and respiration rate are unchanged and much higher than normal, so the jury is still out. For the medically inclined:  I was started on a Z-Pak (azithromycin) Monday, then in the hospital they added a cephalosporin IV antibiotic Tuesday.  By today (Thursday) we didn't see much progress, so the hospital doctor finally talked me into oral Levaquin, dropping both of the others. That dose was this noon , so it's ...
Source: Myeloma Hope - August 1, 2014 Category: Cancer Tags: pneumonia Source Type: blogs

Hospital Quality Measures: Value Based Purchasing 2.0 (The Funny Version).
For years, hospital quality measures have been tracked by private and government insurance programs to try and improve the healthcare services received by their beneficiaries.  The most recent example is the Value-Based Purchasing Program (VBP) initiative by The Centers For Medicare & Medicaid Services (CMS).  How does CMS describe VBP?"Under the Program, CMS will make value-based incentive payments to acute care hospitals, based either on how well the hospitals perform on certain quality measures or how much the hospitals' performance improves on certain quality measures from their performance during a ...
Source: The Happy Hospitalist - March 14, 2014 Category: Internists and Doctors of Medicine Authors: Tamer Mahrous Source Type: blogs

Top stories in health and medicine, March 12, 2014
From MedPage Today: Docs Unprepared for Payment Reform. A pair of recent reports call into question the ability of physician practices to embrace health reform efforts. Even a Few Drinks Tied to Poor Birth Outcomes. Women who consumed low levels of alcohol before conception and during pregnancy were more likely to have adverse birth outcomes such as low birth centile, low birth weight, and premature birth than nondrinkers. Can Antibiotics Trigger Arrhythmias?. Azithromycin and levofloxacin were both associated with elevated risks of death and serious cardiac arrhythmias during standard lengths of prescription. HIV: M...
Source: Kevin, M.D. - Medical Weblog - March 12, 2014 Category: Family Physicians Tags: News Heart Infectious disease OB/GYN Source Type: blogs

A Guide To: Levaquin
One of the newest antibiotics on the market, Levaquin is frequently prescribed by doctors. This guide offers basic information about the antibiotic.Contributor: Nicole M.Published: Nov 22, 2013 (Source: Most Recent Health Wellness - Associated Content)
Source: Most Recent Health Wellness - Associated Content - November 22, 2013 Category: Other Conditions Source Type: blogs

Quality and Safety Implications of Emergency Department Information Systems: ED EHR Systems Pose Serious Concerns, Report Says
A report "Quality and Safety Implications of Emergency Department Information Systems"appeared in the Oct. 2013 issue of "Annals of Emergency Medicine."  It is available fulltext at http://www.annemergmed.com/article/S0196-0644%2813%2900506-4/fulltext, or in PDF via the tab, free as of this writing.First, a preamble:  I once tried to alert a hospital where I'd trained decades before, Abington Memorial Hospital (http://www.amh.org/), of impediments to safe care I'd noted in their EHR's, predominantly their ED EHR.  They did not listen.  In fact, their response to my concerns was chara...
Source: Health Care Renewal - October 8, 2013 Category: Health Medicine and Bioethics Commentators Tags: healthcare IT risk Abington Memorial Hospital postmarketing surveillance EDIS healthcare IT regulation healthcare IT safety Chris Jay Hoofnagle emergency department Source Type: blogs

Nerve Damage and Fluoroquinolone Antibiotics
By Diane Fennell The US Food and Drug Administration (FDA) is requiring updated labeling on fluoroquinolone antibiotics that includes a stronger warning of the drugs' potential to cause rapid, and potentially permanent, development of peripheral neuropathy. Peripheral neuropathy, which affects up to 70% of people with diabetes, is a type of nerve damage that can cause symptoms such as pain, numbness, and tingling in the hands, legs, arms, and feet. The condition is a known risk factor of systemic fluoroquinolones, and warnings about the risk were added to the drugs' labels in 2004. After reviewing the FDA Adverse Event ...
Source: Diabetes Self-Management - August 23, 2013 Category: Diabetes Authors: Diane Fennell Source Type: blogs

Certain Antibiotics Linked to Blood Glucose Swings
By Diane Fennell People with diabetes who take a certain class of antibiotics are more likely to experience severe swings in blood glucose, according to new research from Taiwan. Previous research and case reports have raised concern about the possibility of severe high and low blood glucose associated with the use of fluoroquinolones, a class of antibiotics that includes ciprofloxacin (brand name Cipro), levofloxacin (Levaquin), and moxifloxacin (Avelox). One drug in this class, gatifloxacin (Tequin), was removed from the US market due to the risk of blood glucose fluctuations. To assess the risk of severe blood gluc...
Source: Diabetes Self-Management - August 16, 2013 Category: Diabetes Authors: Diane Fennell Source Type: blogs

How safe is a Z-pak?
Text message: “John, This cough and congestion is killing me. It’s turning thick and green. Can you write me a Z-pak? It always works for me.” If you write a blog on medical decision-making and heart rhythm matters, it seems an incredible omission not to opine on the FDA warning concerning the commonly used antibiotic azithromycin (the drug in a Z-Pak). Quoting directly from the FDA warning: [Azithromycin] can cause abnormal changes in the electrical activity of the heart that may lead to a potentially fatal irregular heart rhythm. Should we say this more clearly: that simple antibiotic you are taking f...
Source: Dr John M - March 27, 2013 Category: Cardiology Authors: Dr John Source Type: blogs

J&J ‘Informational’ Faxes Are Not Junk: Judge
Doctor beware: some of those faxes arriving from drugmakers may be perfectly legitimate and not the sort of unwanted missive that have prompted some physicians to file lawsuits. Johnson & Johnson, in fact, won such a case when a federal judge last week tossed a lawsuit filed by a doctor who claimed two faxes concerning reimbursement information he received about the Levaquin antibiotic were unsolicited “junk.” The drugmaker succeeded in convincing US District Court Judge Freda Wolfson that the lawsuit filed by a Cincinnati physician named Jose Martinez did not violate the Telephone Consumer Protection Act, ...
Source: Pharmalot - February 5, 2013 Category: Pharma Commentators Authors: Ed Silverman Tags: Uncategorized Forest Laboratories JJ Johnson & Johnson Levaquin Telephone Consumer Protection Act Source Type: blogs

Healthcare Update — 02-04-2013
Chinese man runs out of money to pay for dialysis. Government “insurance” only pays half the costs of treatment (keep that in mind, Affordable Care Act supporters). Then human ingenuity kicks in. The man builds himself a dialysis machine out of used and discarded medical equipment, mixes his own dialysis fluid, and has been dialyzing himself … and it has been keeping him alive for 13 years. Doctors hearing about his unorthodox methods warned him about the risk of serious infection and “long-term complications” because he wasn’t using sterile water to make his dialysis fluid. Something t...
Source: WhiteCoat's Call Room - February 4, 2013 Category: Emergency Medicine Doctors Authors: WhiteCoat Tags: Healthcare Update Source Type: blogs

Cancelling surgery: When the show can’t go on
It’s showtime.  No need to worry.  This is just another routine performance.  I can do this.  All I need to do is get on stage, do my dance, and wait for the curtain to fall.  Then move on to the next stage and do it all again.The curtain opens.My patient is wheeled into the operating room.  With the help of the circulating nurse, we guide her from the hospital gurney over to the operating room table.  With the grace and precision of a ballerina, I start my recital by securing an oxygen mask over her face.  Next, I apply the monitors – a blood pressure cuff to her right a...
Source: Kevin, M.D. - Medical Weblog - January 31, 2013 Category: Family Physicians Tags: Physician Pulmonology Source Type: blogs

Not Heart Failure
I wasn’t giving in to the patient who wanted a prescription for Levaquin after the standard ZeePack didn’t cure his cough. He had a normal chest x-ray and labs the day before but was convinced that he had pneumonia. I tried explaining the difference between bacteria and viruses. I used the “RAID doesn’t work on dandelions” routine. He wasn’t convinced. “I NEED a stronger antibiotic to break this up. Levaquin has worked in the past.” “You know, I think I’m going to start you on some heart medications, instead. Some nitroglycerin and some Lasix for your heart failur...
Source: WhiteCoat's Call Room - January 18, 2013 Category: Emergency Medicine Doctors Authors: WhiteCoat Tags: Patient Encounters Source Type: blogs