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 extremities. ...
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 had never heard of such a...
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 to TB m...
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 th...
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 why he would have low ...
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 t ell the difference between a docto...
Source: EM Physician - Backstage Pass - September 8, 2015 Category: Emergency Medicine Authors: Taylor 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 doctor 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 can be us...
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 ertapenem (1 g/d) for 3...
Source: Kevin, M.D. - Medical Weblog - August 7, 2015 Category: Journals (General) Authors: Jeffrey Parks, MD 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 drug screen a...
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 urine drug s...
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 much grea...
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 nega...
Source: WhiteCoat's Call Room - January 13, 2015 Category: Emergency Medicine Authors: WhiteCoat Tags: Random Thoughts Source Type: blogs
