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: 7/22/2025)
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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
(Updated: 7/22/2025)
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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: 7/22/2025)
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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
(Updated: 7/22/2025)
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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: 7/22/2025)
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Category: Critical Care
Posted: 7/13/2010 by Mike Winters, MBA, MD
(Updated: 7/22/2025)
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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: 7/22/2025)
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Category: Geriatrics
Keywords: infection, cellulitis, geriatric, elderly (PubMed Search)
Posted: 7/11/2010 by Amal Mattu, MD
(Updated: 7/22/2025)
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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: 7/22/2025)
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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
(Updated: 7/22/2025)
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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: 7/22/2025)
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Category: Critical Care
Posted: 7/6/2010 by Mike Winters, MBA, MD
(Updated: 7/22/2025)
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Asthma, Peak Pressures, and the Ventilator
Manthous CA. Avoiding circulatory complications during endotracheal intubation and initiation of positive pressure ventilation. JEM 2010; 38:622-31.
Category: Medical Education
Keywords: Pulmonary Embolism (PubMed Search)
Posted: 7/5/2010 by Rob Rogers, MD
(Updated: 7/22/2025)
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Risk Stratification in Pulmonary Embolism
The following are the principal markers useful for risk stratification:
Patients with one or more of these markers have a higher mortality rate.
Guidelines on the diagnosis and management of acute pulmonary embolism. European Heart Journal. 2008
Category: Geriatrics
Keywords: tachypnea, pneumonia, elderly, geriatric (PubMed Search)
Posted: 7/4/2010 by Amal Mattu, MD
(Updated: 7/22/2025)
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The majority of "classic" symptoms and signs in elderly patients with pneumonia (fever, cough, sputum production, leukocytosis,chest pain) are unreliably present. However, tachypnea is one of the most reliable early findings in elderly patients with pneumonia, and in fact the same can be said about other serious bacterial illnesses in the elderly. The takeaway point here is simple: always count the respiratory rate in elderly patients (and don't trust those triage respiratory rates)!
Category: Gastrointestional
Keywords: Diverticular, bleeding, gastrointestinal (PubMed Search)
Posted: 7/3/2010 by Michael Bond, MD
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Diverticular Bleeding
Category: Neurology
Keywords: TIA, Stroke (PubMed Search)
Posted: 7/1/2010 by Aisha Liferidge, MD
(Updated: 7/22/2025)
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Category: Critical Care
Posted: 6/29/2010 by Mike Winters, MBA, MD
(Updated: 7/22/2025)
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Pre-existing acidosis and mechanical ventilation
Manthous CA. Avoiding circulatory complications during endotracheal intubation and initiation of positive pressure ventilation. JEM 2010; 38:622-31.
Category: Vascular
Keywords: Pulmonary Embolism (PubMed Search)
Posted: 6/28/2010 by Rob Rogers, MD
(Updated: 7/22/2025)
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Silent Pulmonary Embolism?
As many as 50% of patients with isolated DVT will be found to have silent pulmonary embolism (i.e. no chest pain or shortness of breath) on VQ scanning. Studies performed in the last year or so with CT scanning show that this percentage is much higher.
The clinical take-home point is NOT to get a pulmonary CTA on suspected DVT patients but to remember that many patients can and do have PE in the absence of cardiopulmonary symptoms. Pretty frightening....
Stein. Silent Pulmonary Embolism. Arch Intern Med.2000;