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Thread: Medical Pearls

  1. #11
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    Planning ahead helps cardiac patients during emergencies

    For cardiac patients who have a history of significant electrocardiographic changes (eg, an old infarction, bundle branch block, second- or third-degree conduction block, ventricular hypertrophy, atrial flutter or fibrillation), I have a wallet-sized copy of their most recent electrocardiogram, along with a list of their medications and their attending physician's name and phone number, laminated for them to carry in their purse or wallet. Many patients suffer a cardiac event away from home, and this precaution offers the treating physician an opportunity to compare findings with previous conditions. This is extremely helpful in recognizing changes.

    Morton Krakow, PA-C,
    Homewood, Illinois

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    Avoid trauma while removing nasal foreign bodies


    Here's a trick I use in the emergency department to help remove a foreign body from the nose of a child.
    First I administer 4 or 5 drops of adult-strength xylometazoline hydrochloride (Otrivin) to the affected nostril and allow 5 minutes for vasoconstriction of the inferior turbinate and nasal mucosa.
    Then I ask the child to take a deep breath through the mouth and exhale through the affected nostril while I occlude the contralateral nostril.
    This removes the foreign body about 30% of the time and at least moves it more anteriorly--for easier removal with bayonet forceps--in about half of cases.

    J. Madison Clark, MD
    Portland, Oregon

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    Cold compresses beat heat in treating chalazions





    For years, I followed textbook advice on treating chalazions--which included application of warm compresses and topical antibiotic therapy--with unsatisfactory and unpredictable results.
    I have found that cold compresses applied early in the process and every 2 hours for at least 2 days can rapidly resolve nearly all chalazions in 2 to 3 days. I still instruct patients to apply a thin film of antibiotic ointment nightly for 3 to 5 days. Using this technique, I rarely have had to refer patients for ophthalmologic evaluation or surgical removal.

    Jeffrey M. Edmondson, MD
    Harker Heights, Texas

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    Stickers can aid fundus examination







    Visualizing the fundi of young children can be an exercise in futility. But I have found that the following pearl overcomes this:
    Place a glow-in-the-dark sticker of any object (eg, pumpkin face, rocket ship, the moon) on a wall a few feet from the exam table at about eye height to a sitting child. Instruct the patient to look at the glow as you turn off the lights. Children will hold this "fun" vision as you ask them questions about it, giving you plenty of time to accurately evaluate the disks. It really works!

    Gary M. Gorlick, MD, MPH
    Los Angeles



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    Warning signs for healing wounds


    In the pediatric emergency department, I repair lacerations and then give wound-care instructions many times nightly. To help patients and parents remember what to look for as the wound heals--and when to see a DOCTOR--I tell them to return for:

    D rainage
    O pening (of the edges)
    C ellulitis (what these signs would indicate)
    T emperature change (local warmth or systemic fever)
    O dor
    R edness


    When all goes well, I do not see patients until the scheduled suture removal, but they have an easy way to remember what would warrant an earlier wound check by their DOCTOR.

    Terry Kind, MD
    New York
    --------------------------------------------------------------------------------------

    Types of wound closure:
    1- 1st intention (primary healing): closure be direct approximation
    2- 2nd intention (spontaneous healing): closure depend on contraction & epithelization.
    3- 3rd intention (tertiary healing): delayed closure

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    Arm drop test for parkinsonian rigidity


    In patients who have muscle ridigity associated with parkinsonism, a simple arm drop test can help confirm the diagnosis. To test arm drop, have the patients hold their arms straight out to the sides, parallel to the ground. Tell them to drop the arms to their sides. In patients with ridigity, the arms descend slowly and do not make the slapping sound against the thighs that this maneuver normally makes.

    Bruce L. Saltz, MD
    Boca Raton, Florida

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    Evaluating lipid panel results


    I try to remember these helpful points as I evaluate the results of lipid panel studies:

    - Total cholesterol and high-density lipoprotein (HDL) levels are more accurate when samples are from nonfasting patients.
    - Triglyceride levels should be measured only in samples from fasting patients, because triglycerides increase after a fatty meal.
    - Low-density lipoprotein (LDL) is usually indirectly calculated, using this formula:

    Total cholesterol minus HDL minus triglycerides
    divided by 5

    LDL values cannot be accurately calculated when the triglycerides rise above 400.
    It is important to keep in mind that the higher the triglycerides, the lower the calculated LDL. Thus, be aware that the LDL may be falsely low in the nonfasting state, rather than elevated as is sometimes assumed.


    Daniel Lee, MD
    Santa Monica, California

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    Tremor in Graves' disease


    Tremor is an important feature of hyperthyroidism but can be subtle and difficult to detect accurately. We have found that placing a sheet of paper on the patient's outstretched palms provides helpful information. This "paper shaker" phenomenon illustrates tremor more clearly than does viewing the hands alone.

    Michael W. Felz, MD, and Peter P. Stein, MD
    Augusta, Georgia

    -------------------------------------------------------------

    Auscultation for pleural effusions


    Students and residents are taught to percuss a posterior hemithorax to assess the fluid level before thoracentesis in patients with pleural effusion.
    However, the perception of dullness to percussion is not always clearly discernible.
    I have found that percussing the sternum with one or two fingers while listening with the diaphragm of the stethoscope over the posterior hemithorax can more easily allow the listener to hear dullness replace tympany when the level of the effusion is reached. This allows greater confidence when performing the thoracentesis.

    David Wisinger, MD
    Phoenix

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    Making the acetaminophen antidote more palatable


    The mainstay of therapy for acetaminophen poisoning is administration of acetylcysteine, which can pose problems. Acetylcysteine smells like rotten eggs, and swallowing it can be a challenge.
    We have found that the oral solution can be made more palatable by diluting it to 5% with soda or juice. Other ways to improve palatability include diluting the solution even more, changing the diluent, chilling the solution, sipping slowly, using a straw, and drinking from a covered container.

    Anup Dev T. Salgia, DO, and Shawn David Kosnik, DO
    Camp Lejeune, North Carolina

    ----------------------------------------------------------

    Reducing pain with lidocaine injections

    We have found that the least painful method of lidocaine infiltration is deep dermal infiltration of a warm, buffered solution over 10 seconds with a 30-gauge needle. Buffering the slightly acidic lidocaine with sodium bicarbonate in a 10:1 ratio (10 mL of 1% lidocaine to 1 mEq/mL of sodium bicarbonate) has worked well for us.

    Dwight W. Smith, MD, Matthew R. Peterson, MD, and Scott C. DeBerard, DO
    Anchorage

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    Don't forfeit the fetor

    When you see a patient with suspected alcohol or other substance abuse, there is no substitute for simply smelling the patient's breath. Physicians sometimes relinquish the benefits of such an examination because they believe it is impolite or insulting to get close enough to the patient to get a good whiff.

    In this situation, I usually examine the optic fundi with the ophthalmoscope, whether such an examination is indicated or not. This allows me to get as close as possible to the patient. Even a cheating declared nonsmoker can be detected this way. At the same time, the fundi may provide valuable information as well.

    Naimer Sody Abbey, MD, DN
    Hof Gaza, Israel

    ================================================== ====

    Pathophysiology of alcoholism:

    Alcohol is absorbed into the blood, principally from the small intestine. It accumulates in blood because absorption is more rapid than oxidation and elimination.
    From 5 to 10% of ingested alcohol is excreted unchanged in urine, sweat, and expired air
    The remainder is oxidized to CO2 and water at a rate of 5 to 10 mL/h (of absolute alcohol); each mL furnishes about 7 kcal.

    Chiefly, alcohol depresses the CNS:
    -A blood alcohol concentration (BAC) of 50 mg/dL (11 mmol/L) produces sedation or tranquility;
    -50 to 150 mg/dL (11 to 33 mmol/L), lack of coordination;
    -150 to 200 mg/dL (33 to 43 mmol/L), intoxication (delirium);
    -300 to 400 mg/dL (65 to 87 mmol/L), unconsciousness.
    -BAC > 400 mg/dL (> 87 mmol/L) may be fatal.

    The legal BAC while driving is <= 100 mg/dL in most states, and intoxication is often defined as present at this level. Recent U.S. legislation threatens the loss of driving license to persons < 21 yr of age who have a BAC > 20 mg/dL





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