Nov 2013 1) Magnets are stronger than ever as they now contain neodymium. And they are around- magnetic earrings are simulations for those who have not yet pierced their ears who do not want to. wallowing magnets can !e devastating- they can cause perforation and ulceration if another magnet or another metallic o!"ect is concurrently ingested. A!dominal # ray is still used for diagnosis. $%ed &astro Nutr''$3)23(). )on*t wait for the + A guys to ma,e this diagnosis- +A./ 01M/ M/ A&/2 Magnet ingestion can !e dangerous. 2) A definite may!e. +his tiny study said that &a!apentin did help with post dural induced headaches. $Anest 3nten 4are 50$5)615) +hese headaches were tough ones as some failed !lood patch. 3t wor,ed in '07 of patients which actually is not that great. 8eing that &a!apentin is a ,nown pain reliever9 3 do not ,now if using a cheaper one may wor, "ust as well. +A./ 01M/ M/ A&/2 &a!apentin is another option in pain relief 3) 34: stuff- 3 really did not ,now this $c*mon cott- tell me you did). +hey present a case where they could not ventilate a patient who they intu!ated. +hey did all the )1%/ stuff $Dislodgement; O!struction; Pneumothora#; E<uipment failure) and nothing helped. +hey too, them off the vent and !agged = !ut no luc,. /ven the suction catheter did not advance. +hen they got a revelation. 3 was crushed. o was the /+ tu!e. eems that if you !low up the !alloon more than 10 cc you can occlude the tu!e. Now they went !ac, to the la! and tried this in vitro and discovered this can only happen in tu!es smaller
36 ‫ מתוך‬1 ‫עמוד‬

than a 6 !ut in any case; !e careful = too much air is !ad = for /+ tu!e !alloons and politicians. $>esp 4are '6$?)1352). 3 do not intu!ate many ,ids; !ut occasionally 3 do use a @.' on petit adults; so this is good info. +A./ 01M/ M/ A&/2 )o not overinflate those /+ !alloons. 4) A word = actually too many words- on penicillin allergies. %4N allergies are usually = not allergies !ut long ago reactions that that were never allergies or were out grown. Most patients who say they have an allergy who undergo s,in testing do not have the allergy and if you do this test and it is negative; it is pro!a!ly safe to give the stuff. )esensitiAation if it was ever done may not !e permanent. Bastly = and you all ,now this already from past /M:s- you can give cephalosporins in %4N allergies- cross reactivity is low with the newer ones. $4lin >ev All 3mmun 53$1)?5) +A./ 01M/ M/ A&/2 %4N allergies are usually not -and you can do a simple s,in test to determine this. +his month*s <uotes are philosophical as seen !y the eyes of a si# year- we are spea,ing a!out 4alvin and 0o!!s

36 ‫ מתוך‬2 ‫עמוד‬


“Reality continues to ruin my life.” “I'm not dumb. I just have a command of thoroughly useless information.” 5) 3 can summariAe this fast and you pro!a!ly wish 3 would.

+oday*s wound care is2 moist; and do not distur!. &auAe macerates wounds so do not use it- use a petroleum !ased dressing or one that has a plastic side that doesn*t stic,. $C

36 ‫ מתוך‬3 ‫עמוד‬


Dound 4are 21$?)3'()

“Calvin !here's no "roblem so a#ful$ that you can't add some guilt to it and ma%e it even #orse.” &) 0ere is a clinical <uiA. +he case is a man with

arcoid who presents with respiratory failure. 0e is tu!ed; put on a propofol drip and started on >ocephin and AAithromycin. 0e ta,es amlodipine and prednisone. 0e is !uc,ing the vent so the propofol is increased and fentanyl is added.5? hours later- his urine is green. 0e did not receive arsenic nor has the urine !ag !een filled with spinach $yu,). o what happenedE % urine porphyrins were negative $Neth C Med 60$@)2?2). +he two authors were from NF = one from :NF :pstate and one form
36 ‫ מתוך‬4 ‫עמוד‬

:NF downstate $do they neutraliAe each otherE) = Dhy they stretched to the Neth C of Med is un,nown !ut this is not the first report of this case. Dhat is going onE

+his statue is in %rague. &ives new meaning to a pissing contest; right Gather &regE ') %eople can have a stro,e while ta,ing 4oumadin and giving +%A is complicated under such conditions. +hey gave this fellow with an elevated 3N> and a sign of a stro,e %44 and within 1' minutes the 3N> was 1H2 of what it was and he got his +%A. $4ere!ro )is 33$@)'(6). +his is pretty <uic, and 3 was unaware reversal could !e so <uic, !ut nevertheless; it is only a case report; and 3 am surprised they could get the 3N> $and the type and cross) results !ac, so fast as this is one of the la! tests from the /) that ta,es a while to do. +A./ 01M/ M/ A&/2
36 ‫ מתוך‬5 ‫עמוד‬

%44 can reverse 3N> if you need to do so <uic,ly. “I've been thin%ing
(obbes) )*n a #ee%end+) ),ell$ it #asn't on "ur"ose” “I have all these great genes$ but they're recessive. !hat's the "roblem here -) RHD-that is- Rheumatic Heart Disease- can occur in adults and e on

the loo!out" accordin# to the $a%anese& '(nt )ed 51'1*+2,-5+ .oo! ( !no/ 0ou 1mericans are all lau#hin# at me e ein# concerned a out this and since sanitation is #reat in 0our countr0 '( !no/" 0ou alread0 ou#ht the se/a#e mana#ement %lant 2or the cit0 o2 Detroit- and the %olice station as /ell+ ut this disease e3ists in the de4elo%ed /orld as /ell and ( thin! it is onl0 a matter o2 time until it hits 0our shores& 5o let me remind 0ou o2 the $ones criteria& Here it is co%ied 2rom 6i!i%edia
)odi2ied $ones criteria /ere 2irst %u lished in 1*44 0 7& Duc!ett $ones" )D& 839 7he0 ha4e een %eriodicall0 re4ised 0 the 1merican Heart 1ssociation in colla oration /ith other #rou%s&849 1ccordin# to re4ised $ones criteria" the dia#nosis o2 rheumatic 2e4er can e made /hen t/o o2 the ma:or criteria" or one ma:or criterion %lus t/o minor criteria" are %resent alon# /ith e4idence o2 stre%tococcal in2ection; ele4ated or risin# antistre%tol0sin < titre or D=1ase&819 >3ce%tions are chorea and indolent carditis" each o2 /hich 0 itsel2 can indicate rheumatic 2e4er& 8598698?9

Major criteria[ • @ol0arthritis; 1 tem%orar0 mi#ratin# in2lammation o2 the lar#e :oints" usuall0 startin# in the le#s and mi#ratin# u%/ards& • Aarditis; (n2lammation o2 the heart muscle 'm0ocarditis+ /hich can mani2est as con#esti4e heart 2ailure /ith shortness o2 reath" %ericarditis /ith a ru " or a ne/ heart murmur&
36 ‫ מתוך‬6 ‫עמוד‬

• •

5u cutaneous nodules; @ainless" 2irm collections o2 colla#en 2i ers o4er ones or tendons& 7he0 commonl0 a%%ear on the ac! o2 the /rist" the outside el o/" and the 2ront o2 the !nees& >r0thema mar#inatum; 1 lon#-lastin# reddish rash that e#ins on the trun! or arms as macules" /hich s%read out/ard and clear in the middle to 2orm rin#s" /hich continue to s%read and coalesce /ith other rin#s" ultimatel0 ta!in# on a sna!e-li!e a%%earance& 7his rash t0%icall0 s%ares the 2ace and is made /orse /ith heat& 50denhamBs chorea '5t& CitusB dance+; 1 characteristic series o2 ra%id mo4ements /ithout %ur%ose o2 the 2ace and arms& 7his can occur 4er0 late in the disease 2or at least three months 2rom onset o2 in2ection&

Minor criteria[ • De4er o2 3,&2E3,&* FA '1-1E1-2 FD+ • 1rthral#ia; $oint %ain /ithout s/ellin# 'Aannot e included i2 %ol0arthritis is %resent as a ma:or s0m%tom+ • Raised er0throc0te sedimentation rate or A reacti4e %rotein • .eu!oc0tosis • >AG sho/in# 2eatures o2 heart loc!" such as a %rolon#ed @R inter4al8,98*9 'Aannot e included i2 carditis is %resent as a ma:or s0m%tom+ • @re4ious e%isode o2 rheumatic 2e4er or inacti4e heart disease Other signs and symptoms • 1 dominal %ain • =ose leeds
36 ‫עמוד ? מתוך‬


@recedin# stre%tococcal in2ection; recent scarlet 2e4er raised antistre%tol0sin < or other stre%tococcal anti od0 titre" or %ositi4e throat culture& Gotta lo4e Dr& $ones 2irst name& 6hat did the0 call him

2or shortH Iou are ri#ht- the0 called him Dred '0ou didnBt reall0 thin! ( /ould sa0 Duc!0 /ould 0ouH+ 71J> H<)> )>551G>; RHD is around and can a22ect adults& Calvin: Moms and
reason are like oil and water. Calvin: That's one of the remarkable things about life. It's never so bad that it can't get worse. .) Beu,otriene receptor antagonists do not reduce asthma

admissions and there is not enough evidence to provide any !enefit in lung function +his is an /8M review $ %aed >esp >ev 13$5)22@) Nice com!ination of !oth a patient and disease oriented outcome. Are they steroid sparingE 3 really do not care as steroids are really not that dangerous that 3 would want to spend money on this med +A./ 01M/ M/ A&/2 Beu,otriene
36 ‫ מתוך‬, ‫עמוד‬

inhi!itors really do not wor, well. And may !e dangerous- this is a series of aggressiveness that started with the medication !eing used and ceased when it was stopped. All occurred !etween the ages (-15H 3ncidence cannot !e ,nown as the article did not provide the denominator; !ut suicide does occur at 1 in 25000 e#posures $C 3nvest All 4lin 3mmun 22$@)5'2)
Calvin: I don't need parents. All I need is a recording that says !"o play outside#! Calvin: $very time I've built character I've regretted it. /0) /lectrical in"ury $that is low voltage) can cause chronic

wea,ness parathesia and memory pro!lems. +his is !ecause the nerves are such good conductors. $C Neuro Neuro %sych ?3$() (33). +his reminds me of D4 Gields IMy Gather had a chair in applied electricity at the tate %enitentiaryI

Calvin: As far as I'm concerned if something is so complicated that you can't e%plain it in &' seconds then it's probably not worth knowing anyway.

36 ‫עמוד * מתוך‬

//) 3 mention these two articles !ecause of the : A*s great love

affair with M>3 $while at the same time complaining a!out health care costs). 3n these patients with chest pain; elevated troponin and normal coronaries on %+4A- they then underwent M>3 as outpatients = much later- and 107 were found with evidence of myocarditis and 107 were found with an M3. $8C> ?'$101@)/5@1). +he ,ey point here is that M3 is still possi!le even with clean coronaries- pro!a!ly from spasm- an issue we have discussed !efore. 0owever; we also see the M>3 was not that useful most of the time. Now also there are cases of nursemaid*s el!ow that do not reduce and an M>3 can tell you the reason- in this case report for e#ample- full entrapment of the annular ligament. $C %ed 1rtho 32$')/20) 4ould 4+ or ultrasound have shown the sameE +A./ 01M/ M/ A&/2 M>3 can !e used for nursemaids el!ow and elevated troponin in the face of a %+4A that is negative ; !ut the <uestion is if it is cost effective. /1) 8ac, to you 34: guys- what can 3 do = 3 am a frustrated 34: guy-they have soooo much fun. Dell there are four psych emergencies in the 34: that you need to ,now how to handle. )elirium-lower the noise level; ma,e sure sleepHawa,e cycles are preserved; avoid !enAos = yes you heard me right- avoid !enAos- and anticholinergics; and give %+. 3f there is agitation; use antipsychotics and de3medetomidine- see last month*s /M:. NM - here you want to stop the medications causing it. Dhat to give is a <uestion; dantrolene; dompamine agonsists. !enAos or even /4+. erotonin syndrome- again discontinue meds and
36 ‫ מתוך‬1- ‫עמוד‬

consider !enAos. And of course- !e careful with overdosing psych meds in patients with hypotension or failing ,idneys which are all so common in the 34: palace. $44M 50$()2@@2) +A./ 01M/ M/ A&/2 %sych emergencies in the 34:- delirium; serotonin and NM syndromes and psych iatrogenic overdoseshere are the ways to deal with them. Calvin: $verybody I know needs a
complete personality overhaul Calvin: "ive me the strength to change what I can the inability to accept what I can't and the incapacity to tell the difference /2) De 4+ everyone with a first time seiAure !ut if they return to

them selves it really isn*t necessary in the /). 3n this Gam %ract article- they here recommend it only in focal seiAures or those with developmental delay. 0owever they then say that those with no structural !rain disease do not need anti seiAure medswell how do you ,now with out the 4+E Naturally; if !leeding is suspected then 4+ should !e performed. $AG% ?@$5)335) 3 thin, the important point here is not doing the 4+ from the /) and truth !e told; 3 never found any surprises on 4+ after a first time seiAure in the /). +A./ 01M/ M/ A&/2 4+ after a first time seiAure- in the /) is not necessary if it wasn*t focal and the patient is normal now. 3n the clinic- pro!a!ly still need one.

36 ‫ מתוך‬11 ‫עמוד‬

/4) )elicate su!"ect- men refer to these

di22erentl0 than

/omen however; things do go wrong with the mammary glands and you should ,now
36 ‫ מתוך‬12 ‫עמוד‬


a!out them. Masses; pain and discharge are the pro!lems. Masses- mammography is the standard !ut ultrasound is more sensitive in the under thirty group $since ultrasound has no radiation; 3 am not sure why they don*t "ust ultrasound everyone). %ain is usually not due to a malignancy and medications can !e common causes which include hormones; 14s; psych meds and some 4J meds. )ischarge is more complicated. 3f it is one sided; associated with a mass or is spontaneous- that is suspicious. 3f it is !ilateral; chec, out + 0 and prolactin $i!id p353) Note that they do not discuss trauma where fat necrosis can occur. 8y the way; the !irds a!ove are a tufted titmouse; and a !lue footed !oo!y !ird. +here; we got that past the censors. +he last !ird is a tunning Ginch it has nothing to do with our discussion and even 3 do not ,now what it is doing here. +A./ 01M/
36 ‫ מתוך‬13 ‫עמוד‬

M/ A&/2 8reast disorders re<uire wor,ups if they are masses or discharges.
Calvin: (eave it to a girl to take all the fun out of se% discrimination. )usie I #as going to as% you to "lay (ouse$ but I thin% you'd be a #eird e3am"le for our children. /5) Another case for you $ i!id p3@1) A rash- we all love these =

that is very itchy and spreading. teroids creams did not help. 0e has no allergies and no sensitivities. +he rash has coalesced over the shins. +he rash is scaly. Fes it could !e tinea versicolor; !ut that has smaller and circular lesions. 3t could !e pityriasis rosea !ut this is usually asymptomatic. /#creta and tinea corporis are also good thoughts; !ut loo, differentecAema has a crac,ed appearance and tinea tends to !e more papular. 3t will help if 3 say this came after a strep throat. 1h;

36 ‫ מתוך‬14 ‫עמוד‬

you want to see the rashEE

/&) 3f you read /M: in the !athroom = and you should !e- then you

may fall asleep as this isn*t terri!ly useful. Bet me ma,e it <uic, so other people can use the lavatory- t wave inversions in the anterior and inferior leads can !e a sign of %/. 3t occurs a!out 117 of the time which is more than 1K333+333 !ut was less li,ely to !e pic,ed up. $C/M 53$2)22@) +hey then do .appa to see how people agreed on this finding; !ut this muddies the study !y trying to do two things in one study. Also; .appa is a hard thing to use- if the prevalence is low; the ,appa- a measure of agreement- loo,s !etter. 3 however included this study also !ecause 3 li,e Amal Mattu who is a !rilliant man and a great lecturer although he refused my offer $through his resident) for
36 ‫ מתוך‬15 ‫עמוד‬

a free /M: su!scription. My offer is still open Amal- thin, of all the good "o,es you are missing- +A./ 01M/ M/ A&/2 + wave inversions in the anterior and inferior leads can mean a %/.

Calvin: If you do the *ob badly enough sometimes you don't get asked to do it again. Calvin: "irls are like slugs + they probably serve some purpose but it's hard to imagine what

16) 1ne last clinical <uiA. o there was this young guy who had a fever and wasn*t !reathing too well. 0is D84 was only ?.? !ut his 8% was 100H60 and his creatinine went up to '.?. %latelets were only 25. 3f it helps; 3 first heard a!out this diagnosis when reading a National &eographic in a !ar!er shop on 8la,ely treet in )unmore right outside of cranton %A. Dhat was itE 1?) Fea 3 ,now 3 didn*t give you much to go on. Dell; the author*s name was 0ong and he was from .orea. Dhy would that !e importantE 1() 1h the reference is important also- C 4lin Jir ''$1)1. 3 have for sure made this too easy at this point
36 ‫ מתוך‬16 ‫עמוד‬

20) +heophylline- didn*t we put this med to sleep alreadyE Dell if you are a !eliever in meta analysis- and you shouldn*t !e- than this is the !est thing since sliced !read to prevent contrast induced ,idney in"ury $AC.) @0$3)3@0). Dell; do not start giving this dreadful drug yet- this helped only with creatinine elevations which is not a patient oriented outcome- most patients with !umps in creatinine do well with tincture of time. Also it didn*t help with patients who started with a creatinine of 1.' = which is the population that most worries us. No long term !enefits either. o you can return this medication to the shelf- hopefully at some point we will find a use for it. ame goes for me as well +A./ 01M/ M/ A&/2 +heophylline was thought to help prevent contrast induced ,idney failure; !ut it did not. 1/) +A />- 3 haven*t had any e#perience with this- neither on the treating; receiving or distri!uting end. +his is a device that shoots two sharp electrodes and delivers a high voltage low current shoc, to a person which temporarily immo!iliAes them $from what 3 remem!er from electricity = current is this the more damaging than voltage). According to 1hm*s law $JL3>) the electricity will travel the path of least resistance and this is along tissue layers; so the ris,s to hearts is minimal. 0owever muscles can !e damaged and e#pect an increase in 4%.- up to 15@'. Nerves seem to !e preserved. +hey recommend that only medical personnel remove the darts !ut that all depends on where they are. $C Gorensic cience '6$@)1'(1) +A./ 01M/ M/ A&/2 +A /> seems to !e safe- !ut you should ta,e the
36 ‫ מתוך‬1? ‫עמוד‬

darts out of the patient. 1r yourself if you are a ,lutA. 1r even if you are not Calvin: I hate to think that all my current e%periences will someday
become stories with no point. Calvin 4ome#here in Communist Russia I'll bet there's a little boy #ho has never %no#n anything but censorshi" and o""ression. 5ut maybe he's heard of 6merica$ and he dreams of living in this land of freedom and o""ortunity7 4omeday$ I'd li%e to meet that little boy...and tell him the a#ful !R8!( 65*8! !(I4 9:6C;77 Calvin's ,ad Calvin$ be <uiet and eat the stu"id lima beans. --. Calvin: /hy waste time learning when ignorance is instantaneous0 12) 0i .en and .no#- are you guys still reading at this pointE = so

you got this case of a (3 year old man with a massive cere!ral !leed //& was unremar,a!le; !ut this guy is a vegeta!le and is going to stay this way. %1A is the caregiver who was appointed as such after the son- the previous %1A- was ousted over his alledged trying to admit the father to a nursing home. +he %1A wants aggressive treatment and the son does not. +he %1A says the son is only concerned a!out the inheritance; the son claims that the %1A will get paid for as long as the patient lives and so he is acting out of self interest. 3t is clear to the son the Gather would never have wanted his life prolonged li,e this. +hey as,ed for the perspectives of many people. +he lawyer says = the law is clear-the %1A is considered the voice of the patient and the family is powerless. 0owever the physicians caring for the patient do not have a legal o!ligation to provide futile care. +he lawyer and the ethicists recommended sending this to the ethics committee of the hospital and trying to get them to resolve the !ad !lood !etween son and %1A. After this they get the social wor,ers; nursing and physician*s perspective that raise further issues. $AC 0ospice and %alliative
36 ‫ מתוך‬1, ‫עמוד‬

4are 2($@)5(6) 3 "ust have two comments here- 3 thin, a clergy perspective is critical here; !ut the authors of the article apparently did not agree. Gurthermore; the <uestion is pretty clear according to the law. Dhat if there is no %1A designated and the family mem!ers do not agreeE +A./ 01M/ M/ A&/2 Fou must follow %A1 !ut you do not have to provide futile care.
Calvin 9eo"le thin% it must be fun to be a su"er genius$ but they don't reali=e ho# hard it is to "ut u" #ith all the idiots in the #orld. 1obbes Isn't your "ants =i""er su""osed to be in the front+ )usie I see you're bringing a glove today. >id you sign u" for recess baseball+ Calvin ?eah$ don't remind me. ?ou're luc%y that girls don't have to "ut #ith this nonsense. If a girl doesn't #ant to "lay s"orts$ that's fine7 5ut if a guy doesn't s"end his afternoon chasing some stu"id ball$ he's called a #im"7 ?ou girls have it easy7 )usie *n the other hand$ boys aren't e3"ected to live their lives t#enty "ounds under#eight. Calvin 6nd if you don't "lay s"orts$ you don't get to ma%e beer commercials7

25) +he AA88 provided new practice guidelines for !lood transfusions which is !ased on a restrictive rather than a li!eral transfusion policy. +here is no hemoglo!in level which is for sure an indication for transfusion $although 3 assume that a level of 0.01 gramHdl may trigger a transfusion) and this means that people with a 6 or ? who are "ust fine than, you can stay that way. /ven more so; they admit that there is little evidence for that well accepted nut that all heart patients need to !e over 10mgHdl. $Ann 3nt Med 1'6$1)5(). 0owever; read the editorial. 3n many cases the dangers
36 ‫ מתוך‬1* ‫עמוד‬

anemia may !e worse than transfusions !ut sometimes the case may !e vice versa. /specially since the safety of !lood transfusions has improved significantly- !oth from leu,o reduction and from !etter storage which calls in <uestion the higher mortality seen in li!erally transfused patients = and that study was done long ago; and was stopped !ecause of the slow recruitment of patients. Gatigue and tachycardia may !e drivers for giving !lood !ut there are many drivers that physicians use. 3n short; the editorial is against a one siAe fits all. 3ndividualiAation is important $i!id p61) 3 would li,e to point out- one transfusion reaction especially +>AB3 will ma,e you thin, twice a!out randomly giving !lood. +A./ 01M/ M/ A&/2 &ive !lood to those who need it.

Fes guys; that is 8ella Bugosi in his role as )racula.
36 ‫ מתוך‬2- ‫עמוד‬

Calvin In my o"inion$ #e don't devote nearly enough scientific research to finding a cure for jer%s. Calvin @iss ,orm#ood$ I "rotest this )C) grade7 !hat's saying I only did an )average) job7 I got '5A of the ans#ers correct$ and in today's society$ doing something '5A right is outstanding7 If government and industry #ere '5A com"etent$ #e'd be ecstatic7 I #on't stand for this artificial standard of "erformance7 I demand an )6) for this %ind of #or%7 Bne3t "anel)I thin% it's really gross ho# she drin%s @aalo3 straight from the bottle. Calvin I understand my tests are "o"ular reading in the teachers' lounge 14) 3 guess this is only relevant if you are 3sraeli; Cordanian or from

:tah; !ut dead sea water into#ication can happen and is dangerous- even a swig of '0 cc can elevate your magnesium and calcium significantly $%/4 2?$?)?1'). My hospital is the nearest to the )ead sea and we see a lot of these9 my director )r. 4armi was ,ind enough to allow me to interview him on how he treats this. 4alcium is generally easily treated with fluids and diuretics. Magnesium responds less well to diuretics. Girst aid includes fluids !ut then = if the level is eight or higher = or the patient is comatose you !etter consider dialysis. 3 thin, Gather &reg can !e the first to tell you = you got to !e careful what you drin, +A./ 01M/ M/ A&/2 hypermagnesemia can result swallowing small amounts of )ead ea water. Calvin *ne of
my baby teeth came out7 I have to say$ I'm not entirely comfortable holding a "iece of my o#n head. Calvin Cigars are all the rage$ >ad. ?ou should smo%e cigars7 Calvin's Mom Clatulence could be all the rage$ but it #ould still be disgusting. Calvin I see. ,ad Dicely "ut$ dear
36 ‫ מתוך‬21 ‫עמוד‬

2@) Fes; so it was !ac, in 1((3- 3 was in &rand >apids and a young man had arm pain after lifting weights. Fea; you ,now; arm pain; lifting weights- well; itMs a sprain and give it some ice and N A3) and life will !e rosy. A wee, later 3 get called in !y the !oss- he got a dirty letter that we missed an upper e#tremity )J+. Dell; 8oss; 3 said; 3 accept what you say; !ut don*t you remem!er that you saw him too and missed it a few days laterE +hen there was a strange <uiet- !ut it is a good point- this is a commonly missed diagnosis. And it is occurring more often. +he reason is !ecause of more use of indwelling central lines. 0owever; the case 3 mentioned is called %aget chroetter disease $&osh; that %aget guy got around) and is found in young men who do vigorous e#ercise usually as a result of an undiagnosed underlying venous thoracic outlet syndrome. %/ is less li,ely than lower e#tremity )J+s and a distal )J+ in the arm causing a %/ is very rare. +he data is not clear as to the occurrence rates for post throm!otic syndrome. +hey continue anti coagulation for three months !ut the evidence ain*t great for how long you really need to anticoagulate. 1!viously if this was due to a catheter you remove the catheter; and if it is %aget syndrome- they may need surgical correction for the outlet syndrome $ 4irc 12@26@?) +A./ 01M/
36 ‫ מתוך‬22 ‫עמוד‬

M/ A&/2 :pper e#tremity )J+ is safer !ut is often missed.
Calvin (ey 4usie$ #hat's the ans#er to Euestion '+ )usie ,erkins Imadoofus. Calvin !han%s. BCalvin reali=es 4usie has tric%ed him) Calvin !he !ooth Cairy's gonna ma%e you rich tonight$ 4usie

“Mom will you drive me into town?” Reply “Why should I drive you, Calvin? It’s a perfect day outside! What do you think people have feet for?” “To work the gas pedal.” - Calvin and Hobbes

1') )islocations- there are three in the hand you !etter

,now !ecause you may miss them on plain films. +his article s on perilunate dislocations. +hey are high energy outstretched hand things. +he can tether the median nerve and cause aseptic necrosis from compromised !lood supply so this is a dislocation that you want to deal with immediately. 1ften there will !e associated fractures such as of the scaphoid or the radial styloid. $8MC 35'2 e602@)

36 ‫ מתוך‬23 ‫עמוד‬


7he 2irst %icture is a %erilunate dislocation& 7he second is a lunate dislocation& +hese dislocations are !est seen on lateral films. +he last dislocation is a scaphoid lunate dislocation which you see !est on A% = there is a large hiatus !etween these two !ones- it can !e less pronounced than this picture

+A./ 01M/ M/ A&/2 )on*t miss dislocations in the hand. After Calvin nails Susie with a
snowball he walks up to her and says “I must say, the stinging snow makes your cheeks look positively radiant.” “I have a hammer. I can put things together! I can knock things apart! I can alter my environment at will and make an incredible din all the while! Ah, it’s great to be male!” - Calvin and Hobbes 36 ‫ מתוך‬24 ‫עמוד‬

2?) 1ne last fun article which laments the preponderance of fran,ly dum! a!!reviations in medical articles. $>adiolgy 2@@$2)3?3). 0e !rings a funny N/CM letter from 1(?( 320$16)11'2 $would you !elieve those rats from N/CM want me to pay for the articleE Must !e friends of 8ill 8elichec,) 8ut seriously spea,ing- many a!!reviations have you leafing !ac, through the paper to see what they are tal,ing a!out or can !e confused with other things- li,e M> can !e Magnetic >esonance or Mitral >egurg or Mental >etardation $ 3 ,now that is not politically correct !ut it is still in use in many countries) +A./ 01M/ M/ A&/2 $+0M) Avoid A!!reviations $AA) 2() +hose who do not read the /M: for the centerfold often read the letters only. /ven though /M: went out late last month; A#el was ,ind enough to forgive me for it; although Gather &reg re<uested a num!er of 0ail Mary. 3 than, you for your forgiveness and forgive the Grench for Bes 4harlots. pea,ing of Gather &reg; he did chec, in with us last month; which will get him less home attendant hours from his social wor,er. ?osef$
6nother brilliant #or% of medical insights and comments on the "assing seen. ?ou can "retend that Israel can avoid #or% redesign but it is coming. !he best #ay to "redict the future is to ma%e it. ,e need to get on to" of this situation and run it to" to bottom before nitF#its shove it do#n our throats. 5y the #ay the death of the male 5lac% ,ido# 4"ider #hich you so gra"hically described #ould not be so bad de"ending on #hich head the female bites off. Gust as% 5ill Clinton. 5y the #ay$ my sand#ich of the month is the 4u"er Ruben at HingermanIs >eli in 6nn 6rbor$ @I. I tIs a meal to die for$ or to die from$ IIm not sure #hich. I %no# you ;ast Coasters are no# ho#ling I #ould mention the @id#est and great deli in the same sentence but trust me it can hold its o#n in the deli #ars. Cather (enry Actually;

Gather; while the medical system in 3srael is depressing; it is the
36 ‫ מתוך‬25 ‫עמוד‬

way you guys are going. 8ut 3 did li,e the line a!out ma,ing the future. 3 am no longer an /ast 4oaster; !ut 3 drifted a little further /ast. +han,s for the cogent comments- 3 will definitely thin, of you ne#t time 3 have a sandwich or get my head chewed off. 0ey; what is a month without a letter from .enE
(i ?osef 6gain$ great Dovember issue of ;@8. Jee" u" the fine #or%7 4ince you #rote that you #ere e3"ecting me to #rite about scor"ions$ I #onIt disa""oint. In my e3"erience$ the diagnosis is usually made in children due to the acute onset of bi=arre sym"toms. !hey thrash around$ have roving eye movements$ unusual head and nec% movement$ mild cholinergic sym"toms and$ if they are verbal$ "ain at the sting site. 6dults "rimarily have severe "ain Bsometimes re<uiring IK narcotics) that may last for months. 6s for antivenom$ >r. :eslie 5oyer B"ediatricianLto3icologist) at our 8niversity of 6ri=ona #ent through the multiFyear "rocess of getting the @e3icanF"roduced antivenom a""roved in the 8nited 4tates. 4he #on the (ero of @edicine a#ard for that. 5ut$ #e need to remember that the @e3icans develo"ed the vaccine and have it in use. Regarding the item on "hysical$ es"ecially the chest e3am$ I assume that #as a jo%e. 6s emergency "hysicians #e routinely get unconscious "atients #ithout a history and$ at least #here I often "ractice internationally$ I canIt get a radiogra"hM<uic%ly or at all. 4o$ the "hysical is our “goFto” evidence to direct our treatment. In the develo"ed #orld$ I use it to confirm #hat I have diagnosed via history and observation or$ if I have no idea #hatIs going on$ to loo% for clues. 4o$ at last for me$ the "hysical e3am remains
36 ‫ מתוך‬26 ‫עמוד‬

a vital "art of my armamentarium. I assume it does for you and most ;@8 readers$ also. 5y the #ay$ my ne#est boo%$ “!he Nlobal (ealthcare KolunteerIs (andboo% ,hat ?ou Deed to Jno# 5efore ?ou No” B###.galen"ress.com) #ent to the formatter today. It then goes to the "rinter and should be out in Ganuary7 ?eah7 5est #ishes$ Jen

+hat !oo, sounds very interesting. 3 will give it a plug and vouch for all of .en*s wor,; while not !e a!le to accept a free copy; since 3 can not accept any gifts. 0owever; if it was given to meN. 8y the way; that guy was serious a!out the chest e#am-3 stand in the middle- 3 am not going to diagnose any +> murmurs !ut it does help for wheeAing and the li,e. +han,s for writinginterested in ,nowing where you can get a good sandwich in MichiganE +ry Glint. 30) Num!er si# was a patient with respiratory al,alosis which causes propofol to !e meta!oliAed to pretty green urine. 0ere is the )) for green urine form the article "ust in case you wondered why you have a su!scription to /M:2 Aimetidine; @romethaKine" (ndomethacin" )etoclo%ramide" Dlutamide" )eth0lene lue; 1s%ara#us; Alorets 'chloro%h0ll+; 6ilisan %ills 'Ahinese her al medication+" Hartnu% disease" (ndicanuria" @seudomonas urinar0 tract in2ection" Lile 4ia 4esicoenteral 2istula" Green eer 'DatherH+" some #reen d0es& Num!er 15 was guttate psoriasis which will respond to higher potency steroids and :J8 treatments. 3 would have thought this was a fi#ed drug reaction !ut there was no
36 ‫ מתוך‬2? ‫עמוד‬

e#posure to any meds. 3 included it !ecause if you aren*t a genius- and 3 am not = at least you will thin, of this when standard anti allergy treatments do not wor,. 1h and of coursetreat his strep throat please. Bastly num!er 1?; 1( and 20 was of course a 0antavirus infection which comes from aerosoliAed dry feces of a mouse. 3t can turn !ad; !ut treatment is supportive. Named 0anta !ecause of its discovery in .orea. And it is a virus. 3 made that one too easy.

EMU LOOKS AT: Looking great and breathing easier
7his month /e loo! at t/o su :ects that /e !no/ little a out 'at least ( do+ @erior ital cellulitis 'Aurr <%in <%tho 23;4-5+ .un# trans%lant emer#encies 'Res%iration ,4;163+ 1+ .etMs 2ace it E it isnBt al/a0s o 4ious /hat that red droo%0 e0elid is& .etBs lea4e trauma out o2 this- that is the eas0 one 2+ (n2ectious is the one that is most othersome and the one /e most o2ten see& Hordoleums and le%haritis can cause this as can the usual stre%s and sta%hs& Ho/e4er" do not miss these; >LC seems to ha4e a %redilection to cause edema around the e0elidN He% L can do this too& .0me and R)5D can cause this due to a 4asculitis& <4a can cause h0%ersensiti4it0 reactions" so consider trichinellosis 'still common in some %laces in rural O51 and in the rest o2 the /orld+ Aha#as" 2ilarialand amoe a& Do not 2or#et in2ected ites or non in2ected ites& 1nd o2 course=ec Dasc can stri!e here as /ell& 5inusitis" es%eciall0 @ottBs @u220 tumor 2rom the 2rontal sinus can cause %erior ital edema" and or ital cellulitis can start out this /a0&
36 ‫ מתוך‬2, ‫עמוד‬

3+ =on in2ectious causes- aller#0 is #oin# to e the leadin# cause& Dacial creams" e0e dro%s and ma!eu% do the most dama#e" althou#h s0stemic

aller#ies can cause this as /ell& Guess /hat- the th0roid can cause this also" ut that doesnMt other me- the th0roid seems to cause e4er0thin#& 7his /ill cause or ital s/ellin# as /ell& Do not 2or#et dermatom0ositis and lu%us& 6e /ill mention tumors" ut ( do not thin! that /ill e that hard to dia#nose& 4+ 7here is a /eird ird called le%harochalsis /hich is a disease o2 0oun# adults that comes and #oes 2or an a4era#e o2 t/o da0s& 5+ 7he article doesnBt sa0 this" ut ( use heat as hel%in# me ma!e the dia#nosis& 1ller#0 in onl0 one e0e is rarer" is usuall0 less hot and less red& (t ma0 e itch0& 6+ He0 /hat a out medsH (matini causes this o2ten ut /e use that onl0 2or A). and most o2 us /ill not see that& Li%hos%honates can cause this as /ell as scleritis and u4ietis& H0aluronidase is o2ten a 2iller in cosmetics and o2ten causes edema& =51(D5 and some anti%0shotics do it as /ell& ?+ @ost sur#ical causes can come 2rom the ears as /ell- cochlear trans%lants can do thisP
36 ‫ מתוך‬2* ‫עמוד‬

,+ (2 0ou are 2aced /ith a case that 0ou are not sure o2 the cause" so there is an al#orithm here /ith all sorts o2 lood tests" ut this is orin# enou#h&

.un# 7rans%lant >mer#encies; 1+ 7hese 5/iss docs are honest 2rom the outset- the0 sa0 this is /hat the0 do& Iou arenBt #oin# to see much science here" ut it at least ma!es some sense& Jee% in mind this article is not 2or %ost o% com%lications ur rather 2or the lun# trans%lant %atient
36 ‫ מתוך‬3- ‫עמוד‬

that comes to 0our >D or clinic 2rom the communit0& Lut one thin# ( li!ed a out this article /as the 2irst authorBs name had t/o O in it '5chuurmans+& Jind o2 reminds me o2 this 2ello/- do 0ou

remem er himH 2+ Ies" that is O 7hant" the 2ormer 5ecretar0 General o2 the O=& =ot Quite sure /hat %eo%le /ho didnBt !no/ his name said to him 'Rhe0" 0ouRRIesHR+ 3+ 6ell" 0ou #uessed it- the li2elon# ta!in# o2 sometimes three or more immunosu%rressi4es causes most o2 their %ro lems& (n2ection" #ra2t re:ection" and one marro/ su%%rsion& Lut do not sto% readin# 0et&
36 ‫ מתוך‬31 ‫עמוד‬

4+ Re:ection o2ten occurs ecause inadeQuate immunosu%rresion& 7hese s0m%toms can e 4er0 su tle such as malaise" d0s%nea and lo/ #rade 2e4er& 1ctuall0" the onl0 si#n ma0 e reduction on s%irometr0 Eso as! E most o2 these %atients !no/ ho/ to measure this themsel4es& Ho/e4er do not #o reachin# ri#ht then and there 2or the meds- e sure that 0ou are not loo!in# at a res%irator0 in2ection 2irst& @ro lems is that clinical assessment is not enou#h and chest 2ilm ma0 e con2usin# as ronchietasis and %leural e22usion ma0 e %resent /hich can e seen in re:ection or inSS ronchietasis and %leural e22usion& A7 hel%s a lot '/ithout (C contrast- the0 #et renal 2ailure too easil0+" ut sometimes ronchosco%0 and io%s0 ma0 e necessar0 to rule in or out re:ection& Dor me as an >@" (Mll do a A7 and #o 2rom there i2 there is a ona 2ide in2ection& Hi#h acute 2e4er and a lous0 loo!in# %atient /ill hel%& A0clo%sorine #ets the !idne0s- so !ee% an e0e on them /ith Ar and urea chec!s& @rednisone is o2ten ta%ered" ut :ust !ee% in mind that #ettin# this ri#ht ta!es 0ears sometimes and des%ite all e22orts" ronchiolitis o literans s0ndrome can occur- 0ou /onBt e treatin# this" ut it is :ust an e3am%le a out ho/ im%ortant #ood immunosu%rresion is here& ( do not %ersonall0 2eel com2orta le ad:ustin# immunosu%%resi4es on m0 o/n& 5+ Alarith0omi0cin ma0 cause the le4el o2 c0clos%orine to #o u%" so the0 %re2er 1Kithro" 1Kole anti2un#als are another %ro lem" so the0 use cas%o2un#in& 7he0 ne4er use 2luconaKole& Le care2ul to use %ancreas enK0me re%lacement 2or A0stic Di rosis %atients a2ter lun# trans%lant& 7he0 ha4e a list o2 common medications
36 ‫ מתוך‬32 ‫עמוד‬

interactions that /ill cause re:ection or to3icit0 or ne%hroto3icit0 in the article& Le care2ul /ith metoclamide 'Re#lan" @ramin+ as this is commonl0 used and can cause lo/er le4els o2 c0clos%orine& 6+ .i!e stran#e names E here is a 5ecretar0 General o2 the O= 2rom

e2ore O 7hant& His name /as Da# Hammars!:old- #ood luc! tr0in# to %ronounce that one 'THe0 0ouU /ould %ro a l0 /or! here too+ ?+ A0to%enia is 2airl0 common #i4en the tonna#e o2 meds the0 ta!e& Do /atch the 6LA& 1nti iotics do this es%eciall0 7)V-5)W" and Dla#0l& 5ome anti 4irals can do it too& Iou ma0 ha4e to mi3 and match the meds ,+ 5o 0ou see this #u0 /ith a runn0 nose& 7he0 attac! him /ith nasal 4iral and acterial cultures and then start mo3i2lo3icin& (2 it
36 ‫ מתוך‬33 ‫עמוד‬

is the 2lu season the0 start <setami4ir& @atients that loo! /orse and older 2ol!s #et %ut in the hos%ital& 7he0 do not li!e macrolides 2or reasons /e stated a o4e and e4en i2 all the cultures are ne#ati4e the0 still continue mo3i 2or another /ee!& Dun#i and at0%icals are searched 2or& 7he truth e told the0 actuall0 a##ressi4el0 /or! u% all chan#es in the status o2 the %atients& 6ho am ( to ar#ueH A)C is al/a0s tested 2or- its %neumonia can e treacherous in these %atients and it is o2ten reacti4ated a2ter trans%lant *+ G( %ro lems occur alot& Recall that immunosu%ressi4es mas! normal si#ns o2 intra a dominal disasters& (ntestinal motilit0 is lessened 0 the meds so #i4e them la3ati4es& AD %atients es%eciall0 need this ecause the0 de4elo% distal intestinal o struction s0ndrome& Comitin# is another disaster- e4en a little as%iration can lead to in2ection or re:ection and esides it ma!es it hard 2or 0ou to !no/ ho/ much med the0 did mana#e to #et into their lood stream 7he0 %re2er 2eedin# tu es and not =G7 tu es 'Konde+& Diarrhea occurs ut do not 2or#et A Di22icile as these 2ol!s are constantl0 #ettin# that )o3i& .a3ati4es can cause this diarrhea" ut as /e noted last month- sometimes this is consti%ation /ith onl0 liQuid stool comin# out& 6hen in dou t- 3 ra0& 7he0 do not #i4e %ro iotics- /ho !no/s /hen these 2riendl0 u#s can turn mean& O7(s a ound ecause the si#ns are o2ten a sent&

36 ‫ מתוך‬34 ‫עמוד‬


1-+ Here is another #reat name

Ara%honso 7hor%e& ( am not #oin# to attem%t to %ronounce that one 11+ <steo%orosis and osteo%enia is 4er0 common amon# these %atients and most /ill e #ettin# calcium" 4itamin D and a i%hos%honate& 5till" 2ractures are Quite common& 1lso do not 2or#et that since man0 are ta!in# a res%irator0 Quinolone1chilles tendon %ain or transection ma0 e %resent& Ose lidocaine %atches" do not use =51(D5& 7he0 do use anti iotics as %ro%h0la3is Quite 2reQuentl0 'li!e 2or dental %rocedures+ ut a#ree the literature is s%arse& 12+ H7= is commonN the0 a4oid calcium channel loc!ers ecause o2 the edema the0 can cause& Remem er /ith the su%%ressant dru#s the0 ta!e" the0 can ha4e a ad )( or AHD and sho/ 2e/ si#ns& Ditto /ith %ulmonar0 em olism" so i2 there is a DC7 E chec! those lun#ers& Le2ore sur#er0- s%ea! to these #u0s- mortalit0 is hi#h

36 ‫ מתוך‬35 ‫עמוד‬



Ies that is Ha Ha Alinton Di3a name onl0 ri4aled 0 the =e/ $erse0 7o/n

Ha4e a #reat 7han!s#i4in# and Hanu!ahP

36 ‫ מתוך‬36 ‫עמוד‬