If It Walks Like the Flu and Talks Like the Flu-Then it is the Flu.

http://www.aafp.org/news/health-of-the-public/20160205fluantiviral.html

A quick reminder that many people have heard me say ad nauseum but bears repeating this time of year: Do NOT totally rely on a false negative flu swab in telling the patient that they do not have the flu. This maxim bodes especially true for high risk patients (see article).

As mentioned above, while the rapid flu swab is very accurate with its positive results, a NEGATIVE result is untrustworthy (high rate of false negatives). So, when a high risk flu appearing patient comes in achy with a 102 fever and you tell the patient  "no tamiflu for you...go pound sand", your scientific dogma may be on shaky ground, especially when they land in the hospital in the ICU (because they are 2 years old with secondary pneumonia).

Trust your eyes and your gut here. I know it is blasphemy to say that in this evidence based medicine world. I place a lot of faith in the old saw of: if I walk in the exam room and the patient is curled up in the fetal position on the exam table due to entire body aches (note flu, unlike typical colds, tends to attack/ache the larger muscle groups in the quads, hamstrings, glutes, lumbar areas-hence it hurts to walk)-then I have a high index of suspicion for the flu, rapid test be damned.

Be careful out there-and watch out for the high risk patients.

Stone Cold Facts on Renal Stones

Over at www.familypracticenews.com, a fairly decent family medicine periodical, in the April 1, 2015 edition resides a nice summary of current recommendations for renal colic prevention. We all, especially in the more dehydration prone summers, see many painful renal colic patients. I admit I often get confused as to what to suggest, as like diet therapy to prevent diverticulitis, the evidence for/against various suggestions seems to sway form year to year. One year peanuts are good, the next year and study later they are bad! Usually, once the toradol has taken hold and the writhing/pacing have lessened, the patient often asks what he/she can do to prevent a recurrence. I will summarize the tips below, most of which are based from the American College of Physicians, or ACP.

• Tactfully tell the patient that once you have ONE stone, the odds are high (30-50%) that within 5 years a recurrence will occur. For people with one recurrence already, the repeat odds are even higher.
• There is no current evidence to support the use of stone analysis in tailoring any type of prevention therapy.
• Major prevention pearl #1 is: All patients should be told to increase fluids to attain 2 liters of urine per day. A good comparison is the old maxim, "except for the first am void, all other voids should be crystal clear."
• Major prevention pearl #2 is: To decrease soft drink/cola consumption. In people with renal stones who stopped colas, the recurrence rate went from 40.6% down to 33.7%. DO NOTE the studies were mainly done with colas that were acidified by phosphoric acid, as opposed to many fruity colas that use citric acid.
• Major prevention pearl #3 is: Although unlikely to be initiated in urgent care as it is a long term medicine, in order of efficacy one can consider potassium citrate and other citrate supplements (most efficacious with 75% reductions), high dose thiazide diuretics, and lastly allopurinol coming in last with 35% reductions. Surprisingly combination therapy was not more effective than monotherapy for any of these.

And so, to fully seize the painful teaching moment of the first episode of renal colic, advise the patient to stop the soda, crank up the water, and see his/her primary for a preventive agent if they are willing to adhere to a daily regimen.  

Don't Let Your Mono Knowledge Fatigue!

Welcome back y'all. After a reprieve from Ebola and such, I recently saw in the 3/15/15 American Family Physician journal a superb summary with actionable points on one of our most common urgent care conditions- mononucleosis. If you are an AAFP member, you can get the article online, but for the ER people, mid-levels, and others, here are the salient points:

• The article cites a 2008 Clinical Journal of Sports Medicine EBM literature review stating that all athletic participation should be curtailed in mononucleosis for the FIRST 3 WEEKS OF ILLNESS. Yes, that is news to me also, but that is why you keep reading in life. Note that is the first 3 weeks of the actual illness, not when the patient presents to you on day 7. I know that this will make many ultra competitive high school athletes happy that the "old school" 4- 6 weeks regime of rest has been countered, in a rigorous, medico-legally safe sort of way.
• As I often harp about to other providers, the article cites that the rapid "monospot" heterophile antibody test has a 25% false negative rate in the first week of illness. This fact matches the physiology, since it takes several days to get the antibody counts cranked out from the immune system. As such, for the child presenting on day 3 with the parent insisting for a mono test, you may want to write in your discharge instructions to return in a few days if symptoms (usually fatigue) continue for a recheck. In this CSI world it breaks patients' hearts that the medical religion of lab testing has limits, but this is a case where some patient education is needed. 
• For that false negative monospot, early presenting case though, you may want to co-order a CBC, since you may luck up and get a lymphocyte count LESS than 4,000. The article states, a lymphocyte count of less than 4,000 has a negative predictive value of 99%. Not too shabby. 
• Steroids only help the sore throat within the first 12 hours of illness. Beyond that, there is absolutely no benefit to steroids or antivirals either. For the patient needing the "magic of a prescription", it may be the safer alternative to alleviate the sore throat with Magic Mouthwash, as opposed to steroids. 
• While splenic rupture only occurs in 0.1%-0.5% of mono patients, the most common cause of hospitalization for mono is actually airway obstruction, more commonly in children than teens. I am sure you all have seen in the clinic firsthand that usually the "nastiest mouths" are indeed exudates from mono.

Hope this helps, but certainly the points are pertinent to our real world practices.

Sink Your Teeth Into this TIME SENSITIVE Topic!

http://www.dentaltraumaguide.org/permanent_avulsion_treatment.aspx

******PLEASE ALSO REVIEW VIA THE REX WEBSITE LIBRARY THE TOOTH AVULSION CHAPTER IN UPTODATE, WHICH HAS SUPERB PICTURES******

While we are obviously not dentists, facial and dental trauma are a part of urgent care practice. I will be the first to admit that a medical provider can quickly get lost in the dental terminology of dental concussion, subluxation, intrusion, extrusion, and avulsion. Here are the imperative points though:

• With a facial trauma, and a "knocked out tooth", in the mayhem of patient and understandable parent panic, don't lose sight of the forest for the (tooth) trees. In other words, make sure that the c-spine is alright, assess for loss of consciousness and intracranial injury risk factors that take precedence over the tooth, and do a quick body survey and history for potential child abuse.
• The most dreaded and time sensitive is a full tooth avulsion. These injuries, for PERMANENT TEETH, need care within 1 hour and if not placed in proper medium, the tooth and its essential periodontal ligament have a zero percent survival rate. 

      As such, our main focus is:
1. Is this a permanent tooth? Here is a basic guide:
-All teeth are primary for kids less than 5.
-Permanent incisors usually erupt around age 6-7. Note the frontal maxillary incisors are the 2 most commonly injured teeth.
- Mixed dentition occurs in ages 6-12. As such, this will be the "tough group."
-Most kids over 13 have all permanent teeth.

2. Is this an avulsion? Again, I suggest the UptoDate pictures, but in non dental language the tooth is totally knocked out at the gumline, the periodontal ligament is severed, and a fracture of the alveolar ridge may also be present. AVULSION NEEDS REIMPLANTATION AS SOON AS POSSIBLE. NOTE THAT FROM THE TRAUMA UNTIL REIMPLANTED AND SEEN BY A DENTIST, COLD MILK IS THE BEST TRANSPORT SOLUTION, OR IF THE CHILD IS OLD ENOUGH TO NOT ASPIRATE IT, INSIDE THE BUCCAL MUCOSA.
Per UptoDate, here is the basic-and doable-guide to reimplant the avulsed tooth and quickly being sent to the ER or dentist. Again, the 1 hour window applies to reimplantation, so you can make a big difference here...

• handle the tooth carefully by the CROWN and avoid the ligament
• remove debris by gentle rinsing with saline or tap water (again, milk is the preferred storage medium over saline for transport). DO NOT ATTEMPT TO STERILIZE OR SCRUB THE TOOTH, as you want to keep the periodontal microfibers.
• manually reimplant the tooth in the socket- see picutre 8 in up to date.
• keep the tooth in place by having the child bite down on a clean gauze or towel.
• see the dentist or pediatric ER as soon as possible.   

Again new things are always intimidating, but here is the cheat sheet summary:
1. SEE ALL DENTAL INJURIES ASAP IN THE CLINIC. 
2. IF A PARENT CALLS IN ROUTE, OR IF THE PATIENT HAS THE TOOTH IN HAND, PLACE IT IN COLD MILK OR THE BUCCAL MUCOSA. NO SCRUBBING.
3.IF A PERMANENT TOOTH, REIMPLANT IT TO MAINTAIN VIABILITY AND SEND TO THE DENTIST ASAP. 

 

Enter the Enterovirus D68

http://www.cdc.gov/non-polio-enterovirus/about/EV-D68.html?s_cid=cdc_homepage_whatsnew_001

Above is the link to the CDC website for enterovirus D68. Note that at least as of September 22, 2014 the CDC says it is not in North Carolina yet, but given its spread and proximity it is safe to say it is here and just undetected, or will be soon. A few salient urgent care points for this after reviewing the current information on EV-D68.

• Recall this is an enterovirus, which technically is the same grouping as polio. Recall that with these enteroviruses, while droplet spread is typical, a large amount of organism is shed in the stool.  As such, a valuable pearl for prevention in families is to remind family members to be especially diligent about washing hands (for at least 20 seconds) after diaper changes.
• Perspective is a key ally against the fear mongering in the news media. So far,  175 people in 27 states were confirmed to have EV-D68. Most of these patients were tested due to a need for hospitalization. For comparison, think how many children and adults are hospitalized in an average flu season.
• EV-D68 especially attacks babies, infants, children and teens. Most adult immune systems have already seen an immunologic plethora of enteroviral infections, and as such more immunity is present in older people. 
• MOST CRUCIAL POINT- FEVER, ESPECIALLY HIGH FEVERS, ARE NOT TYPICAL FOR EV-D68.  Almost subconsciously, like a pneumonia, one would expect respiratory severity to correlate with fever, but this is not the case. Yes, fever can cause tachypnea but EV-D6 can cause respiratory distress without fever.
• SECOND MOST CRUCIAL POINT: RESPIRATORY DISTRESS IS THE ATTACK MODE FOR THIS VIRUS. AS SUCH, IT IS IMMENSELY HELPFUL TO GAUGE THE CHILD'S RESPIRATORY STATUS BY SITTING AT THE BEDSIDE- SHIRT OFF (TO SEE ABDOMINAL BREATHING, NECK, AND RIB RETRACTIONS)- AND THEN TIME THE RESPIRATORY RATE FOR A FULL 30-60 SECONDS. USE A CLOCK, AS OTHERWISE YOU WILL STOP AT 15 SECONDS BECAUSE IT FEELS  LIKE 30 SECONDS.  This "old school" physical diagnosis pearl yields a veritable cornucopia of information. Plus, to the concerned parents this shows concern as this exam exudes thoroughness and an attention to detail. Try it- you will be amazed how a simple task can go so far. I have lost count of the number of times I thought a patient would need the hospital at triage, or conversely was unimpressed at triage, only to pull a "complete 180" after doing this maneuver. 

Obviously, much like Ebola, I suggest checking with the CDC website about every 2 weeks, especially as these are fluid epidemiological situations that are very much in the public mind. 

Nice Review that Will Raise Your Blood Pressure

http://reference.medscape.com/viewarticle/827504?src=wnl_edit_specol&uac=61764CK

Above is a link to a decent Medscape question/summary on hypertensive urgency and emergency, one of our Express Care bread and butter topics.
My only add on is to remember to thoroughly document your "end organ targets" in your note. For instance, don't forget to document your (undilated) fundoscopic exam. Get an urinalysis if you feel the need, or an EKG. Keep the end organ targets in mind to keep your documentation on target!

An Early Flu Guidance Tip

http://www.jwatch.org/fw108998/2014/06/27/cdc-panel-recommends-nasal-flu-vaccine-over-shot-kids?query=pfw

At the end of June 2014- for the 2014-2015 flu season, the CDC's Advisory Council on Immunization Practices (ACIP) formally voted that for healthy children ages 2-8, that the FluMist (the nasal flu vaccine that is attenuated- not killed like the shot) be the flu shot of choice for this age group. The reasoning was studies show much greater immunogenicity to the nasal spray as opposed to the shot.

While we do not give flu shots in this age at the Express Cares, this is a key guidance item to stay up to date on since we field many flu questions in our clinic.

Just to add to the controversy, the American Academy of Pediatrics disagrees with the ACIP, citing the higher cost of the FluMist and it's restriction to healthy kids, including excluding those with a history of asthma.

I think common sense here is to advocate as the first priority for all people over 6 months of age to simply get vaccinated. Then, for this age group and if accessibility is not an issue, one can show preference for the nasal vaccine. As always, www.cdc.gov and www.immunize.org are supreme, reliable resources for all vaccine information, and you can print out any VISs if needed.