You May Be Surprised-When to Refrain with Chest Pain

http://www.medscape.com/viewarticle/766543
 Like the previous blog entry, you may need to sign into Medscape to view this article.

Above is a very current (7/5/12) article on what signs and symptoms truly lead to adverse outcomes (death, MI, urgent need/revisit for revascularization) within 6 months of a medical evaluation. Thanks to Dr. Citron for the excellent article which very much applies to our practice.

One more preface note, the author, Amal Mattu, MD, is a prolific medical writer on common ER pitfalls. While in my humble opinion, not to the level of Dr. Gregory Henry in "Bouncebacks", Dr. Mattu definitely focuses and has pithy wisdom on items that "can trip doctors up." If you like this article I suggest an Amazon book/Kindle search on his name. Of note, Mattu has an "urgent care pitfall" book that will be published October 2012.

The jist of the article is that "classic" MI signs, sternal pressure going into the left jaw and neck, etc. may not be so classic. This prospective study of 796 patients in an inner city in England intensively tracked what signs and symptoms were most correlated actual MIs (true cardiac disease). Per the article, CORRECT signs that most point to cardiac disease include:
-Pain radiating to the RIGHT arm or shoulder (odds ratio(OR) 2.23)
-Pain going to BOTH shoulders (OR 2.69)
-Vomiting (OR 3.50)
-Central Location of chest pain- (OR 3.29)
-Clinician observed Diaphoresis (OR 5.18). For the record, patient reported diapohoresis (but not observed) did correlate to MI but not as highly as clincian observed diaphoresis.

I can do no better than parpaphrase the 3 take home points at the end of the article, which are:

1. While this study and the mentioned studies can provide guidance, note that obviously NO sign or symptom can fully stratify a patient to "no risk". Use the findings as guidance-not gospel.
2. If you are taking the "plunge" and sending a patient home with chest pain, document as many of the "low" risk features as possible in your chart to display your medical reasoning and increase your defensibility. The article mentions pleuritic chest pain, positional chest pain, sharp pain, pain reproduced by palpation, and pain not associated with exertion. To be devil's advocate though, recall that pleuritic chest pain may then open you up to pulmonary embolism (I threw that in for you, Dr. Wood).
3.The most important predictors of acute coronary syndrome and MI appear to be: chest pain that radiates (especially bilaterally or to the right side), associated diaphoresis, associated vomiting, and pain on exertion. The article suggests asking and documenting these 4 items for all chest pain patients, and to really refrain from sending people with these traits home with the usual "pleurisy", "costocondritis", or "GERD" diagnosis.

Thanks again to Dr. Citron for the useful article. Let me hear some comments on your opinion of the "right shoulder" phenomenon.

Dog Days and Bug Bites and Swimming Issues

http://reference.medscape.com/features/slideshow/bug-bites?src=nl_slide

Above is an interesting and picture laden summary of several bug bite lesions. A few quick reminders that were spurred by the pictures:
1. When confronted with an "odd" rash" or fever, don't forget to document any travel history. While a full workup for say, malaria, would be best started in the emergency room ( better lab access to a "thick" blood smear, easier blood culture attainability), it is important to maintain your clincial suspicions.
2. Make no mistake,I am amazed by the number of "red bugs" or chigger bites in this region. Explain to patients that because the chiggers may have been residing on one clump of grass or brush, it is not unusual for only one person in the outdoor party to be affected, even when doing similar activities, such as hiking together.
3. For all our patients enjoying ocean and lake activities (and for those taking board recertifications!) don't forget the difference between "swimmers itch" and "seabathers eruption". The itch is when non-human schistomsomes (often from birds and small mammals) invade the EXPOSED skin. As such, the "itch" is on non swimsuit covered areas, such as arms and legs. Usually the swimmer's itch is freshwater. In contrast, the seabathers eruption is from 2 saltwater animals, and get "caught" under swim clothing. So, people return from their beach trip with an itchy rash that affects only areas UNDER their clothing. Both respond to topical/systemic itch relief. Note that the swimmer's itch is a different schistosome from the human parsitic schistosomes that infect the bladder and other sites from exposure in areas like the Nile in Africa.

Please note you may need to "become" a Medscape member to access the article. The Medscape feed is useful though.