A Primer on Hiccups

http://www.medscape.com/viewarticle/815243?nlid=41484_426&src=wnl_edit_medp_fmed&uac=61764CK&spon=34

Urgent care has a lot of the same diagnoses, but sometimes some oddball diagnoses walk in. Here is one that is off the beaten path but you will see once or twice a year- hiccups.

Note the video is 12 minutes, but you can skip to the last 1/3 that is on hiccups.

Crux take home point here is a good history and physical for anything along the diaphragm, esophagus, trachea, or neck, as anything that irritates the phrenic/vagal routes can trigger hiccups.

Enjoy, and happy holidays to all.

Poor Tortured Testicles

http://reference.medscape.com/features/slideshow/testicular-pathology?src=wnl_ref_critim&uac=61764CK#1

Just by the simple fact that we all work in acute care, testicular torsion should always be in the back of your mind. If you need motivation to remain vigilant on this issue, see this excellent slide show on common testicle disorders. The OR pictures are resplendent. A few caveats that present themselves in urgent care with regard to testicular issues and torsion:

• When you suspect torsion, please be sure to document in your history very thoroughly when the patient had the onset of pain, swelling, etc. If someone waits (i.e. 24 hrs) until necrosis sets in, then you want documentation that is was the patient's delay, not your delay, that led to necrosis. Note that while our express care front desk MOAs lack any formal medical training, "testicular pain" of any type is one of their "red flag" issues that needs immediate attention and triage by a nurse. 
• Try to always remember that with the baby/toddler presenting with "irritability" that is without source, such as no fever, be sure to at least do a visual inspection of the scrotum and document no swelling. A quick glance below the diaper line may cinch the diagnosis. Another "stealth irritability" inducer that many parents miss is on the toes a small hair tourniquet on one of the toes.
• Note the high recovery rate of 90-100% if the torsion is caught within 6 hrs. This time period is the gold standard. 
• The slide show has an excellent synopsis, and some of the best pictures I have ever seen, of torsion of the appendix testis, a common imitator of torsion. 

Urgent Care Troublemakers!

No fancy links or articles today, just a quick listing to serve as a reminder of some diagnoses that can easily "sneak up" on the urgent care provider. It is one issue to have diagnoses that are dangerous because their presentation is subtle or vague. Many of these items, such as PE, despite their stealthiness, are at the forefront of or diagnostic radar because they are common. 

Consider though, the ultimate challenge though are entities that are rare and that have perplexing presentations. I am not talking about "diseases you only see on the boards" such as pheochromocytomas. I am talking about the diagnoses that you see every 5-10 years once, and even then your mind is struggling to piece the clinical clues together. Review the list, feel free to add others in the comment section below, and as you read each entry, think to yourself, "Can I recall what one of those patients "looks like" and would I think of it/catch it in a busy clinic?"

• Kawasaki Disease- Fairly rare. The prolonged fever often leads to several physician visits, and you may be seen in the urgent care after one or several pediatrician visits have been fruitless. More vexing, is can you mentally link the eye issues, or the hand/feet issues, and the lymph nodes? Recall Rex has UpToDate, so feel free to quickly review these disease criteria. 
• International Travel. Everyone travels. No one takes their malaria meds. No one gets their shots. No one listens, but they will blame you for what you miss when they return from their business/missionary trip with a fever. I do not encourage malaria smears in the express care; rather, I encourage ample consideration for the ER for anyone with a fever and international travel in the last month. Too many diagnoses, not enough time or labs or continuity to address the labs.
• Acute Angle glaucoma- Don't be ashamed, if you don't recall what this is take the opportunity to look it up. Again, its rarity will allow you to miss this diagnosis.
• Compartment Syndrome- I advise go with your gut here. Recall many of the classic "p's" are late signs. 
• Temporal Arteritis- Don't be fooled into ignoring jaw pain. Edge on the side of caution, and consider steroids with appropriate, timely referrals. We see so many benign headaches and are always on the lookout for subarachnoid hemorrhage so much that this major diagnosis possesses great stealth. 

What items would you add to this list? All are uncommon. All are dangerous. Are all on your radar? 

One or Two Bid? Riddle me this CA-MRSA....

http://blogs.jwatch.org/hiv-id-observations/index.php/back-to-school-top-questions-from-id-in-primary-care/2013/10/18/?query=pfw-featured

Above is an article from the entertaining and useful, non academic knowledged Paul Sax, an infectious disease specialist with the excellent Journal Watch ID blog. The above link outlines that despite some influential texts ( Sanfords, and even my beloved Tarascons) listing standard treatment for CA-MRSA to be two Bactrim DS tabs bid, that this may well be "urban legend" and one can safely get by with the more frequent, UTI-like one tab by mouth bid.

While I would usually say in these skin abscess cases to simply use doxycycline, as many of you all know the pharmaceutical companies have found a way to remove doxy from the "$4 dollar drug list" and it is now much, much more expensive. As such, Bactrim DS has become my main gunner for CA-MRSA lesions.

As Sax mentioned, this 2 tablet bid dosing leads to heinous nausea and patient non compliance. The medicine cannot heal if the patient is non complaint.

Do you use the 2 tab bid dosing? Or, has too many patient call backs triggered you to return to the one tab bid?

Some Knowledge Bonding With Dermabond

http://jucm.com/magazine/issues/2013/1013/files/11.html

     Hands down, this linked article the the Journal of Urgent Care Medicine is one of the best clinical summaries of Dermabond I have ever read. Note the author does a solid melding of academics and "real world" experience. A few highlighted pearls

• The majority Dermabond failures are not due to the "glue breaking" or cohesive failure. Most of the time it is substrate failure, or the glue not bonding to the skin. Remedies include alcohol swabs around the wound to remove oil and other skin contaminants, and keeping the area as dry as possible. One superb tip was to be sure to include a boundary of 1-2 CENTIMETERS of normal skin around the laceration to allow an increased bonding area and lessen the chance of wound dehiscence. I will admit I have been using usually an area of about 5mm at most to anchor the glue. (Hint-get out a ruler and see these exact sizes- you too will be surprised!)
• Many patients bark out to the medical provider, "Well geez Doc, I could have just used the super glue I use on my exhaust pipe to pass my license tag inspection!" The article actually cites that over the counter "Super glue" polymerizes much faster than medical glue and as such, releases enough heat to cause first degree burns. So, now you get the last laugh!
• The article highlights a use I may explore, which is Dermabond on large elderly skin tears that are too frail to suture. Key here is avoiding tears that look as if they may form a large hematoma.
• Confession- I have done this too. Air movement (waving your hand) does not speed glue polymerization. The package insert for Dermabond is a 2 minute period. The article states 2.5 minutes.
• Lastly, don'f forget the #1 credo of all wound healing: The key to lessen scarring is to properly approximate the skin layers. So, you must be able to pull the wound "tight" enough to align the dermis, epidermis, and thereby prevent the glue from improperly seeping deep into the wound and slowing healing. Consider a small steristrip to approximate the area if routine skin tension does not approximate layers well. Obviously you want a small steristrip, since as mentioned above you need the skin surface area to allow full bonding. 

The article is well worth your time. I guarantee you will find an item to help your practice and improve outcome.

"Urine" Trouble if You Forget This New Pathogen

http://www.familypracticenews.com/index.php?id=2633&tx_ttnews%5Btt_news%5D=216531&cHash=ff838b0caa41c6e4bbcb00b5ac003482

I consider this one of the most influential articles ever for this blog because it will change your urgent care practice. The link mentions a semi-new and virulent urethritis pathogen- Mycoplasma genitalium.  Long lumped under the amorphous microbiological class of "atypical pathogens for urethritis", this mycoplasma strain in recent studies has been implicated for 15-20 % of clinically significant urethritis issues. Moreover, this mycoplasma displays considerable resistance to the usual urethritis empiric meds of doxycycline, cipro, and zithromax. In fact, it currently (unless resistance patterns morph over time) is mainly susceptible to Avelox. 

Just think, how many times has a male (or female) come in with urethritis, you see some WBC on the UA, you empirically start zithromax or doxycycline, and then they still have significant symptoms 5 days later when he or she returns to the clinic and you say, "Well, good news is your gonorrhea and chlamydia are negative. I am unsure why you still have urinary issues (you internally think non compliance)." Perhaps you send them to a urology consult, expecting interstitial cystitis. Regardless, this article outlines that persistent urethritis (or even cervicitis) issues unresponsive to the usual antibiotics with a negative gc/chlamydia need a course of Avelox (to eradicate M. genitalium), and also a course of concomitant  Flagyl, to eradicate the less common Ureaplasma urealyticum. 

SUMMARY: Don't shrug your arms with urethritis when the patient returns with issues despite treatment. Instead, try a 7-10 day course of Avelox and Flagyl, The article estimates 15-20% of urethritis is due to these non culturable organisms. Hence, this means the urine culture also will show up negative. Note also with M. genitalium that there seems to be resistance to traditional fluoroquinolones like Cipro or Levaquin. While Avelox and Flagyl should NOT be first line treatments, they certainly should be second line urethritis interventions. I can say this will give me new options for many of my frustrated patients, and I am sure you too have patients like this....if you just keep your eyes open..... 

Do you Know about Cipro?

http://www.medscape.com/viewarticle/809520

Above is a reminder about the potential side issues associated with fluoroquinolones. Note that I could not see how many reports the FDA had received, but I do question how many since last year alone over 23 million fluorquinolone prescriptions were written. Sadly, note that in some cases the neuropathy is permanent (the cynic in me would question how many of these cases had disability hearings pending).
Lastly, note that topical (otic and ophthalmic) fluoroquinolones have not been implicated for neuropathy.

The take home point from this should be the importance of urine cultures. If this article pushes you "back to bactrim" then please remember to send a urine culture. Sanford's suggests first line fluoroquinolones if local E. coli resistance is above 15-20% for sulfa meds, and from local data I suspect Rex's antibiogram is close to or above this number. Thanks to Dr. Citron for the article referral.

Don't forget the cultures! Empiricism is an academic myth for a non existent lawyerless world!

Finding the Needle in the Haystack

http://jucm.com/magazine/issues/2011/0911/files/35.html

Without a doubt, it is easy to be "asleep at the wheel" during a routine sports physical. However, vigiliance, like all of medicine, is a must, because you don't want the student that you just cleared yesterday to be on the 6 o' clock news dead.
Full disclosure, when the lawyers are removed and pure science is involved, Osler himself would still not "find" all the athletes at risk for sudden death. The truthful article cited above, from the Journal of Urgent Care Medicine, cites the well publicized case of professional football player Thomas Herrion, who despite legion exams from collegiate and professional team physicians, collapsed and died from autopsy proven "long standing heart diesease." Further weigh in your mind an author quoted in the article:

"...although the conduction of the preparticipation exams is considered medically and legally necessary and benevolent by many, the actual utility of at least the cardiovascular component, specifically in terms of screening for lethal conditions, is questionable from an epidemiological standpoint." ( Bold faces are my doing.)

 Like most things today, you are "damned if you do, and damned if you don't" but here are some tips for lessening, but not eliminating, your sports physical risk, and of course help the patient.

1. Remember many lawsuits don't start with negligence but the perception of negligence. As such, be sure to take an extra 2-3 seconds and focus on the cardiac auscultation. I suggest listening your normal amount, then adding 3 seconds consciously.

2 For myself personally, in an effort to actually show my vigilance, I often ask the patient to valsalva while listening to the heart, in an effort to hear the louder murmur from hypertrophic cardiomyopathy. Recall the murmur sounds louder with valsalva. I do this by asking the patient to "poke their stomach out" while auscultating. I will admit though, no evidence based medicine proves this works; rather, it is a display to the parent and patient that I am doing the best I can to screen for an unscreenable condition. I also write on each sports pe form "no murmur on valsalva."

3. The American Academy of Pediatrics suggests the "Big 3" cardiac components of the sports physical are cardiovascular symptoms (syncope, exercise intolerance, etc.), blood pressure, and family history. Wake County sports physicals cover 2 of these 3 on the history questionaire, which most parents neglect to fill out. As such, I do not perform the physical until the history is filled out. Second, I also sign the history form to prove I examined it and it was not glossed over.

The JUCM article above is pithy but well written from the real world stance of a seasoned MD/JD. Take the time to read it, as it will open your eyes.

Swelling Up with Solutions

http://www.aafp.org/afp/2013/0715/p102.html?aafpvlogin=7281773&aafpvpw=&URL_success=http%3A%2F%2Fwww.aafp.org%2Fafp%2F2013%2F0715%2Fp102.html

Above is an American Family Physician article from this summer outlining lower extremity edema. The article nicely delineates the algorithms for unilateral/bilateral edema, and also has some excellent photos as reminders.

A few summary tips if you cannot access the link:
1. Obviously, don't forget the #1 priority with unilateral lower extremity edema is to rule out DVT. Document a full history complete with a thorough risk factor assessment. Please comment below if you have had success with the new "direct referral DVT doppler" program outlined at the May 2013 provider meeting.
2. Use the skin (hemosiderin deposits) to help you document venous insufficiency.
3 Table 3 of the (often forgotten) medicines that can cause bilateral edema is a helpful reminder. Note that beta blockers, calcium channel blockers, and clonidine are prime culprits!
Reading this article can swell your medical diagnostic ability, so please peruse it.

Know the Limits of Your Science

At many of the past provider meetings and often face to face, I have repeatedly stated that when taken on a "macro" view, medical science is woefully inadequate and is often playing "catch up" to current tick borne diseases. As such, not only should caution be applied to the actual tick lab interpretation, but one should be cognizant that the pool of knowledge is shallow. To paraphrase Donald Rumsfield in the early 2000's, "the real danger is not what you don't know, but what you do not know that you do not know."

The bottom line is that with tick diseases, there are numerous "unknown unknowns."

As proof of this, consider the below linked article describing- yet again- another tick entity.

http://www.aafp.org/news-now/health-of-the-public/20130708bmiyamotoi.html

Add to the mix the fairly recent discovery of a new tick viral disease, outlined here:

http://www.cdc.gov/ncezid/dvbd/heartland/index.html

As such, what is a provider to do in these uncertain waters? While there are no absolutes, I think it is prudent given the evolving nature of tick disease etiology that one ensures:

- Caution with "shotgun labs." Aside from the usual caveat emptor with Lyme and tick titer interpretations, don't let the white blood cell count of 13,000 ( viral...or something else?) deepen your diagnostic dilemma.

-Rigorous documentation of "pertinent normals." No doubt, this blind spot in medical understanding is being easily exploited by chronic pain sufferers, disability seekers, and anxiety ridden people whipped into a frenzy by the evening news. This tsunami of "rushing to assume the sick role" means your note has to well document normals, such as no fever, no rash, rash less than 5cm (for Lyme), no arthralgias, no Bells, etc. In other words, "dot your i's and cross your t's" if you are witholding medicines, because society is requiring that validation.

-Clear discharge instructions assume an even more vital role here, especially since from an urgent angle we may see the tick bite before true tick disease develops. Note that many of the novel tick zoonoses often manifest as severe "prostration", to the level of hurting daily functioning. Aside from the usual headache, fever and rash, it may be prudent to warn patients of these issues also in your written discharge note. 

-The first article cites the need for a longer period of doxycycline (more of a 2 week Lyme type regimen than the "presumed RMSF" 1 week regimen). So, if you are writing for a "tick illness" seriously consider going for 2 weeks instead of one week. If you are crossing the Rubicon and treating, then treat with the proper regimen.  

A Common "By the Way..." Issue

     Nail issues and abnormalities are one of the most frequent additional questions from patients. Exposed and always unclothed, nails are readily in sight and patients often ask about them. While most nail issues are trivial, many times as medical providers we often experience an inner nagging fear that we could be missing signs of a more significant internal disease. Here is a decent article of common nail issues.

http://reference.medscape.com/features/slideshow/fingernail-abnormalities?src=wnl_ref_critim&uac=61764CK#1

This article is not only a quick read but has excellent pictures too. Comment below if you have ran into any of these issues-trivial or otherwise.

"Vigilance" Never Goes Out of Style

As any experienced urgent care practitioner knows, the true clinical challenge in urgent care is to remain sharp and vigilant- ever aware- for the rare but real urgencies and emergencies that could otherwise get lost in the daily drone of clinical minutia. Consider the "sinus headache" that 3 hours later is a subarachnoid hemorrhage. At least in the emergency room the basic volume, due to selection bias, of clinical catastrophes is enough to prod one to awareness. Urgent care lacks that daily external prodding, which means as a professional, the drive to vigilance must derive from an internal source.

THAT SOURCE IS YOU.

As a reminder of this, consider the mnemonic of "vigilance." Yes, it is cheesy, but it may come in handy at 7:59:59pm with that last patient walking through the door. Note that vigilance is not excessive or overbearing workups as much as it is constantly remaining open to the worst-not the best-outcome, and then guarding properly against it.

•  v is for vision/snellen charts. It is hard to say you "did no harm" unless you document the damage present before your exam. Also, it may be a tip off to acute angle glaucoma or occult globe perforation (as occurred in Wakefield).
• I is for incision and drainage. With CA-MRSA, only good usually comes from this procedure. Much like intubation, "if you think an abscess may need I&D", then it should be done. You and the patient will sleep better.
• G is for a general view of the patient. As a past pediatric article mentioned, your global, "gut" impression can go a long ways to ruling out occult sepsis.
• I is for proper inquiring.  Medical students only wonder about answering the questions a patient has. Experienced clincians wonder why the patient is asking the question in the first place.
• L is for looking at skin (in areas of pain) to confirm no visible Zoster. We all have heard of the "heart attack" that showed itself to be shingles when a patient's shirt came off, but what about the vesicles hiding in the scalp for a patient's "headache."
• A is for acknowledging that you cannot remove all the uncertainty from clinical decision making (even though society and lawyers expect us to), but you can "do enough to get comfortable with your uncertainty."
• N is for pertinent negatives. Newbie diagnosticians often focus on exam findings that are present, but be sure to document important findings that are not present.
• C is for credit. Remember you can never give enough credit to your nurses, lab techs, and x-ray techs. They supply the data points that you assemble into a cohesive picture.
• E is for efficiency. Ideally, for nearly every chief complaint, walk into the room with the top 1 to 3 things that you want to rule out, and then proceed. For many general, nonspecific issues, sometimes telling the patient what he/she does not have can be as reassuring as finding (the perhaps non existent) answer.

Are there any pearls you all would add?

Some Otitis Externa Reminders

http://www.aafp.org/afp/2012/1201/p1055.html?aafpvlogin=7281773&aafpvpw=&URL_success=http%3A%2F%2Fwww.aafp.org%2Fafp%2F2012%2F1201%2Fp1055.html

As usual, as the weather warms and swimming increases, otitis externa ramps up. The above is an excellent article updating suggestions for otitis externa. The article is from the American Family Physician. Some pearls are:
1. While rare, always be on the lookout for malignant otitis externa, which is a medical emergency and needs the hospital/emergency room. The "prototype" patient is a middle aged poorly controlled type 2 diabetic. However, be on the alert for any immunosupressed, febrile patient with a "severe" otitis externa. In cases where you judge the issue to not need ER evaluation and CT scan, consider documenting in your note "no tenderness on mastoid palpation."
2. Don't forget the aural cotricosteroids (along with the appropriate antibiotics) to lessen pain and inflammation.
3. I also suggest reminding concerned parents they can assist with acetaminophen or ibuprofen.
4. On your discharge instructions, remind the patient to use a cotton ball/ear plugs to keep the ear totally dry- except for your prescription drops- to speed healing.
  

A Practical Derm Pearl

     Make no mistake, steroid creams of varying potency are a mainstay in urgent care rash treatment. Knowing the exact amount of cream/ointment to prescribe for though, can be a bit of a 'guessing game."  Too much, and you risk an overzealous patient using the cream 6 months later on their jock itch (We have met the enemy-it is ourself.). Too little leads to needless patient suffering, extra trips to the pharmacy, and even more copays. Below is a table, based on body region, estimating the necessary amount of topical steroid needed to cover a 2 week period. ENJOY!

Estimating the Necessary Amount of Topical Corticosteroid for Adults

                        Area                                            Amount Needed for BID dosing x 2wks 

                Face and Neck                                                       36g

                Trunk (front and back)                                        186g

                One Arm                                                                48g

                One Hand                                                               17g

                One Leg                                                                  81g

                One Foot                                                                25g

(Source:Long CC, Finlay AY. The Finger Tip Unit-A New Practical Measure. Clinical Exp Dermatology 1991; 16(6):444-447.)   

Some Pearls on Corneal Abrasion

http://www.aafp.org/afp/2013/0115/p114.html

     Spring in urgent care means outdoor work, and that means outdoor eye injuries. For those of you who receive the American Family Physician, the January 15,2013 issue has an excellent summary article on corneal abrasions. Some pertinent pearls are:

• Never forget to ask about and document contact lens use. Contact lenses=pseudomonas, so don't fool around with the usual erythromycin, polytrim, and Bleph-10. You need to up the ante and cover infection with fluoroquinolones or aminoglycosides.
• Conversely, you may want to avoid aminoglycosides for NON contact lens corneal abrasions, as there is some evidence of eye toxicity with these medicines, especially if overused. Then, you may want the polytrim- for non contact lens issues.
• Abrasions more than 4mm are an indication for ophthalmology referral. (So, it may help to document the approximate size of the abrasion in your note.)
• Topical cycloplegics and mydriatics are NOT recommended for routine corneal abrasion pain. 
• Eye patches are not suggested for corneal abrasions as evidence shows they do not improve pain and can delay corneal abrasion healing. Eye patches for corneal abrasions are like my hair- long gone and passe'.
• Topical NSAIDs do help corneal abrasion pain (Dr. Caulway loves these meds.) If you prescribe these though, make sure you give written instructions to stop the eye drops after 2 days, as overuse quickly leads to corneal toxicity. 

Remember to always use extra caution with the high function areas- eyes and hands!

 

When "Gout" Is Not Gout-Risks for Septic Arthritis

     As many people have heard me state, septic arthritis is an insidious diagnostic quandary. It can skirt many fairly reliable labs, yet have long term, devastating consequences.

Septic arthritis is the stealth bomber of joints. 

     Even worse, like most urgent care work, this feared enemy may only show itself every 3-5 years or so in your patient pool, so complacency can grow on your diagnostic lenses, like moss on a roof. Complacency is even more tempting by the preponderance of gout in our patients and its similar presentation of a hot, red, tender joint.
     The October 2012 released book of Urgent Care Emergencies- Avoiding the Pitfalls and Improving the Outcomes, by Goyal and Mattu, has a nice blurb on warnings that "gout may not be gout." I also attached some real world commentary.

RISK FACTORS ASSOCIATED WITH AN INCREASED LIKELIHOOD OF SEPTIC ARTHRITIS

(in no particular order)

1. PROSTHETIC JOINT
2. AGE >80 YEARS
3. RHEUMATOID ARTHRITIS
4. OVERLYING CELLULITIS
5. HISTORY OF TRAUMA TO AREA OVER THE JOINT
6. IV DRUG USE
7. IMMUNOSUPPRESSION

Real World Commentary Point by Point:
1. People almost always forget to mention surgeries from years ago. If you see an old scar, ask about it! You will be surprised how often you get, "Oh, that's my knee replacement from 8 years ago...."
2. Age brings wisdom but robs the body. Enough said.
3. Note the "perfect storm" of points 3 and 7-just think how many RA patients are on immunomodulators like Humira, Embrel, and the like now. Don't show your age by forgetting or "blowing off" the role of these medicines. Remember, "immunosuppression" is a heck of a lot more nowadays than COPDers on 20mg of daily prednisone! Note also the urgent care pitfall that most people view immunomodulators as pulmonary risks (ie- get the chest x-ray) due to all the publicity and litigation over activated fungal lung infections from these medicines.
4. We all see countless superficial CA-MRSA abscesses. If the entire joint though starts to look red and angry, push for the septic joint work up. Recall that the major pathogen in septic arthritis is Staphylococcus aureus, especially MRSA.
5. Ask and document about the IV drug use if you are even remotely considering septic arthritis. The patient may lie, but you need to show your diligence by asking. (Ask about HIV status also-remember the last provider meeting?)
6. The article mentions that all the tests- CRP, ESR, WBC, are riddled like swiss cheese with holes in sensitivity and specificity. A positive has little predictive value, and a negative has little predictive value. As such, stay aware of the above risk factors.

Lastly, recall that the diagnostic test of choice is joint arthrocentesis with joint fluid analysis. Hence, take advantage of your orthopedic comrades in the same office building, and also do not be afraid to avail yourself of the emergency room, with its needed IV antibiotics and consultations, especially for pediatric cases.

 

A Summary of What Comes Back to Bite You...

http://archinte.jamanetwork.com/article.aspx?articleid=1656540

Above is a decent article on the most common reasons people end up in the ER, after he/she has seen their primary within the last 2 weeks. In other words, what were the most common "missed diagnoses."
One fault I found with the article, was that especially in the VA population, I imagine if a primary care provider saw a patient, was deemed to have a URI, and then ended up in the ER 14 days later with pneumonia, how do we not know that the pneumonia developed over the 14day interim period? Furthermore, with chest x-ray being a late indicator and often lagging clinical findings, would an x-ray 2 weeks earlier have changed anything? Regardless, the article serves good fodder for the lawyers against you in a deposition, so it is worth reading. A few pearls:
1. The #1 missed diagnosis was pneumonia.
2. The second most missed diagnosis was decompensated CHF.
3. Note that despite what the policy makers want you to do, nearly 79% of the "misses" involved issues in the "physician-patient encounter", and within this realm the largest area for mix ups (57%) was not ordering enough diagnostic tests. (Shhh....I know that is non trendy to say nowadays.) In other words, the creatinine, urinalysis, or x-ray was not performed and the patient was sent out.
4 Don't forget acute renal failure on the list. This is a major issues in the elderly, multimorbidity patient, where it is hard to "piece things together....and by the way their creatinine is 5."
5. I will use this article as a reminder...use caution with the bouncebacks.

Rabies and Tetanus Primer

http://www.medscape.org/viewarticle/749029

Above is a superb summary of current rabies and tetanus guidelines. While it is a video presentation, you can "speed things up" via advancing the slides. A few quick pearls (but again the summary is chock full of good information).
1. As a reminder, avoid closure as much as possible on bite wounds. If for "flap" reasons you need some type of closure, keep it as loose as possible, such as steri-strips over sutures.
2. Make sure your documented cleansing includes an antiviral agent, such as povidone-iodine or benzalkonium-chloride.
3. I think it started about 2 years ago, but for worried parents sent to the Health Department (ie- wild animal bite and animal not caught), the current rabies vaccine series is a total of four shots at days 0, 3, 7 and 14. Previously it was 5 doses.
4 The slide comparing high risk tetanus injuries versus low risk tetanus injuries is very useful...caution with the crush injuries!
5. Don't forget to check tetanus status for burns (as well as frostbite.)
Again- check out the presentation- you can even get CME for it at the end I believe.

Stevens-Johnson Syndrome Reminder

http://www.jucm.com/magazine/members.php?issue=/magazine/issues/2013/0113/

While not the New England Journal of Medicine, this month's Journal of Urgent Care has a nice "reminder" article on maintaining your clinical suspicion for Stevens-Johnson Syndrome (pages 26-29 in the online magazine version. Note free registration may be required.)
Stevens Johnson Syndrome (SJS) is a tragic disease for the patient because of its severity, and a tragic disease for the provider because it has grave implcations and is easily overlooked, especially at first/initial presentation. A few key pearls:
1. To be safe, it is a good mental exercise for any patient with a rash to query and possibly examine for any mucus membrane involvement, since by definition SJS involves mucus membranes. Toxic epidermal necrosis, which is even more fatal and problematic, has larger expanses of mucosal involvement. Recall mucus membranes can include the vagina, sclera and conjunctiva, and the oral mucosa. As such, ask about eye discharge, blurry vision, vaginal discharge, and other mmebranous areas in your history and physical. I think out of routine most medical providers just "look in the mouth" and may forget other areas.

2. The list of tiggger medications for SJS are legion, but include TNF-x modulators, anti gout meds, antipsychotics, anticonvulsants, and of course antibiotics, especially the "textbok" sulfonamides as well as penicillins. So, basically the entire American public is at risk. All kidding aside though, keep this in mind if a patient returns from a recent visit for community acquired MRSA and was placed on Bactrim.

3. Being an urgent care, send the SJS patient to the emergency room. This disease, while technically less severe than TEN, can be fatal, and as the article bluntly states, " Patients with SJS burn from the inside out." As such the ER is the best place for burn treament, IV therapy and a proper pain regimen.

Respect SJS and remain vigilant for it by thoroughly reviewing your medication list, and taking seriously any rash that also includes mucosal involvement.