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.