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.