Les Bijoux of Doctor Latte

What's in my pillbox?

2009-10-02T09:08:00.000-07:00

Find out at the NLM website:

Pillbox

Ingrown Toenails

2009-10-02T09:06:00.000-07:00

The American Academy of Orthopaedic Surgeons offers these suggestions:

Soak the foot in warm water three or four times each day.
When not soaking, make sure the foot is clean and dry.
Wear open-toed sandals or similar while the condition heals. Otherwise, opt for comfortable shoes that don't squeeze the toes.
Carefully wedge a small piece of clean cotton or waxed dental floss between the skin and the toenail. Be sure to change this packing daily.
Use an over-the-counter pain reliever such as ibuprofen or acetaminophen.
You should start to see improvement within two or three days. If you don't, contact your doctor.

Pathology / Rubins @ Google Books

2009-09-19T11:21:00.000-07:00

Rubins Clinical Pathology

Refractory pharyngitis

2009-09-11T12:00:00.000-07:00

DDx: Strep A, Strep C, Strep G, HIV acute retroviral syndrome, EBV, Lemierre's syndrome

Group C: Can have rising ASO titers, glomerulonephritis, pharyngitis epidemics. PCN usually effective.
Group G: PCN usually effective, some vanc resistance
EBV: anterior and posterior nodes positive; can develop peritonsillar abscess
Lemierre's syndrome: Fusibacterium necrophorum with septic thrombophlebitis of the IJV

USDA DRI Fe

2009-09-11T06:45:00.001-07:00

Daily:
8mg healthy, non-mentruating adult
18mg menstruating female
16mg vegetarians
20mg blood donors

Note: Bone marrow response limited to 20mg per day.

Expect Hgb to improve 1g/dL every 2-3 weeks in compliant patient

FeSO4: 300mg = 60 mg elemental Fe
FeGluconate: 325mg = 36 mg elemental Fe

Add Vit C
Avoid tea/tannins, phytates (bran, cereal), PPI/antacids, H2 blockers

Iron Loss

2009-09-11T06:41:00.000-07:00

Non-menstruating females, males: 1 mg / day
Menstruating females: 10mg or more (42mg per cycle possible)
Pregnancy: 700 mg
Whole blood donation: 250mg

DDx Rosacea

2009-09-08T13:12:00.001-07:00

Acne
SLE
Polymyositis
Sarcoidosis
Photodermatitis
Drug eruption
Granuloma

Evidence Based Diabetes Care: The ABCs of a visit

2009-09-08T13:01:00.000-07:00

A1C: <7.0
BP: <130/80
Chol: LDL<100
D: Diet & exercise
E: Eye @ ophtho
F: Foot exam w/ eyes.
G: GFR>60 or d/c metformin

Tennis Elbow

2009-09-08T11:40:00.000-07:00

Interesting exercise for tennis elbow. Results encouraging:

See NYTimes article:

An Easy Fix for Tennis Elbow

Good advice in general for traveling and food

2009-09-08T11:25:00.000-07:00

Boil it, peel it, cook it or forget it.

Bedbugs

2009-09-08T11:21:00.000-07:00

Two great resources!

A PDF for travelers from Cornell University

What if you've been somewhere there are bedbugs, you're sure of it. How do you keep them away?

From the University of Minnesota, the Beg Bug Exposure Guide

Before you stay in a hotel, Google "Bed Bugs" plus the name of your hotel. Tripadvisor.com often has up-to-date information from recent guests who will not be shy about letting the internet know about infestations.

Allergic Potpouri

2009-08-24T08:22:00.000-07:00

Before giving an injection, say, "Here comes your....." Perhaps, although the patient has already been asked 50 times about medication allergies, when the medication is looming over their arm with something sharp a distantly recalled reaction will be recalled.
Wait 30 minutes after an injection. Most anaphylactic reactions occur within 30 minutes of exposure.
High risk latex patients include: health care workers, rubber industry employees, children with spina bifida or urogenital abnormalities.
All patients with anaphylaxis to Hymenoptera need referral to A&I
Epipen for all! Rx to patients with Hymenoptera allergy (who have not been densensitized), food allergic, latex allergic, idiopathic anaphylaxis, and exercise allergic patients)
Epipen (www.epipen.com) and Twinject (www.twinjecttraining.com) for instruction on use of medication. Don't forget to instruct patient to use lateral thigh.
Written action plan available at www.aaaai.org.
Caution patients to keep Epipen, Twinject out of glove compartment. Heat destabilizes. Also check expiration dates frequently.
Jewelry available at www.medicalert.org
Avoid betablockade in patients with a history of anaphylaxis. ALS are contraindicated for patients on BBlockers (including eye drops).

PO vs. IV ABX

2009-08-24T08:16:00.000-07:00

Most deaths from anaphylaxis to ABX occur when administered parenterally. If there is a question about PCN rxn and ABX must be given parenterally, consider a PO dose first.

Egg Vaccines

2009-08-24T07:58:00.000-07:00

Not safe if patient has anaphylaxis to ingested eggs:
Yellow fever
Influenza (both live and inactivated vax)
Consider skin testing for egg allergy if yellow fever or flu is necessary. For rabies consult allergy. If allergy not available treat, but prepare for analphylaxis.

Safe regardless of history with eggs:
MMR and purified chick embryo rabies

MDD notes

2009-08-17T08:20:00.000-07:00

Lowest rate sexual side effects: bupropion
Highest rate sexual side effects: paroxetine
Suicide attempts most common first 1-2 mos. tx.
Give meds 6-8 weeks to work
Treat 4-9 mos for 1st episode; 2 or more tx years to life.

Crabby Keloids

2009-08-17T07:46:00.000-07:00

Keloid comes from Greek cheloides = Crab's Claws.

Risks:

Dark pigmentation
Familial
Race: Black, Hispanic, Asian
Young (peak 10-20)
Hormonal
Burns

Prevention in the predisposed
Silicone elastomer sheets
CCS injection
Taping

Treatment:

Same as prevention
Cryotherapy for small lesions (caution: hypopigmentation in dark-skin)
Pulsed dye laser

CCS:
Triamcinolone intralesionally plus or minus pretx with cryo
Space tx over several mos.

Sheets:
12-24 hours per day / 2-3 mos after open wound has healed
Pressure dressing alternative esp. burns

Novel:

Imoquimod QO HS for 8 weeks
5 FU
Bleomycin tattoo
Alpha-interferon

Discourage:

Vitamin E: contact dermatitis, impaired tensile strength
Medera

OCD: Did I wash my hands after I took my medication?

2009-08-17T07:37:00.000-07:00

Pharmacotherapy for OCD:

1st line, on-label: fluoxetine (40-60), fluvoxamine (200), paroxetine (40-60), sertraline (200).
1st line, off-label: citalopram (40-60), escitalopram (20)
NNT per Cochrane: 6-12.
Often higher dosages (see target range above). Titrate over 4-6 weeks; treat 8-12 weeks with at least 4-6 weeks at maximal tolerable dosage. May take 10-12 weeks to notice improvement.
Can go higher: monitor for serotonin syndrome (anxiety, tremor, tachycarida, sweating)
Treat 1-2 years. Taper over several months.
2nd line: (after 2 SSRI treatment failures): clomipramine (start at 25mg), venlafaxine, mirtazapine.
Add on therapy: atypical antispychotic including risperidone (most evidence), quetiapine, olanzapine.
Comorbid tics: haloperidone or risperidone.

MRI with Contrast: No thanks, please, my kidneys are failing

2009-08-17T06:18:00.001-07:00

If the river don't rise the way it is supposed to, that is to say, if your GFR is less than 30mg/1.73 m2 (Stage 4-5 CRI) AND you need an MRI with gadolinium you should have hemodialysis right after imaging. The risk is NSF or nephrogenic systemic fibrosis. This is a presky little problem involving thickening of the skin, fibrosis of the dermis and muscle, fascia, lungs, and heart. It's rare (200 cases since January 2008) but boy, if it happens to you? Bad day.