Podcasts about ruq

Contributor: Jorge Chalit-Hernandez, OMS3 Typically presents with biliary colic Right upper quadrant abdominal pain lasting more than 30 minutes and subsiding over several hours Often associated with fatty meals but not always Must rule out other causes of pain Peptic ulcer disease - typically presents with epigastric pain Pancreatitis - pain that radiates to the back or family history of pancreatitis Laboratory workup  LFTs including ALT, AST, and alkaline phosphatase are within the reference range Lipase and amylase within the reference range Imaging workup RUQ ultrasound is unremarkable Upper endoscopy with ultrasound can help rule out peptic ulcer disease and small stones HIDA scan may show a reduced gallbladder ejection fraction below 30-35% or it may be normal  Opiates may give false-positive results Opiates can sometimes make biliary colic worse due to their contractile effect on the sphincter of Oddi Some patients may benefit from surgical intervention i.e. cholecystectomy Classic biliary-type pain (best predictor of response to cholecystectomy) Pain for > 3 months duration Positive HIDA scan References Alhayo S, Eslick GD, Cox MR. Cholescintigraphy may have a role in selecting patients with biliary dyskinesia for cholecystectomy: a systematic review. ANZ J Surg. 2020;90(9):1647-1652. doi:10.1111/ans.16003 Arshi J, Layfield LJ, Esebua M. Mast cell infiltration and activation in the gallbladder wall: Implications for the pathogenesis of functional gallbladder disorder in adult patients. Ann Diagn Pathol. 2021;54:151798. doi:10.1016/j.anndiagpath.2021.151798 Carr JA, Walls J, Bryan LJ, Snider DL. The treatment of gallbladder dyskinesia based upon symptoms: results of a 2-year, prospective, nonrandomized, concurrent cohort study. Surg Laparosc Endosc Percutan Tech. 2009;19(3):222-226. doi:10.1097/SLE.0b013e3181a74690 Joehl RJ, Koch KL, Nahrwold DL. Opioid drugs cause bile duct obstruction during hepatobiliary scans. Am J Surg. 1984;147(1):134-138. doi:10.1016/0002-9610(84)90047-3 Mahid SS, Jafri NS, Brangers BC, Minor KS, Hornung CA, Galandiuk S. Meta-analysis of cholecystectomy in symptomatic patients with positive hepatobiliary iminodiacetic acid scan results without gallstones. Arch Surg. 2009;144(2):180-187. doi:10.1001/archsurg.2008.543 Summarized & Edited by Jorge Chalit, OMS3 Donate: https://emergencymedicalminute.org/donate/  

Contributor: Kiersten Williams MD, Travis Barlock MD, Jeffrey Olson MS2 Show Pearls Hypertensive disorders of pregnancy are one of the leading causes of maternal mortality worldwide. Hypertension (HTN) complicates 2-8% of pregnancies The definition of HTN in pregnancy is a systolic >140 or diastolic >90, measured 4 hours apart There is a range of HTN disorders Chronic HTN which could have superimposed preeclampsia (preE) on top Gestational HTN in which there are no lab abnormalities PreE w/o severe features Protein in urine Urine protein >300 mg in 24 hours Urine Protein to Creatinine ratio of .3 +2 Protein on urine dipstick PreE w/ severe features Systolics above 160 mmHg Diastolics above 110 mmHg Headache, especially not going away with meds, or different than previous headaches Visual changes, anything that lasts more than a few minutes RUQ pain, which could present as heartburn Pulmonary edema Low platelets, if

You get called to see a consult in the middle of the night. It is a middle-aged woman with a bariatric history, and she says her stomach is smaller but doesn't know the name of the operation. She developed worsening abdominal pain after dinner and it's been getting worse. She's not peritonitic, but she's clearly in discomfort. Is it cholecystitis, diverticulitis, pancreatitis, marginal ulcer, or an internal hernia? What do you do? Join Drs. Matthew Martin, Adrian Dan, and Paul Wisniowski on a discussion about initial evaluation and management of bariatric patients with internal hernias.  Show Hosts: Matthew Martin Adrian Dan Paul Wisniowski Show Notes 1.     Initial Evaluation a.     Focused history and physical, labs, and imaging                                       i.     Presenting symptoms may vary and include: nausea, emesis, and abdominal pain ranging from vague to severe.                                        ii.     A basic lab panel can aid in developing the diagnosis and guide resuscitation.                                     iii.     CT of the abdomen and pelvis with IV and oral contrast can assist in identifying intra-abdominal pathology                                     iv.     Reviewing the previous operative report is beneficial to have a framework of the anatomy, i.e. type of bariatric surgery, and configuration of small bowel limbs (ante- vs retro-gastric and ante- vs retro-colic). 1.     According to a 2019 study, 40-60% of closed defects had reopened at time of re-exploration                                       v.     If the patient is peritonitic with abdominal pain, they should be treated similarly to any patient with an acute abdomen with emergent exploration. b.     CT Imaging                                        i.     A mesenteric swirl sign with twisting of the soft tissue and mesenteric vessels with surrounding fat attenuation has been shown to have a sensitivity of 78-100% and specificity of 80-90%. Other findings include: a Bird's beak, dilation of roux or biliopancreatic limbs, SMV narrowing, and displacement of JJ limb to the RUQ and can be used to support the diagnosis of internal hernia                                      ii.     An experienced radiologist familiar with bariatric anatomy has been shown to have a positive predictive value to 81% and negative predictive value to 96% at radiologically diagnosing internal hernia.                                      iii.     A CT scan can provide insight for a suspected diagnosis but it cannot rule out internal hernia c.      Nasogastric/Esophageal Tube                                       i.     Use judiciously based on patient's presenting symptoms                                      ii.     Placement should be done by the surgical team                                      iii.     This may mitigate the risk of aspiration during intubation. 2.     Operative Management a.     Entry should be dependent on the comfort of the operating surgeon.                                        i.     Veress entry into the abdomen with dilated bowels may lead to increased injuries.                                       ii.     Optiview allows for direct visualization of each layer of the abdominal wall. Focusing on twisting the trochar and limiting perpendicular pressure.                                      iii.     Hasson entry also allows for direct visualization but may be limiting in bariatric patients with thick abdominal walls b.     Exploration – a systematic approach                                       i.     Start with evaluation of the gastric pouch and run the roux limb to the jejunojejunostomy, and examine Petersen's and mesojejunal defects.                                       ii.     Follow the biliopancreatic limb to the ligament of Treitz                                     iii.     Lastly, identify the terminal ileum at the sail of Treves and run backwards to the jejunojejunostomy                                     iv.     This will allow for examination of all possible defect and possible intussusception at the jejunostomy c.      Defect Management                                       i.     All defects should be closed, with studies demonstrating reduced rates of internal hernia when defects are closed with a running suture. There is no strong evidence to support the use of a specific suture material. 1.     The use of suture is superior to other methods of closure such as metallic clips, fibrin glue, mesh, or abrasive pads. 2.     A barbed suture can be considered. d.     In a patient with unfavorable anatomy or those unable to tolerate pneumoperitoneum surgeons should consider early conversion to open exploration  3.     Postoperative Care a.     Patients are started on ERAS protocol with limited narcotic use, same day mobilization, early oral nutrition with advancement, and no nasogastric tubes or foley catheters b.     Patients with bowel resection and those with suspected postoperative ileus may benefit from judicious advancement of diet. 4.     Pregnancy a.     Pregnant patients with history of anastomotic bariatric surgery are at increased risk of internal hernia especially in 3rd trimester due to loss of intra-abdominal space b.     Evaluation of a pregnant patient should include abdominal imaging.                                        i.     In a non-acute setting, an MRI abd/pelvis can be considered.                                       ii.     Patients with abdominal pain presenting to the Emergency Department should undergo CT imaging.                                     iii.     The risk of radiation to a fetus, especially beyond the 1st trimester, is limited. Based on the CDC guidelines, a human embryo and fetus are sensitive to ionizing radiation at doses greater than 0.1Gray. The amount of radiation from a typical CT range from 0.015 to 0.034Gray depending if it is multiphasic or not; well below the guideline level. c.      It is important to discuss with women of child bearing age the risk of internal hernia during pregnancy with anastomotic bariatric surgery 5.     Outpatient Presentation a.     Half of patients with internal hernia will present in outpatient setting often >6 months after initial operation with complaints of intermittent nausea, vomiting, and abdominal pain b.     Workup includes: CT abd/pelvis with IV and oral contrast, Upper GI series, EGD, and a RUQ ultrasound based on their symptoms c.      If diagnostic testing is equivocal, proceed with diagnostic laparoscopy to mitigate the risk of internal hernia with bowel ischemia. **Introducing Behind the Knife's Trauma Surgery Video Atlas - https://app.behindtheknife.org/premium/trauma-surgery-video-atlas/show-content The Trauma Surgery Video Atlas contains 24 scenarios that include never-before-seen high-definition operative footage, rich, original illustrations, and practical, easy-to-read pearls that will help you dominate the most difficult trauma scenarios. Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.   If you liked this episode, check out more recent episodes here: https://app.behindtheknife.org/listen

Mini episode- High-yield over view of Management of Acetaminophen Poisoning in the US and Canada Consensus Statement In this Ryan sits down with Dr. Richard Dart MD, PhD. He is the lead author of the recently released "Management of Acetaminophen Poisoning in the US and Canada Consensus Statement" from the American Academy of Clinical Toxicology, American College of Medical Toxicology, Americans Poisons Centers, and the Canadian Association of Poison Centers. Listen to be informed on the most recent treatment recommendations.  They dive in to the definitions established by the guideline and notable treatment recommendations, dissecting the ratinonale for each desiscion point and how to apply the guidelines. A mini episode was released along side this episode that is a high yield review of major treatment recommendations and definitions estabilished by the consensus statement.  Links :Mini episode- High-yield over view of Management of Acetaminophen Poisoning in the US and Canada Consensus Statement Guidelines https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2808062Definitions made by the guidelineAcute ingestionAny overdose taken with 24 hours periodOverdose "dose" not defined>7.5 g in 24 h was criteria for Rumack Matthew nomogramConsensus statementAdult overdose at 10g/d or 200 mg/kg/d in 48 hours) AND signs of APAP toxicity (vomiting, RUQ abd pain, AMS)Treat if APAP >20 ug/ml OR AST/ALT elevatedAcuteNon-detectable [APAP] between 2 and 4 hours excludes ingestionGive SDAC w/in 4 hours (something I've been a proponent of since ATOM2)TreatStart treatment with NAC if unable to plot on nomogram by 8 hoursNAC dose“Higher dose” NAC (undefined) for high risk ingestionMinimum NAC regimen should include 300 mg/kg orally or within 20-24 hoursCAP NAC dose at 100 kg (this was known with PO, but IV there was always some question since it delivers less overall)Unique scenariosLine crossersAPAP with anticholinergic or opioidIf 1st  concentration below treatment line repeat in 4-6 hoursAPAP Extended releaseIf 1st  concentration below treatment line @ 4-12 hours, repeat in 4-6 hoursDialysis-Dialyze If APAP >900 w/ AMS or acidosis.NAC IV rate during HD 12.5 mg/kg/hr minimum. No dose change for PO (not new but good reminders)Consult liver transplant for rapid AST/ALT inc w/ coagulopathy, AMS, or mulistytem organ failureThe addition of fomepizole to acetylcysteine in the treatment of serious acetaminophen ingestions has been proposed. The panel concluded that the data available did not support a standard recommendation. As for any complicated or serious acetaminophen poisoning, a PC or clinical toxicologist should be consulted.

This episode is a a high yield "just the facts" break down of the recently released "Management of Acetaminophen Poisoning in the US and Canada Consensus Statement" from the American Academy of Clinical Toxicology, American College of Medical Toxicology, Americans Poisons Centers, and the Canadian Association of Poison Centers. Listen to be informed on the most recent treatment recommendations. This was released alongside a full interview with the consensus statement corresponding author Dr. Richard Dart MD, PhD. Be sure to check out the full interview to hear it straight from the source! (link in show notes).Link to the guidelines:Full interview with consensus statement author Dr. Richard Darthttps://jamanetwork.com/journals/jamanetworkopen/fullarticle/2808062Definitions made by the guidelineAcute ingestion>7.5 g in 24 h per Rummack Matthew initial studies10 g/d or 200 mg/kg/day in 48 hHigh risk ingestionReported dose >30 grams OR[APAP] 2 x Rummack-Matthew nomogram treatment lineNAC stopping criteriaAPAP4 g x >48 hours) AND signs of APAP toxicity (vomiting, RUQ abd pain, AMS)Treat if APAP >20 ug/ml OR AST/ALT elevatedAcuteNon-detectable [APAP] between 2 and 4 hours excludes ingestionGive SDAC w/in 4 hours (something I've been a proponent of since ATOM2)Start treatment with NAC if unable to plot on nomogram by 8 hoursNAC dose“Higher dose” NAC (undefined) for high risk ingestionMinimum NAC regimen should include 300 mg/kg orally or within 20-24 hoursCAP NAC dose at 100 kg (this was known with PO, but IV there was always some question since it delivers less overall)Unique scenariosLine crossersAPAP with anticholinergic or opioidIf 1st  concentration below treatment line repeat in 4-6 hoursAPAP Extended releaseIf 1st  concentration below treatment line @ 4-12 hours, repeat in 4-6 hoursDialysis-Dialyze If APAP >900 w/ AMS or acidosis.NAC IV rate during HD 12.5 mg/kg/hr minimum. No dose change for PO (not new but good reminders)Consult liver transplant for rapid AST/ALT inc w/ coagulopathy, AMS, or mulistytem organ failureThe addition of fomepizole to acetylcysteine in the treatment of serious acetaminophen ingestions has been proposed. The panel concluded that the data available did not support a standard recommendation. As for any complicated or serious acetaminophen poisoning, a PC or clinical toxicologist should be consulted.

Dr. Navin Kumar, an attending Gastroenterologist at Brigham and Women's Hospital, medical educator at Harvard Medical School, and co-founder of the Run the List podcast and host Blake Smith discuss how to approach a patient presenting with acute right-upper quadrant (RUQ) pain. Together, they discuss the various causes of RUQ pain, in addition to how to approach a set of liver function tests (LFTs), differentiating hepatocellular injury from a cholestatic pattern. They then discuss how various forms of imaging (RUQUS, CT) can guide diagnosis and management, leading to a discussion about the use of ERCP and cholecystectomy in such cases. Lastly, the episode closes with a diagnosis and three clinical pearls about RUQ pain and abnormal LFTs.

Pratik presents a case of dyspnea and RUQ pain to Fred.   Fred McLafferty Fred McLafferty, MD is a fellow in the Division of Pulmonary and Critical Care at the University of California, San Francisco.  His research interest is in how certain environmental particles and pathogens drive lung remodeling and pulmonary fibrosis.  He is clinically… Read More »Episode 246: Clinical Unknown with Fred, Pratik, and Simone

Show Notes: PID is often missed because the exam can be unimpressive. Remember more than 50 percent of men and more than 80 percent of women have no symptoms with chlamydia, so if you use your logical brain, it follows many cases are mild. In terms of risk, remember that PID is not always an STI; it is caused by vaginal flora in about 15 percent of cases. Fitz-Hugh-Curtis (FHC) is also often missed, and you are probably missing it if you are not diagnosing about one case a year. The classic case is pleuritic RUQ pain in a sexually active woman, normal LFTs, elevated D-dimer, and normal CT angiograph of the chest. If it is from chlamydia, patients almost never have pelvic symptoms. Incubation is usually about three weeks. Do a sexual history. If there is a new partner, consider FHC even if the pain is nonpleuritic. Gallstones can be a red herring.

Episode 89: Gonorrhea Basics. Written by Robert BensacenezRobert, Dr. Schlaerth, and Dr. Arreaza discuss the basics of gonorrhea, including presentation, treatment, and even a potential gonococcal vaccine.Introduction: Gonorrhea is commonly known as “the clap” or “the drip”. This ancient disease, described as “the perilous infirmity of burning” in a book called The History of Prostitution, has been treated with many remedies throughout history, including mercury, sulfur, silver, multiple plants, and even gold. Today we will discuss the clinical features, diagnosis, and current therapy of gonorrhea. By the way, did you know that gonorrhea in Spanish is used as an insult in Colombia? Well, now you know it. Definition: Gonorrhea is a sexually transmitted disease caused by the bacterium Neisseria gonorrhoeae (common name gonococcus), which is a gram-negative, intracellular, aerobic, diplococci. This disease leads to genitourinary tract infections such as urethritis, cervicitis, pelvic inflammatory disease (PID), and epididymitis. This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it's sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. ___________________________Gonorrhea. Written by Robert Besancenez, MS4, Ross University School of Medicine. Moderated and edited by Hector Arreaza, MD. Discussion participation by Katherine Schlaerth, MD. Epidemiology: The disease primarily affects individuals between 15–24 years of age (half of the STI patients in the US). CDC estimates that approximately 1.6 million new gonococcal infections occurred in 2018. Incidence rates are highest among African Americans, American Indians, and Hispanic populations.Transmission is sexual (oral, genital, or anal) or perinatal (causing gonococcal conjunctivitis in neonates). Risk factors include unsafe sexual behaviors (lack of barrier protection, multiple partners, men who have sex with men (MSM), and asplenia, complement deficiencies. Individuals with low socioeconomic status are at the highest risk: poor access to medical treatment and screening, poor education, substance use, and sex work. Presentation: The incubation period is ~ 2–7 days, and sometimes patients do not develop any symptoms. Urogenital infection: Gonorrhea is commonly asymptomatic, especially in women, which increases the chance of further spreading and complications. When symptoms are present, typical symptoms include purulent vaginal or urethral discharge (purulent, yellow-green, possibly blood-tinged). Discharge is less common in female patients. Urinary symptoms include dysuria, urinary frequency, and urgency. Male: - Typical presentation is urethritis. - Penile shaft edema without other signs of inflammation.- Epididymitis: unilateral scrotal fullness sensation, scrotal swelling, redness, tenderness, relief of pain with elevation of scrotum —Prehn Sign— and positive cremasteric reflex.- Robert: Prostatitis: fever, chills, general malaise, pelvic or perineal pain, cloudy urine, prostate tenderness (examine prostate gently). Female: - Cervicitis: Friable cervix and discharge (purulent, yellow, malodorous), - PID: pelvic or lower abdominal pain, dyspareunia, fever, cervical discharge, cervical motion tenderness but also uterine or adnexal tenderness, abnormal intermenstrual bleeding. PID can be subclinical and diagnosed retroactively when tubal occlusion is discovered as part of a workup for infertility. PID can cause Fitz-Hugh-Curtis syndrome (perihepatitis with RUQ pain).- Bartholinitis presents with introitus pain, edema, and discharge from the labia. - Vulvovaginitis may occur but is rare (due to the tissue preference of gonococci)Extragenital infection: Proctitis: Rectal purulent discharge, possible anorectal bleeding and pain, rectal mucosa inflammation, or rectal abscess (less common).Pharyngitis: sore throat, pharyngeal exudate, cervical lymphadenitis.  Disseminated gonococcal infection (DGI): Triad of arthritis, pustular skin lesions, and tenosynovitis.  As mentioned in Episode 46, on December 23, 2020, the California Department of Public Health (CDPH) sent a “Dear Colleague” letter to warn the medical community about the increased cases of DGI in California and Michigan. Increased cases may be caused by decreased STD testing and treatment because of the COVID-19 pandemic, and not necessarily because of a more virulent strain of gonorrhea. Later, treatment of gonorrhea was updated because of resistance.  Epidemiology: ∼ 2% of cases. Most common in individuals younger than 40 years old, the female to male ratio is 4:1. A history of recent symptomatic genital infection is uncommon. Asymptomatic infections increase the risk of dissemination due to delayed diagnosis and treatment. Clinical features: Two distinct clinical presentations are possible. Arthritis-dermatitis syndrome:Polyarthralgias: migratory, asymmetric arthritis that may become purulent.Tenosynovitis: simultaneous inflammation of several tendons (e.g. fingers, toes, wrist, ankle).Dermatitis: vesicular, pustular, or maculopapular lesions, possibly with a necrotic or hemorrhagic center.  Most commonly distributed on the trunk, extremities (sometimes involving the palms and soles). Typically, < 10 lesions with a transient course (subside in 3–4 days). Additional manifestations: fever and chills (especially in the acute phase). Purulent gonococcal arthritis: Abrupt inflammation in up to 4 joints (commonly knees, ankles, and wrists). No skin manifestations, rarely tenosynovitis. Genitourinary manifestations in only 25% of affected individuals. Not to be confused with reactive arthritis.  Health care providers living in California: Order Nucleic acid amplification test (NAAT) and culture specimens from urogenital, extragenital mucosal sites (e.g., pharyngeal and rectal), and from disseminated sites (e.g., skin, synovial fluid, blood, and cerebrospinal fluid) before initiating empiric antimicrobial treatment for patients with suspected DGI. Report within 24 hours of diagnosis to the California Department of Public Health. Complications of DGI: sepsis with endocarditis, meningitis, osteomyelitis, or pneumonia. Diagnosis of gonorrhea: The test of choice is Nucleic acid amplification testing (NAAT) of first-catch urine or swabs of urethra, endocervix and pharynx, and synovial fluid in disseminated infection. Other possible tests: gram stains and bacterial cultures (Thayer-Martin agar, useful for antibiotic resistance, results may take 48 hours, sensitivity is lower than NAAT.)Synovial fluid analysis: Appearance of fluid can be clear or cloudy (purulent), high Leukocyte count (up to 50,000 cells/mm3): especially segmented neutrophils, gram stain positive in < 25% of cases. Treatment: Ceftriaxone and doxycycline for uncomplicated cases, but may require different approaches in case of allergies or intolerance to these antibiotics, or in severe cases.  Uncomplicated gonorrhea (affecting cervix, urethra, rectum, pharynx)First-line treatment: single-dose ceftriaxone 500 mg IM (1 G for patients >150 Kg) PLUS doxycycline 100 mg PO twice a day for 7 days If a chlamydial infection has not been excluded.During pregnancy: Ceftriaxone PLUS single-dose azithromycin 1 gram PO(doxy is contraindicated – teratogen) Complicated gonorrhea (salpingitis, adnexitis, PID/ epididymitis, orchitis)Single-dose ceftriaxone IM PLUS doxycycline PO for 10–14 days  (women may require additional administration of Metronidazole PO for 14 days).  DGICeftriaxone IV every 24 hours for 7 days In case Chlamydia infection has not been ruled out: PLUS doxycycline PO twice a day for 7 daysDrainage of purulent joint(s) Sequelae: Without treatment, a prolonged infection may lead to complications, such as hymenal and tubal synechiae that lead to infertility in women. Prevention:-Screening for gonorrhea (USPSTF recommendations, September 2021, Grade B): Annual NAAT screening of gonorrhea AND chlamydia for sexually active women ≤ 24 years (including pregnant persons) or > 25 years with risk factors (e.g. new or multiple sex partners, sex partner with an STI, etc.). Evaluate for other STIs if positive (e.g. chlamydia, syphilis, and HIV).  There is insufficient evidence to recommend for or against screening gonorrhea in asymptomatic males (Grade I).In all patients: Evaluate and treat the patient's sexual partners from the past 60 days. Provide expedited partner therapy if the timely evaluation of sexual partners is not feasible. Single-dose cefixime PO (if chlamydia has been excluded in the patient) OR Single-dose cefixime PO PLUS doxycycline PO for 7 days. Sexual partners must be treated simultaneously to avoid reinfections. A possible gonococcal vaccine: A gonococcal vaccine is theoretically possible, let's remember that the meningococcal vaccine exists. Meningococcus is closely related to gonococcus. A study published in 2017 showed that MeNZB® (a vaccine used in New Zealand until 2011 to fight against a meningitis epidemic) provided partial protection against gonorrhea. Food for thought for you guys. Conclusion: Let's remember to screen asymptomatic women for gonorrhea, identify symptomatic patients and start treatment promptly, and prevent serious complications, and more importantly, let's promote safe sex practices to prevent this disease.Now we conclude our episode number 89 “Gonorrhea Basics”. Gonorrhea affects mainly the urogenital area, but it can spread to the pharynx, rectum, skin, and even joints. When you see septic arthritis in patients with high risk for gonorrhea, suspect disseminated gonococcal infection and start treatment promptly. Even without trying, every night you go to bed being a little wiser.Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. This podcast was created for educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Robert Besancenez, and Katherine Schlaerth. Audio edition: Suraj Amrutia. See you next week! _____________________References:Seña, Arlene C, MD, MPH; and Myron S Cohen, MD.  Treatment of uncomplicated Neisseria gonorrhoeae infections, UpToDate, updated on Jan 27, 2022. Accessed on April 5, 2022. https://www.uptodate.com/contents/treatment-of-uncomplicated-neisseria-gonorrhoeae-infections Ghanem, Khalil G, MD, PhD. Clinical manifestations and diagnosis of Neisseria gonorrhoeae infection in adults and adolescents, UpToDate, updated on Sep 17, 2021, accessed on April 5, 2022. https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-neisseria-gonorrhoeae-infection-in-adults-and-adolescents Klausner, Jeffrey D, MD, MPH. Disseminated gonococcal infection, UpToDate, updated on March 3, 2022. Accessed on April 5, 2022. https://www.uptodate.com/contents/disseminated-gonococcal-infection Petousis-Harris H, Paynter J, Morgan J, et al. Effectiveness of a group B OMV meningococcal vaccine on gonorrhea in New Zealand – a case control study. Abstract presented at: 20th International Pathogenic Neisseria Conference. Manchester, UK; 2016. 

Aujourd'hui je discute avec l'ami Sylvain Grenier. Sylvain c'est le pionnier de l'ultra cyclisme au Quebec. Il s'occupe de ces affaires là depuis minimum 2014 et depuis mène sa barque paisiblement, entre vélo de route, fatbike dans la neige, troubles de l'attention et l'organisation de 14 épreuves. Et détail intéressant, Sylvain a instauré quelques règles originales dans ses épreuves, comme les temps de repos obligatoires ou le classement sans catégorie de genre. Un épisode qui sent bon la Poutine et le pogos. Voir le RUQ : https://www.facebook.com/ultracyclismeSpotzle : https://spotzle.ccSur Instagram : https://www.instagram.com/spotzle/#bikepacking #quebec #ultracycling Voir Acast.com/privacy pour les informations sur la vie privée et l'opt-out.

Intrahepatic Cholestasis of Pregnancy (ICP).Amel and Dr Wonderly discuss the signs, symptoms, and management of ICP. A reminder for alcohol use disorder screening.Introduction: Screening for alcohol use disorder. Written by Hector Arreaza, MD. Reviewed by Jacqueline Uy, MD. Today is December 3, 2021.Substance misuse occurs in about 20% of patients seen in primary care settings. For example, alcohol-related disorders are present in up to 26% of general clinic patients, “a prevalence rate similar to those for such other chronic diseases as hypertension and diabetes”[1]. The USPSTF recommends screening for unhealthy alcohol use in adults 18 years or older, including pregnant women, and provide those engaged in risky drinking with brief behavioral counseling to reduce alcohol use (this is a Grade B recommendation). This brief introduction is to encourage everyone to screen adults for alcohol use disorder. Let's start with the basics.  It is important to know the size of a standard drink so you can counsel your patients appropriately. According to the CDC, a standard drink is equal to 14 grams (0.6 ounces) of pure alcohol. Generally, this amount of pure alcohol is found in:12 ounces of beer (5% alcohol content).8 ounces of malt liquor (7% alcohol content).5 ounces of wine (12% alcohol content).1.5 ounces or a “shot” of 80-proof (40% alcohol content) distilled spirits or liquor (such as gin, rum, vodka, whiskey).Moderate alcohol drinking means 2 drinks or less in a day for men and 1 drink or less in a day for women. Binge drinking means drinking enough to bring your blood alcohol concentration (BAC) level to 0.08% or more. This may be different in each patient, as humans metabolize alcohol differently, but usually it corresponds to 5 or more drinks on a single occasion for men or 4 or more drinks on a single occasion for women, generally within about 2 hours[2]. A good approach to screen for alcohol use disorder is by asking: “Do you sometimes drink alcoholic beverages?”, and then the single screening question, “How many times in the past year have you had 5 or more drinks (men) OR 4 or more drinks (women) in a day?”[3]  The screening is considered positive if the patient answers one or more times a year. If positive, then you may continue your assessment with another tool such as AUDIT. This can be a topic for a whole episode.  For now, we just want to remind you to screen your patients for alcohol use because the prevalence is very high and we as primary care physicians can make a big difference in the prevention and treatment of alcohol misuse in our communities.  This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it's sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. Intrahepatic Cholestasis of Pregnancy (ICP). Written by Amel Tabet, MS3, American university of the Caribbean. Discussion with Sally Wonderly, MD; and Hector Arreaza, MD.What is Intrahepatic Cholestasis of Pregnancy and why does it matter?As its name implies, Intrahepatic Cholestasis of Pregnancy (ICP) is a multifactorial liver dysfunction in some pregnant women that occurs during their either second or third trimester of pregnancy and resolves spontaneously after parturition. It is defined by the presence of pruritus -- previously called pruritus gravidarum or recurrent jaundice of pregnancy-- and abnormally elevated serum bile acid levels and mildly increased hepatic aminotransferase levels, in the absence of diseases that may yield similar laboratory findings and symptoms. Key symptoms are pruritus, high bile acid and high transaminases. How common is ICP?In the US incidence ranges from 0.32 percent to 5.6 percent, depending on the area. The Los Angeles area has a high incidence compared to other areas in the US. The highest rates in Europe are in Scandinavia. It is very frequent in Chile (South America). The indigenous people known as Araucanos have the highest incidence worldwide at 27.6 percent.PathogenesisThe pathogenesis of ICP remains unclear. It is mainly attributed to changes in various sex steroid levels but more recent research points towards an etiology that relates to various mutations in the many genes involved in the control of the hepatocellular transport systems such as the ABCB4 gene, which encodes multidrug resistance protein 3 (MDR3) linked to progressive familial intrahepatic cholestasis, errors of the ABCB11 gene that encodes for the bile salt export pump, and more recently on FXR/NR1H4 and PXR/NR1I2 genes that encode for proteins that critically regulate bile acid synthesis and transport, and the transcription of ABCB11 in humans and the role of epigenetics influence by means of methylation of these genes. Dangers for mother: Beside the discomfort of pruritus, ICP is transient and of little maternal risk generally. The mother may be uncomfortable but it's not fatal. Danger to fetus: The elevated bile acids enter the fetal circulation because it crosses the placenta. Bile acids cause major fetal and neonatal complications, such as abnormal intrapartum fetal heart rate and meconium-stained amniotic fluid that can lead to fetal distress and prematurity or intrauterine demise and to neonatal respiratory distress syndrome associated with bile acids entering the lungs. Who is at risk for ICP?Multifetal pregnancies.Genetics: There is also a significant genetic influence that leads to variability of incidence by population. In North America, cholestasis is infrequent with an overall incidence approximating 1 case in 500 to 1000 pregnancies. Whereas its rate is high in indigenous women from Chile and Bolivia and nears 5.6 % among Hispanic women in Los Angeles. In other countries, for example Sweden, China, and Israel, the incidence varies from 0.25 to 1.5 %.Diet and environment can also have an influence. Research has shown an association of ICP with environmental and dietary factors such as seasonal changes of mineral dietary components and with gut-derived endotoxins subsequent to increased gastrointestinal permeability. This complex nature-nurture interaction suggests that ICP is strongly modulated by epigenetic mechanisms.Liver disease: Women with preexisting liver disease are at risk. Other risks include in vitro fertilization, cholelithiasis, advanced maternal age, and Hepatitis C and fatty liver disease.  History of ICP is an important risk, because it also recurs during subsequent pregnancies in 60 to 70 % of patients. Signs and symptoms:The main clinical presentation is an often-generalized pruritus in late second or third trimester, that usually starts and predominates on the palms and soles and is worse at night. It could range from mild to intolerable pruritus that may precede laboratory findings by several weeks and evidenced by possible presence of scratch marks and excoriations on physical examination. Jaundice arises in 14 to 25 % of patients and it typically develops 1 to 4 weeks after the onset of itching. Other accompanying symptoms may also occur such as nausea, RUQ pain, steatorrhea, poor appetite and sleep deprivation. Other signs include dark urine, pale stools. Diagnosis:To establish a diagnosis, careful history taking, physical examination, and laboratory evaluation are performed. Thus, in the absence of any other liver disease, ICP is diagnosed by the presence of pruritus that is associated with elevated total serum bile acid levels, elevated aminotransferases (seldom exceed 250 U/L), hyperbilirubinemia (4 to 5 mg/dL) and elevated alkaline phosphatase. In severe cases that account for 20%, cholestasis manifests as bile acids levels > 40 micromol/L.Differential diagnosis include: Preeclamptic liver disease, which is ruled out if blood pressure elevation or proteinuria are absent and cholelithiasis and biliary obstruction are excluded by sonography. Moreover, because of mild transaminitis in case of ICP, acute viral hepatitis is an improbable diagnosis. Liver biopsy is generally not needed. Even though not necessary for diagnosis, liver biopsy for research purposes, showed occurrence of changes with presence of cholestasis with bile plugs in the hepatocytes and canaliculi of the centrilobular regions, without inflammation or necrosis. These changes were found to fade after delivery with recurrence in successive pregnancies or with estrogen-containing contraceptives.Management:Management focuses mainly on reducing maternal discomfort due to pruritus and prevention of more serious fetal outcomes and reduce the risks of prenatal morbidity and mortality. For patients that have persistent clinical findings consistent with ICP without any biochemical evidence of ICP, we only treat with antihistamines and topical emollients such as calamine lotion and we perform a weekly evaluation of maternal total serum bile acid (TSBA) level.  In symptomatic patients with positive biochemical evidence of ICP we treat with ursodeoxycholic acid (UDCA) 300 mg BID or TID until delivery. UDCA was found in clinical trials to relieve pruritus, lower bile acid and serum enzyme levels, and to reduce preterm birth, fetal distress, respiratory distress syndrome, and neonatal intensive care unit admission. Along with treatment, we continue the weekly evaluation of the TSBA level with a warranted earlier delivery if TSBA ≥100 micromol/L and the related high risk of stillbirth.  Thus, delivery management is mainly based on the highest TSBA level at any time during pregnancy. If TSBA level is

Welcome to PICU Doc On Call, A Podcast Dedicated to Current and Aspiring Intensivists. I'm Pradip Kamat and I'm Rahul Damania. We are coming to you from Children's Healthcare of Atlanta - Emory University School of Medicine. Welcome to our Episode of 17-year old with h/o of SLE and now acute liver failure. Here's the case presented by Rahul: A 17-year old teenage female year old presents to the PICU with acute liver failure. Important past h/o includes a diagnosis of SLE on therapy with prednisone, mycophenolate (cellcept), and plaquenil. 4 days prior to this admission, patient presented to an OSH with RUQ pain, vomiting (non bloody & no bilious), fever & malaise. Initially due to concern for "lupus Flare" patient was given steroids at the OSH. At the OSH notable initial labs included a mild transaminitis and an INR of 1.5. She suddenly at the OSH developed fluid refractory hypotension and was started on a pressor. Due to continued worsening of her transaminitis well as a rising INR on her repeat labs she was referred to our tertiary PICU for further management. Pertinent history also includes a negative urine pregnancy test. No recreational drug use, and only as needed use of Tylenol. She now is in the PICU. She generally appears tired and ill. She is tachypneic on 4 LPM of nasal canulla and her oxygen saturation is 98%. She has a non-focal lung exam. Her cardiac exam is notable for tachycardia, and pertinently no gallop, rub or murmur. Her abdominal exam is non-focal except for mild discomfort on palpation of the RUQ with a palpable liver edge. Her extremities are cool with 3-4 capillary refill time. She is able to answer questions but intermittently doses off. No rash is noted. To summarize key elements from this case, this patient has: H/o of lupus and is on immunosuppressive medications New onset fever/malaise This sounds like a LUPUS flare as she has a clinical picture of generalized inflammation. Rahul: Lets pause right here and take a look at key history and physical exam components in a patient who has a chronic auto-immune condition: Fever, malaise and feeling tired all signs of constitutional symptoms. She has abdominal pain and vomiting that could again be related to systemic inflammation but also an intra-hepatic lesion. Are there some red-flag symptoms or physical exam components which you could highlight? This patient has signs of shock! Tachycardia with delayed cap refill and cool extremities Tachypnea & hepatomegaly which could indicate increased central venous pressures. Initially her outside presentation of fluid refractory shock is of utmost concern! Fluid refractory shock with multi organ presentation involving liver, kidney and the blood/coagulation systems All of these elements bring up a concern for some acute life threatening process such as sepsis, or even immune dys-regulation due to her h/o of Lupus To continue with our case, the patients labs were consistent with:Acute liver dysfunction (Elevated AST and ALT in the thousands, Total bilirubin 1.6, GGT 56) although the total bilirubin is not elevated to a degree I would expect. AKI (creatinine 2.18) An uptrending Coagulopathy with elevated PT and INR: PT 120 and a peak INR of 16 Thrombocytopenia: Platelets < 50K She had a peak lactate 9.2 and concurrent Metabolic acidemia: serum HCO3 7, and pH 7.18. A Pertinent negative: Normal serum ammonia

Welcome to PICU Doc On Call, A Podcast Dedicated to Current and Aspiring Intensivists. I'm Pradip Kamat and I'm Rahul Damania. We are coming to you from Children's Healthcare of Atlanta - Emory University School of Medicine. Welcome to our Episode of 17-year old with h/o of SLE and now acute liver failure. Here's the case presented by Rahul: A 17-year old teenage female year old presents to the PICU with acute liver failure. Important past h/o includes a diagnosis of SLE on therapy with prednisone, mycophenolate (cellcept), and plaquenil. 4 days prior to this admission, patient presented to an OSH with RUQ pain, vomiting (non bloody & no bilious), fever & malaise. Initially due to concern for "lupus Flare" patient was given steroids at the OSH. At the OSH notable initial labs included a mild transaminitis and an INR of 1.5. She suddenly at the OSH developed fluid refractory hypotension and was started on a pressor. Due to continued worsening of her transaminitis well as a rising INR on her repeat labs she was referred to our tertiary PICU for further management. Pertinent history also includes a negative urine pregnancy test. No recreational drug use, and only as needed use of Tylenol. She now is in the PICU. She generally appears tired and ill. She is tachypneic on 4 LPM of nasal canulla and her oxygen saturation is 98%. She has a non-focal lung exam. Her cardiac exam is notable for tachycardia, and pertinently no gallop, rub or murmur. Her abdominal exam is non-focal except for mild discomfort on palpation of the RUQ with a palpable liver edge. Her extremities are cool with 3-4 capillary refill time. She is able to answer questions but intermittently doses off. No rash is noted. To summarize key elements from this case, this patient has: H/o of lupus and is on immunosuppressive medications New onset fever/malaise This sounds like a LUPUS flare as she has a clinical picture of generalized inflammation. Rahul: Lets pause right here and take a look at key history and physical exam components in a patient who has a chronic auto-immune condition: Fever, malaise and feeling tired all signs of constitutional symptoms. She has abdominal pain and vomiting that could again be related to systemic inflammation but also an intro-hepatic lesion. Are there some red-flag symptoms or physical exam components which you could highlight? This patient has signs of shock! Tachycardia with delayed cap refill and cool extremities Tachypnea & hepatomegaly which could indicate increased central venous pressures. Initially her outside presentation of fluid refractory shock is of utmost concern! Fluid refractory shock with multi organ presentation involving liver, kidney and the blood/coagulation systems All of these elements bring up a concern for some acute life threatening process such as sepsis, or even immune dys-regulation due to her h/o of Lupu To continue with our case, the patients labs were consistent with: Acute liver dysfunction (Elevated AST and ALT in the thousands, Total bilirubin 1.6, GGT 56) although the total bilirubin is not elevated to a degree I would expect. AKI (creatinine 2.18) An uptrending Coagulopathy with elevated PT and INR: PT 120 and a peak INR of 16 Thrombocytopenia: Platelets < 50K She had a peak lactate 9.2 and concurrent Metabolic acidemia: serum HCO3 7, and pH 7.18. A Pertinent negative: Normal serum ammonia

Welcome to PICU Doc On Call, A Podcast Dedicated to Current and Aspiring Intensivists. I'm Pradip Kamat and I'm Rahul Damania and we are coming to you from Children's Healthcare of Atlanta - Emory University School of Medicine. Welcome to our PICU Doc On Call Mini-Case series. In this episode, we present a 15 year old girl who is admitted for shock after returning from her recent travel to NIgeria. Here's the case: 13y F with no significant past medical history presents with 4 days of fever, headache, watery, non-bloody diarrhea, non-bloody, non-bilious emesis, decreased PO intake with worsening myalgias, fatigue, and weakness. She had traveled with her mother to Nigeria earlier this month and returned a week ago. Over the weekend mom consulted her pediatrician who prescribed an antiemetic without significant improvement of her symptoms. Once patient progressed to becoming light headed and weak, the mom decided to bring her to ED where she was found to be have tachycardia and hypotension. She required 3 L of crystalloid resuscitation was started an epinephrine continuous infusion and transferred to the PICU. Patient was found to have acute kidney injury with an elevated Cr, as well as a primarily direct hyperbilirubinemia and associated anemia and thrombocytopenia. Her other history elements were notable for fever and difficulty breathing. Prior to traveling to Nigeria she did receive travel vaccinations and took mefloquine prophylaxis. She also had a negative COVID screen. While in Nigeria she denies exposure to animals, raw food intake, and only recalls that she may have had a few mosquito bites but this was well after returning from Nigeria until 7 days prior to presentation to the ED. She presents to the PICU with hypotension, tachycardia at 160 bpm, tachypnea, and normal saturations. Her physical exam is notable for cool peripheral extremities, RUQ tenderness, and bilateral crackles. She had no murmurs or gallops on her initial exam. Pertinently, she had no rash, lymphadenopathy or scleral icterus. This is a teenage girl who has fever and constitutional symptoms after returning from travel abroad She now presents with fluid refractory shock, tachycardia that is out of proportion to dehydration and signs of end-organ failure. Notable negatives include: No LNadenopathy, hepatosplenomegaly, or a rash Synthesizing these symptoms together → we are thinking that this picture may be related to a contracted infection or inflammatory condition related to her travel. Let's transition into some history and physical exam components of this case. What are key history features in this child who presents with fever and shock after a recent travel outside the US (Nigeria-West Africa) Diarrhea and emesis days before presentation High Fever with no rash Mental status is maintained although she did have an headache Light headed and weakness are symptoms suggestive of dehydration and even shock Physical exam findings of importance here include- patient presenting with tachycardia, signs of poor perfusion such as delayed cap refill, cool extremities, hypotension. It is unique that even though she has RUQ pain there is no jaundice. 2. Are there some red-flag symptoms or physical exam components which you could highlight in a patient with the above history and recent travel. Weakness, light-headedness, shock, tachycardia, poor perfusion, fever and evidence of multi-organ dysfunction are suggestive of an acute and possibly life threatening infection acquired during travel. Given her travel to West Africa: I would be worried about falciparum malaria, dengue fever, typhoid fever, and cholera. Other diseases to be concerned about especially given her travel h/o include leptospirosis, chickungunya, Crimean-Congo hemorrhagic fever, African tick bite fever etc. I would be also concerned about bacterial sepsis with a source such as the kidney, bowel, or intrapelvic organs. To continue with our case, the patients labs were...

Vitals & Useful Links: Learn about one important etiology of fever & abdominal pain (see spoilers below if you want to know which one) EM Clerkship Podcast - Pediatric Abdominal Pain In this episode, Arman (MS4) takes Kyle (MS4) and Neil (MS3) through a case of worsening fever and abdominal pain that had already been previously been evaluated. Nothing is ever too simple in the world of pediatric emergency medicine! As always, Nurse Barb is moonlighting in the pediatric emergency room to guide our hosts to the appropriate management. How would you approach this case? As always, we learn a couple of very important points about the GU side of abdominal pain. If you have any questions, concerns, or comments, please email us at emjccast@gmail.com *****EPISODE SPOILERS BELOW***** Here is the article from Ultrasound Quarterly presented today: Cavorsi, K., Prabhakar, P., & Kirby, C. (2010). Acute pyelonephritis. Ultrasound Quarterly, 26(2), 103–105. https://doi.org/10.1097/RUQ.0b013e3181dc7d0b An article on pyelonephritis from the great site emDocs: http://www.emdocs.net/pyelonephritis-its-not-always-so-straightforward/ And of course - a great UpToDate article on complicated UTIs: https://www.uptodate.com/contents/acute-complicated-urinary-tract-infection-including-pyelonephritis-in-adults DISCLAIMER: The views/opinions expressed in this podcast are that of the hosts/guests and do not reflect their respective institutions. This is NOT a medical advice podcast, if you are having a medical emergency you should call 911 and get help. This is an educational podcast, and as such, sometimes we get things wrong - if you notice this, please email us at emjccast@gmail.com.

Rock ON wit' cha Badassfish self.-----Bonus Episode - BadAssfish-----Supplementary Visual Material:Picture 1 – Profile Drawing of the Bony-eared Assfish - https://bit.ly/3pIBfZtPicture 2 – Top-down and Bottom-up drawing of the head of the Bony-eared Assfish - https://bit.ly/38bSL2tPictures 1 and 2 are from the Report on the deep-sea fishes collected by H.M.S. Challenger during the years 1873-1876 Günther, Albert C. L. G. (Albert Carl Ludwig Gotthilf), 1830-1914, and are public domain. -----Music And Sound AttributionsAll music tracks are under the YouTube Audio license and free to use without attribution.-----Bio-DIVE-rsity has an instagram account now! Check it Out! https://bit.ly/3eYvfHU-----Full Show Notes, Including all Video, Picture, Music,  and Sound Attributions, as well as all informational citations: https://1drv.ms/w/s!Amk89GkQH8YSgodj7cES_ljl14_RuQ?e=gqCzvs-----This episode of the Bio-DIVE-rsity podcast was written and performed by Dane Whicker.The Bio-DIVE-rsity Logo was created by Dane Whicker, using art by Ernst Haeckel. The art utilized is public domain.Official Bio-Dive-rsity Website: https://flippinfunfishfacts.buzzsprout.comQuestion, Comments, or Feedback? I'd love to hear from you! Email me at: biodiversitypodcast@gmail.com

This free iTunes segment is just one tiny snippet of the fully-loaded 3-hour monthly Urgent Care RAP show. Earn CME on your commute while getting the latest practice-changing urgent care information: journal article breakdowns, evidence-based topic reviews, critical guideline updates, conversations with experts, and so much more. Sign up for the full show at hippoed.com/UCRAPPOD Matthieu DeClerck, MD, Mike Weinstock, MD, and Cameron Berg, MD sit down to discuss the diagnostic criteria for acute pancreatitis. They discuss workup: the role of imaging to rule out gallstone pancreatitis. They go into risk stratification of acute pancreatitis as well as Initial management: pain control, IV fluids, nutrition. And ultimate disposition – when to go home? When to admit to a higher level of care?   Pearls: Confirmatory CT scanning is rarely needed to confirm pancreatitis Amylase level is neither as sensitive or specific as lipase. Early feeding, has been shown to improve outcomes in patients with pancreatitis. DIAGNOSING PANCREATITIS Must meet 2 of the following 3 criteria: Clinical presentation that is consistent with pancreatitis - epigastric or upper abdominal pain, frequently radiating to the back often with associated with nausea and vomiting, A lipase level that is three times the upper lab limit of normal for a given assay. Do not order an amylase as it not as sensitive or specific for pancreatitis as lipase. The initial lipase level cannot predict outcomes of patients with pancreatitis and there's no utility in trending lipase levels A CT scan demonstrating pancreatic inflammation consistent with pancreatitis. Note: A CT is rarely needed to confirm pancreatitis but it is the gold standard when there is diagnostic uncertainty. Perform a RUQ ultrasound to rule out gallstone pancreatitis as the most common cause of pancreatitis in the United States is biliary. Patients with biliary tract obstruction will need an ERCP or MRCP urgently that many facilities cannot get 24/7. Obtain a triglyceride level as hypertriglyceridemia is the third most common cause of pancreatitis after alcohol and gallstones. MANAGEMENT Not all patients with acute pancreatitis require hospital stay. Consider the following factors before deciding on admission: Patient vital signs Clinical appearance Ability to perform ADLs Presences or absence of markers of end organ stability Patients with pancreatitis who are admitted should receive adequate fluid resuscitation in the form of 2-3L  of IV crystalloid. Feed the patient orally as soon as possible as early enteral nutrition, rather than bowel rest, has been shown to greatly increase recovery. Patients with gallstone pancreatitis and pancreatitis secondary to hypertriglyceridemia require a higher level of care and should be referred appropriately. REFERENCES: Uhl, W. et al. 2003. IAP Guidelines for the surgical management of acute pancreatitis. Pancreatology. Tenner, S. 2013. American College of Gastroenterology Guidelines: Management of Pancreatitis. The American Journal of Gastroenterology.

Yellowish CholedocholithiasisThe sun rises over the San Joaquin Valley, California.  BIG NEWS! Our program has relinquished our affiliation with UCLA and we have decided to join USC instead. Just kidding, April fools. Today is April, 1, 2020. This week the United States became the country with the most coronavirus cases in the world with over 213,000 confirmed cases, probably more by the time this podcast is over. COVID 19 continues to spread around the world, Italy being the country with the most casualties with over 12,000 deaths.  It is difficult to talk about anything else during these times of turmoil. You may ask yourself, is this the result of a spontaneous viral mutation? Is it a conspiracy against Capitalism? Are extraterrestrials involved? Was the virus created for economic reasons? There are many theories, you can draw your own conclusion. What we can’t deny is that this pandemic has touched every aspect of our lives. "When there is a crisis, let your heart pray, but let your hands work” - John KramerI am reminded of another quote: “Pray as if everything depends on God, work as if everything depends on you”, attributed to Ignatius. Religious freedom is great, isn’t i?  Today our guest is Gina Cha. Gina is known as “the intern” at Kern Medical by her inpatient team. I am glad she accepted the invitation to come and talk to us about a relevant topic today.As you know, Gina, we have 5 questions in our podcast. Let’s start with question number one.Who are you?My name is Gina Cha, I am called “the intern”. I was born and raised in a small town about one hour north east of here called Porterville. I am Hmong and I have 7 siblings. I went to the American University of the Caribbean, Saint Martin. What did you learn this week? This is case I’ve personally experienced this week in the hospital. We had a patient in her late 20s with no significant past medical history present with yellowing of the skin for 1 day. Other associated symptoms include right upper quadrant abdominal pain for one day that had since resolved. She also had episodes of nausea that had since resolved. She had noticed continual yellowing of the skin and reported to the ED. Comment: With the history that you obtained what did you think? Yellowing of the skin is called jaundice. Differential diagnosis of increased bilirubin, yellowing of the skin in this case including:Chronic alcohol use (indicative of chronic liver damage) Hepatitis (viral infections of the liver affecting liver function)Gallstones (that can be block bilirubin excretion) Hemolysis (increased break down of hemoglobin)Comment: Ascending cholangitis triad (Charcot’s): jaundice; fever, usually with rigors; and right upper quadrant abdominal pain. When the presentation also includes low blood pressure and mental status changes, it is known as Reynolds' pentad. How did you narrow down your differential?Physical exam: unremarkable, no abdominal guarding, no Murphy’s sign. Comment: What is the Murphy’s sign? Well this is a technique is highly sensitive for diagnosis of acute cholecystitis. The way we perform this is by having the patient lay down by gently press on the right upper quadrant of the abdomen and having the patient take a deep breath. We are essentially feeling for the gallbladder and with a patient taking a deep breath, it allows the gallbladder to descend and be palpated. Comment: The same principle applies when a technician is performing a RUQ US, if there is pain with inspiration, it is a positive Murphy sign. What is cholecystitis? In short this is infection and inflammation to the gallbladder that can be quite serious if left untreated. It can cause symptoms such as fever, chills, an increase in a patient’s WBC, and can lead to perforation of the gallbladder and sepsis. Comment: What are other things you looked for? It is important to take into consideration lab values. Lab findings remarkable on a comprehensive metabolic panel: elevated liver enzymes including AST, ALT, Alk Phos, total bilirubin. Interestingly enough a meta-analysis of 22 studies revealed that an elevated serum bilirubin has a sensitivity of 69% and specificity of 88% for diagnosis of a stone in the bile duct. Comment: With those findings, were you able to narrow down the diagnosis? With this clinical picture and laboratory findings were indicative of a blockage somewhere in the biliary duct as the patient had RUQ pain that were “colicky” in nature, she was not anemic, hepatitis panel was negative. With these findings we were able to rule out some of our suspected differential diagnosis. To be sure, we obtained an Abdominal US and the patient had a dilated Common bile duct, approximately 8 mm in diameter. The common bile duct is a tube-like structure that carries bile from the liver to be expelled into the intestines.  Any CBD measuring more than 6mm with an elevated serum total bilirubin is highly predicative of a stone obstruction. Which leads to our patient’s diagnosis called Choledocholithiasis. Comment: Choledocholithiasis is a mouthful.  [Chole] stands for “bile”, [doch] stands for duct. [lith[ stands  for stone. So choledocholithaisis is a fancy way of saying stone in the the bile duct. What makes up the biliary tree is the left and right hepatic duct coming together to make the common HEPTATIC DUCT that meets with the cystic duct to make up the command bile duct, which meets the pancreatic duct and drains into the duodenum via the ampulla of Vater. Cholelithiasis is a stone in the gallbladder, and Choledocholithiasis is a stone anywhere in the biliary out of the gallbladder.Question Number 3: Why is that knowledge important for you and your patients? According to the national health and nutrition examination survey there are over 20 million Americans who reported that they have either gallstones or a history of cholecystectomy. It is important to recognize the common signs and symptoms of anyone with gallbladder disease, that way proper work up can be ordered and proper management can be performed.  Question number 4: How did you get this knowledge? Most of the knowledge that I have is from my clinical experience. I’m much more of a hands-on learner than obtaining information from text books. During my rotations in surgery and in during my GI rotation I saw many of these cases. It made it much easier to go home and review in literature cases that I saw in the hospital.  Question number 5: Where did this knowledge come from? There are multiple resources that we have access to including American Academy of Family Physicians and Up to date and multiple questions that I’ve reviewed on USMLE world. For this particular case, I reviewed the articles by Arain, Mustafa and Zakko , Salam F, and Nezam H Afdhal in Up to Date. _____________________Speaking Medical by Lisa ManzanaresThe word of the day is amblyopia.  This is a non-lazy way of saying “lazy eye.” Amblyopia is the functional reduction in visual acuity caused by abnormal visual development early in life, up to age 6 years.  Amblyopiais decreased vision in an eye that otherwise typically appears normal.  Amblyopia is THE most common childhood cause of monocular vision loss.  In Greek, amblyopia means “dullness of vision.” It occurs in 2-6% of U.S. children. Causes of amblyopia include strabismus, which is the most common, followed by refractive amblyopia, and then depravation amblyopia such as that caused by a scar or mass, which is the least common.  Methods of treatment include: patching, atropine, and Bangter filter applied to glasses lens of the good eye, depend on what type and how severe the amblyopia is.  If there is suspicion for Amblyopia, don’t think, “That’s all Greek to me,” place pediatric ophthalmology referral because amblyopia is nearly irreversible by 9 years of age.__________________________Espanish Por Favor (Spanish Word of the Day) by Roberto Velazquez Hi this is Dr RAVA on our section Espanish por favor. This week’s Spanish word is “angina”, which it is spelled the same as angina. Although, angina in Spanish means tonsils. People usually use this word in its plural form anginas referring to both tonsils. This word comes from the Latin root angina which means strangling or choking or narrowing of the throat. So you can have a patient coming to you saying, “Doctor, me duelen las anginas,” and literally it sounds “Doctor, I have angina pain”. If you hear this, don’t panic, your patient is not having a heart attack. He or she is telling you that they have a sore throat.  Now you know the Spanish word of the day, angina or anginas, all you need to do is to assess your patient’s tonsils. Have a great week and take care. __________________________________________[Music] For your Sanity (Medical joke of the day)by Lisa Manzanares and Roberto VelazquezQ: Did you hear about the optometrist that fell into his lens grinding machine?A: He made a spectacle of himselfQ: Does an apple a day keep the doctor away?A: Only if you aim it well enoughQ: Why did Dracula go to the doctor?A: He couldn't stop his coffin__________________________________________During this episode we talked about Choledocholithiasis. Remember, think about the liver, alcohol, gallbladder, hemolysis, and infections when you see a yellow-skin patient. A millimetric stone obstructing the biliary tree can cause a big trouble if it is not diagnosed and treated on time. Don’t forget the medical word of the day Amblyopia or “lazy eye”, and the Spanish word “Angina”, which has little to do with the English word Angina. See you next week!  This is the end of Rio Bravo qWeek. We say good bye from Bakersfield, a special place in the beautiful Central Valley of California, United States, a land where growing is happening everywhere.If you have any feedback about this podcast, contact us by email RBresidency@clinicasierravista.org, or by visiting our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. Our podcast team is Hector Arreaza, Lisa Manzanares, Roberto Velazquez, and Gina Cha. Audio edition: Suraj Amrutia. ________________________________ReferencesArain, Mustafa A, et al. “Choledocholithiasis: Clinical Manifestations, Diagnosis, and Management.” UpToDate, 2 Mar. 2020, www.uptodate.com/contents/choledocholithiasis-clinical-manifestations-diagnosis-and-management?search=choledocholithiasis&source=search_result&selectedTitle=1~112&usage_type=default&display_rank=1.Zakko , Salam F, and Nezam H Afdhal . “Acute Calculous Cholecystitis: Clinical Features and Diagnosis.” UpToDate, Uptodate, 8 Nov. 2018, www.uptodate.com/contents/acute-calculous-cholecystitis-clinical-features-and-diagnosis?search=cholecystitis&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1.

A 46-y/o female has RUQ pain and distension following surgical repair of a splenic laceration. Which process most likely resulted in her current condition? Links: Full Episode Blog Post Meded Media BoardVitals (promo code BOARDROUNDS and save 15% off)

Welcome to part 2 of Choosing pain meds. To learn about choosing opiate pain medications, how to pick IV or PO pain meds, or why pain can be so dang hard to treat, check out last week's episode. There are two different pain pathways (for this talk):  the neurotransmitter substance P and its friends who are released in response to tissue damage.  stretching nociceptors that represents the discomfort, inflammation or more specifically stretching of our visceral organs.   These pathways are different kinds of painful stimuli in the brain & are hard to express. Thus descriptive pain categories like : throbbing, cramping, achy, bloating, pulling, sharp, stabbing, burning, shooting and so many more. In school we learn “textbooks patterns” of pain (like crampy episodic RUQ pain = gallbladder) but these patterns are imperfect == atypical presentations of diseases To discuss specific agents refer to the PDF Pain Chart BONUS: Marijuana Info More & more patients will be looking to us --the medical professionals-- for information and opinions. It is important to educate ourselves with facts, regardless of opinions. To start there are two different chemical compound categories. Terpenoids which are found the in glands of the cannabis flower that help influence the uptake of the other categories  Phytocannabinoids: THC & CBD. Both of these compounds have benefits and serious SE but neither of them are currently regulated. THC: found in 1964, effects include: increased appetite & muscle relaxation, decreased nausea/vomiting & pain/inflammation  SE: dizziness, somnolence, dry mouth, anxiety, psychosis, cyclical vomiting CBD: found in the 1940s with same structure as THC but in a different structure, has no addiction potential (can't bind to the receptor), studies found significant positive use in: epilepsy, anxiety, huntingtons disease, ALS, MS, arthritis. It also stops conversion of THC into metabolite that causes psychosis. Right now, CBD is legal to sell anywhere and is what most of my patients are asking about.   My concern with prescribing CBD: The FDA does not regulate quality of brands, so you don't know what your patients are getting. To learn more about the topic, I go to Harvard’s answer page. I took their continuing medEd class for $200 and I found it politics and opinion-free. To learn about choosing opiate pain medications, check out last week's episode. Or if you would like handier notes for on-shift or in-clinic reference: PDF Pain Chart Do you have questions? feedback? topic suggestions? Leave me a comment below and I'll get back to you.

In this episode, we will cover all those pesky things that can make your patient sick from the RUQ: namely the biliary tract! Ascending cholangitis, Cholecystitis and all the important pearly for imaging, antibiotics and source control options.

Show Notes Jeff: Welcome back to EMplify the podcast corollary to EB Medicine’s Emergency medicine Practice. I’m Jeff Nusbaum and I’m back with Nachi Gupta for your regularly scheduled monthly dose of evidence based medicine. This month, we are tackling an incredibly important topic – Assessing abdominal pain in adults, a rational, cost effective, and evidence-based strategy. Nachi: This incredibly important topic was chosen to mark the 20th anniversary of Emergency Medicine Practice. It is actually a revision of the first issue of Emergency Medicine Practice in 1999, now with updated evidence and recommendations. Thanks Robert Williford and Dr. Colucciello for getting this all started 2 decades ago! Jeff: Wow – 20 years – that’s amazing considering Emergency Medicine as a specialty hadn’t even been around all that long at the time and as Dr. Jagoda writes in his intro “evidence based education was still finding its footing.” Nachi: As a tribute to the man who started it all, EB Medicine again turned to Dr. Colucciello, who is no longer wearing his editor in chief hat, but instead is a professor at the University of North Carolina School of Medicine, to update his original article with the latest evidence. Jeff: Before we dive into the meat and potatoes of this month’s issue, let me also recognize Drs. Taylor and Shaukat of Emory and Coney Island Hospital respectively for their efforts in peer reviewing this huge topic. Show More v Nachi: For a number of reasons, this month is going to be a little different. You will notice that we will focus more on safe disposition instead of on diagnosis. Which is reasonable, as that is the crux of our job as emergency physicians. Jeff: Indeed. So for those of you who can’t wait, here’s a quick spoiler, The CBC isn’t all that useful. CT is good but you really should learn ultrasound, and lastly, sick patients need prompt consultation and resuscitation, not rapid trips to radiology. Nachi: All valid points, but let’s dive in too some actual detail. Jeff: Abdominal pain is the one of most frequent complaint in US emergency departments, representing 8% of all adult ED visits, with admission rates for all patients with abdominal pain ranging between 18-42% and reaching as high as 60% for the elderly. Nachi: With respect to the elderly, statistically speaking, 20% presenting with abdominal pain will undergo surgery, and 5% will die. Jeff: Often the etiology of the abdominal pain is never determined. This happens up to 40% of the time by the end of the ED visit. Nachi: I feel like that needs to be restated for emphasis – nearly half of patients who present to the ED with abdominal pain will have no determined etiology for their pain. Clearly, that doesn’t mean you are a bad ED physician – it’s just the way it goes. Jeff: Definitely still a win to be told you aren’t having an intra-abdominal catastrophe at the end of your visit! Nachi: Moving on to pathophysiology. Visceral pain results from distention or inflammation of the hollow organs or from ischemia from any internal organ, while the more localized, somatic pain is typically from irritation of the adjacent peritoneum. Jeff: And don’t forget about referred pain. Due to the movement of organs and stretching of nerve pathways during fetal development, pain may be referred to distant sites, like diaphragmatic irritation presenting as shoulder pain. Nachi: Let’s talk differential diagnosis. The differential for abdominal pain is tremendously broad and includes both intra-abdominal and extra abdominal pathologies. Check out table 2 for a very thorough list. Jeff: Table 1 is also worth reviewing while you’re on page 3 as it lists a few of the common dangerous mimics that often lead to misdiagnosis on initial presentation. To highlight a few – a AAA can masquerade as renal colic, diverticulitis, or a lumbar strain; an ectopic may present similar to PID, a UTI, or a corpus luteum cyst, and mesenteric ischemia may present shockingly similar to gastroenteritis, constipation, ileus, or an SBO. Nachi: Though misdiagnosis is certainly possible at any age, one must be particularly cautious with the elderly. Abdominal pain in the elderly is complicated by a number of factors, they often have no fever, no leukocytosis, or no localized tenderness despite surgical disease, surgical problems progress more rapidly, and lastly, they are at risk for vascular catastrophes, which don’t typically afflict the younger population Jeff: Dr. Colucciello closes the section on the elderly with a really thought-provoking point – we routinely admit 75 year old with chest pain and benign exams, yet we readily discharge a 75 year old with abdominal pain and a benign exam even though the morbidity and mortality of abdominal pain in this group exceeds that of the chest pain group. Nachi: That’s an interesting perspective, but we still have to think about this in the context of what an admission would offer in either of these cases. Most of the testing for abdominal pain can be done in the ED, CT being the workhorse. This point certainly merits more thought though. Jeff: Most clinicians have a low threshold to scan their elderly patients with abdominal pain, and the data behind this practice is quite compelling. In one study, CT altered the admission decision in 26%, need for surgery in 12%, the need for antibiotics in 21%, and changed the suspected diagnosis in 45%. Nachi: That latter figure, 45% change in suspected diagnosis, that was also confirmed in another study in which CT revealed a clinically unsuspected diagnosis in 43% of the elderly. Jeff: And it’s worth mentioning, that even though CT may be the go-to-tool - biliary tract disease, which we know is best visualized on ultrasound, is actually the most common cause of abdominal pain, especially sudden onset abdominal pain in the elderly. Nachi: The next higher risk group to discuss are patients with HIV. While anti retroviral therapy has certainly decreased the burden of opportunistic infections, don’t forget to keep a broader differential in this group including bacterial enterocolitis, drug-induced pancreatitis, or AIDS related cholangiopathy Jeff: Definitely make sure to check to see if the patient has a recent CD4 count to give you a sense of their disease and what they may be at risk for. At less than 200, cryptosporidium, isospora, cyclospora, and microsporidium all make their way onto the differential in addition to the standard players. Nachi: For more information on HIV and its management, check out the February 2016 issue of Emergency Medicine Practice, which covered this and more in depth. Jeff: The next high risk population we are going to discuss are women of childbearing age. Step one is always the same - diagnose pregnancy! Always get a pregnancy test for women between menarche and menopause. Nachi: The pregnancy test is important not only for diagnosing an intrauterine pregnancy, but it’s also a reminder, that we need to consider and rule out an ectopic. Jeff: Along similar lines, you also need to consider torsion, especially in your pregnant population, as 20% of cases of ovarian torsion occur during pregnancy. Nachi: Unfortunately, you cannot rely on the physical exam alone in this age group, as the pelvic exam may be misleading. Up to a quarter of women with appendicitis can exhibit cervical motion tenderness -- a finding typically associated with PID. Sadly, errors are common and ⅓ of women of childbearing age who ultimately were found to have appendicitis were initially misdiagnosed. Jeff: To help reduce your risk in the pregnant population, consider imaging, particularly with radiation reduction strategies, including using ultrasound and MRI, which is gaining favor in the diagnosis of appendicitis in pregnancy. Nachi: Diagnosis of appendicitis, in a pregnant patient, ultrasound vs. mri. Sounds familiar. Didn’t we just talk about this in Episode 24 back in January? Jeff: We sure did! Take another listen if that doesn’t ring a bell. Nachi: That was focused on first trimester only, but while we’re talking about appendicitis in pregnancy - keep in mind that during the second half of pregnancy, the appendix has moved out of the RLQ and is more likely to be found in the RUQ. Jeff: As yes, the classic RUQ appendix. As if our jobs weren’t hard enough, now anatomy is changing… Anyway, the last high risk group we are going to discuss here are those patients with prior abdominal surgery. Make sure to ALWAYS examine the patient's exposed skin to look for scars. Adhesions are the leading cause of SBOs in the industrialized world, followed by malignancy, IBS, and internal or external hernias. Nachi: Also keep a high index of suspicion for patients who have undergone bariatric surgery. They are especially prone to surgical causes of abdominal pain including skin infections and surgical leaks. Jeff: For this reason, CT imaging should be done with IV and oral contrast, with those having undergone a Roux-en-Y receiving oral contrast on the CT table. Nachi: Perfect. Let’s move on to evaluation once in the ED! Jeff: As we mentioned a few times already - diagnosis is difficult, a comparison of initial and final diagnosis only has about 50-65% accuracy. For this reason, Dr. C suggests taking a ‘worst first’ approach to forming your differential and guiding your workup. Nachi: And as a brief aside, before we continue… Missed appendicitis is one of the three most common causes of emergency medicine malpractice lawsuits - with MI and fractures being the other two. That being said, you, as a clinician, have either missed appendicitis or likely will in the future. In a study of cases of misdiagnosed appendicitis brought to litigation, several themes recurred. For example, patients with misdiagnosed disease has less RLQ pain and tenderness as well as diminished anorexia, nausea, and vomiting. Jeff: Well that’s scary - I know I’ve already missed a case, but luckily, he returned thanks to good return precautions, which we’ll get to in a few minutes. Also, note that in addition to imaging and the physical exam, history is often the key to uncovering the cause of abdominal pain. Nachi: Not to harp on litigation, but in malpractice cases brought up for failure to diagnose abdominal conditions, deficiencies in data gathering and charting were often to blame rather than misinterpretation of data. Jeff: As no shocker here, getting a complete history remains tremendously important in your practice as an emergency clinician. A recurring theme of EMplify for sure. Nachi: In order to really nail this down, consider using a standardized history form -- or memorizing one. An example is shown in Table 1. Standardized forms have been shown to improve patient satisfaction and diagnostic accuracy. Jeff: An interesting question for your abdominal pain patient is to ask about the ride to the hospital. Experiencing pain going over a speed bump has been shown to be about 97% sensitive and 30% specific for appendicitis. So fairly sensitive, but not too specific. Nachi: That’s interesting and may help guide you, but it’s certainly no replacement for CT. And remember that you can have stump appendicitis. This can occur in the appendiceal remnant after an appendectomy and is found in about 0.15% of all appendectomies. Jeff: Alright, so on to the physical exam. Like always, let’s start with vital signs. An elevated temp can be associated with intra abdominal infection, but sensitivity and specificity vary greatly here. Always consider a rectal temp, as these are generally more reliable. Nachi: And remember that hypothermic patients who are septic have worse outcomes than those who are hyperthermic and septic. Jeff: Elevated respiratory rate can be due to pain or subdiaphragmatic irritation. However, it can also be due to hypoxia, sepsis, anemia, PE, or metabolic acidosis, so consider all of those also in your differential. Nachi: Moving on to blood pressure: frank hypotension should make you immediately think of a ruptured AAA or septic shock 2/2 an intra abd infection. You can also use the shock index, which as a reminder is simply the HR/SBP. In one study, a SI > 0.7 was sensitive for 28-day mortality in sepsis. Jeff: Speaking of HR, tachycardia can be a response to pain, anxiety, fever, blood loss, or sepsis. An irregularly irregular rhythm -- or a fib -- is an important risk factor for mesenteric ischemia in elderly patients. This is important to consider in your differential early as it may guide your imaging modality. Nachi: With vitals done, we can move on to the abdominal exam - it is rare that a serious abdominal condition will present without tenderness in a young adult patient, but remember that the elderly patient may not present with much tenderness at all due decreased peritoneal sensitivity. Abdominal tenderness that is greatest when the abdominal muscles are contracted is likely due to abdominal wall pain. This can be elicited by having the patient lift their head or let their legs off the bed. This finding is known as Carnett sign and is about 95% accurate for distinguishing abdominal wall pain from visceral abdominal pain. Jeff: Though tenderness itself is helpful, the location of tenderness can be misleading. Note that while 80% of patients with appendicitis have RLQ tenderness, 20% don’t. The old 80-20 rule! So definitely don’t let RLQ tenderness be your sole guide! Nachi: Voluntary guarding is due to fear, anxiety, or even a reaction to a clinician’s cold hands. Involuntary guarding (also called rigidity) is more likely to occur with surgical disease. Remember that rigidity may be a less common finding in the elderly despite surgical disease. Jeff: Peritoneal signs are the true hallmark of surgical disease. These include rebound pain, pain with coughing, pain with shaking the stretcher or pain with striking the patient’s heel. Rebound historically has been thought to be pathognomonic for surgical disease, but recent literature hasn’t found it to be all that useful, with one study claiming it has no predictive value. Nachi: As an alternative, consider the “cough test”. Look for evidence of posttussive abd pain (like grimacing, flinching, or grabbing the belly). Studies have found the cough sign to be 80-95% sensitive for peritonitis. Jeff: In terms of other sings elicited during the abdominal exam: The murphy sign, ruq palpation that causes the patient to stop a deep inspiration -- in one study had a sensitivity of 97%, but a specificity of just under 50%. The psoas sign, pain elicited by extending the RLE towards the back while the patient lies on their left side -- in one study had a specificity of 95%, but only had a sensitivity of 16%. Nachi: Neither the obturator sign (pain with internal rotation of the flexed hip) nor the rosving sign (pain in the RLQ by palpating the LLQ) have been rigorously studied. Jeff: Moving a bit further south, from the abdomen to the pelvis - let’s talk about the pelvic exam. Most EM training programs certainly emphasize the importance of the the pelvic exam for women with lower abdominal pain, but some recent papers have questioned its role. A 2018 study involving 288 women 14-20 years old found that the pelvic didn’t increase sensitivity or specificity of diagnosis of chlamydia, gonorrhea, or trichomoniasis when compared with history alone. Another study questioned whether the pelvic exam can be omitted in these patients with an early intrauterine pregnancy confirmed on ultrasound, but it was unable to reach a conclusion, possibly due to insufficient power. Nachi: While Jeff and I do find it valuable to elicit as much as information from the history as possible and take value in the possibility of omitting the pelvic in certain cases in the future, given the current evidence based medicine, we both agree with the author here. Don’t abandon the pelvic for these patients just yet! Jeff: While on this topic, we should also briefly mention a reminder about fitz-hugh-curtis syndrome, perihepatic inflammation associated with PID. Nachi: As for the digital rectal exam, this can certainly be of use when considering and diagnosing prostatitis, perirectal disease, stool impactions, rectal foreign bodies, and gi bleeds. Jeff: And let’s not forget the often overlooked scrotal and testicular exam. In men with abdominal or flank pain, this should always be considered. Testicular torsion often presents with isolated abdominal or flank pain. The scrotal exam will help diagnose inguinal and scrotal hernias. Nachi: Getting back to malpractice case reviews for a minute --- in a 2018 review involving testicular torsion, almost ⅓ of the patients with missed torsion had presented with abdominal pain --- not scrotal pain! In ⅕ of the cases, no testicular exam was performed at all. Also, most cases of missed torsion occured in patients under 25 years old. Jeff: Speaking of torsion, about 6% occur over the age of 31, so have an increased concern for this in the young. Of course, if concerned for torsion, consult urology immediately and consider manual detorsion. Nachi: And if you, like me, were taught to manually detorse by rotating in the lateral or open book direction, keep in mind that in a study of 200 males with torsion, ⅓ had rotated laterally, not medially. Jeff: Great point. And one last quick point here. Especially if you are unsure about the diagnosis, make sure to perform serial exams both in the ED and also in the next few days at their PCP’s office. In one study, a 30 hour later repeat exam for patients discharged with nonspecific abdominal pain resulted in a clinically relevant change in diagnosis and therapy in almost 25% of patients. Nachi: So that wraps up the physical. Let’s get into diagnostic studies, starting with lab work and everybody’s favorite topic... the cbc. Jeff: Yup, just the other day I was asked by a consultant “what’s the white count.” in a patient with CT proven appendicitis. Man, a small part of my soul dies every time this happens. Nachi: It appears you must have an evidenced based soul then. According to a few studies, anywhere from 10-60% of patients with surgically proven appendicitis have an initially normal WBC. So in some studies, it’s even worse than a coin flip. Jeff: Even worse, in children the CBC is less helpful. In children, an elevated WBC detects a mere 53% of severe abdominal pathology - so again not all that helpful. Nachi: That being said, at the other end of the spectrum, in the elderly, an elevated WBC may imply serious disease. Jeff: So let’s make this perfectly clear. A normal WBC should not be reassuring, but an elevated WBC, especially in the elderly, should be very concerning. Nachi: The CRP is up next. Though not used frequently, it’s still worth mentioning, as there is a host of data on it in the setting of abdominal pain. In one meta analysis, CRP was approximately 62% sensitive and 66% specific for appendicitis. Jeff: And while lower levels of CRP do not rule out positive findings, increasing levels of CRP do predict, with increasing likelihood, the chances of positive findings. Nachi: Next we have lipase and amylase. The serum lipase is the best test for suspected pancreatitis. The amylase adds limited value and should not be routinely ordered. Jeff: As for the lactate. The greatest value of a lactate level is to detect occult shock and sepsis. It is also useful to screen for visceral ischemia. Nachi: And the last lab test we’ll discuss is the UA. The urinalysis is a potentially misleading test. In two studies, 20-30% of patients with appendicitis also had hematuria with leukocytes and bacteria on their UA. In a separate study of those with a AAA, there was an 87% incidence of hematuria. Jeff: That’s pretty troubling. Definitely not great to diagnosis someone with hematuria and a primary GU problem, when their aorta is actually exploding. Nachi: And that’s a great reminder to always avoid premature diagnostic closure. Jeff: Also worth mentioning is that not all ureteral stones present with hematuria. At least 6% have no hematuria on microscopy. Nachi: Alright, so that brings us to imaging. First up: plain films. I’m going to quote this directly from the article since I think it's so important, ‘never rely on plain films to exclude surgical disease.” Jeff: This statement is certainly evidence based as in one study 40% of x-ray findings were inconsistent with the final diagnosis. In another study, 43% of patients with major surgical disorders had either normal or misleading plain film results. So again, the take home here is that XR cannot rule out surgical disease, and should not be routinely ordered except for in specific settings. Nachi: And perhaps the most important of all those settings is in the setting of possible free air under the diaphragm. In this case, an upright chest visualizing the area under the diaphragm would be the test of choice. But again, even this doesn’t rule out surgical disease as free air may be absent on plain films in ⅓ to ½ of patients who have already perfed. Jeff: Next we have everybody’s favorite, the ultrasound. Because of it’s low cost and ease of use, bedside ultrasound is gaining traction. And we’ve cited this and other similar studies in other issues, this is a skill emergency medicine physicians must have in this day and age and it’s a skill they can learn quickly. Nachi: Ultrasound can visualize most solid organs, but it is best suited for the Right upper quadrant and pelvis. In the RUQ, we are looking for wall thickening, pericholecystic fluid, ductal dilatation, and sonographic murphys sign. Jeff: In the pelvis, there is a role for both transabdominal and transvaginal to rule out ectopic and potentially rule in intrauterine pregnancy. I know the thought of performing your own transvaginal ultrasound may sound crazy to some, but we both trained in places where ED TVUS was the norm and certainly wasn’t that hard to learn. Nachi: Ah, the good old days of residency. I’m certainly grateful for the US tech where I am now though! Next up we have CT. CT scans are ordered in just under 30% of patients with abdominal pain. Jeff: It’s worth noting, that while many used to scan with triple contrast - oral, rectal and IV, recent literature has shown that IV contrast alone is adequate for the diagnosis of most surgical conditions, including appendicitis. Nachi: If you’re still working in a shop that scans for RLQ pain with oral or rectal contrast, definitely check out the 2018 american college of radiology appropriateness criteria that states that IV contrast is generally appropriate for assessing the RL. Jeff: And while we are on the topic of contrast, let’s dive a bit deeper into the, perhaps myth, that contrast leads to contrast induced nephropathy. Nachi: This is another really important point. Current data show that being ill enough to be admitted to the hospital is a risk factor for acute kidney injury and that IV contrast for CT does not add to that risk. In 2015, the american college of radiology noted in their manual on contrast media that the concern for the development of contrast induced nephropathy is not an absolute contraindication for using IV contrast. IV contrast may be necessary regardless of the risk of nephrotoxicity in certain clinical situations. Jeff: Ok, so contrast induced nephropathy may be real, but more studies and a definitive statement are still needed. Regardless, if the patient is sick and they need the scan with contrast, don’t hold back. Nachi: I think that’s a fair take home. As another note about the elderly, CT should be almost routine in the elderly patient with acute abdominal pain as it improves accuracy, optimizes appropriate hospitalization, and boosts ED management decision making confidence for this patient group. Jeff: If they are over 65, make sure you chart very carefully why they don’t need a scan. Nachi: Speaking of not needing a scan, two quick caveats on CT before moving to MRI. Unstable patients do not belong in a radiology suite - they belong in the ED resus bay to be resuscitated first. Prompt surgical consultation and bedside ultrasound if indicated are both a must in unstable patients. Jeff: The second caveat is on the other end of the spectrum - not all CT scanning is created equally - the interpretation depends on the scanner, the quality of the scan, and the experience and training of the reading radiologist. In one study, nearly 13% of abdominal CT scans may initially be misread. Nachi: So if you’re concerned, consider consultation or an extended ED observation to monitor for any changes in the patient’s status. Jeff: Next up is MRI - MRI has an ever expanding role in the ED. The accuracy of MRI to diagnose appendicitis is very similar to CT, so consider it in all pregnant patients, though ultrasound is still considered first line. Nachi: And finally let’s touch upon the ekg and ACS. In patients over 40 with upper abdominal pain, an EKG and troponin should always be considered. Jeff: Don’t be reassured by a response to a GI cocktail either - this does not exclude myocardial ischemia. Nachi: Next, let’s talk the role of analgesia in treating the undifferentiated abdominal pain patient. Jeff: While there was formerly a concern of ‘masking the pain’ with opiates, the evidence says otherwise. Pain medicine may even aid in the diagnosis, so definitely don’t withhold it in the setting of acute abdominal pain. Nachi: Wait I get that masking the pain is no longer considered a concern, but how would it aid in the diagnosis? Jeff: Good question. Analgesics might facilitate the gathering of history and allow a more complete physical exam by relaxing the abdominal musculature. Nachi: Ahh that makes sense. So certainly treat pain! Both morphine at 0.1 mg/kg and fentanyl at 1 mic/kg are appropriate analgesics for acute abdominal pain. In those that are a difficult stick, a recent study showed that 2 micrograms/kg of fentanyl via a nebulizer was a safe alternative. Remember, fentanyl is quick on, quick off, which may make it desirable in certain situations. It actually has the shortest time of onset of any opioid. It’s also safer in patients with a “marginal” blood pressure. Jeff: And just like the GI cocktail - response to opiate analgesics does not exclude serious pathology. These patients need serial exams and likely labs and imaging if their pain is so severe. Nachi: Few things are more important prior to discharge of an abdominal pain patient than documenting repeat exams and a PO trial. Jeff: True. You should also consider haloperidol for patients with gastroparesis and cannabinoid hyperemesis as a growing body of literature supports its use in such settings. Check out the August 2018 EMP or EMplify for more details if you’re curious. Nachi: The last analgesic to discuss is our good friend ketamine. Low dose ketamine at 0.3 mg/kg over 15 minutes is gaining traction as the analgesic of choice in many ED’s. Jeff: The key there, is that it must be given over 15 minutes. Ketamine has a great safety profile, but you make it so much safer and a much better experience if you give it slowly. Nachi: Before we get to disposition, let’s talk controversies and cutting edge - and there is just one this month - and that’s the use of the Alvarado score. Jeff: In the Alvarado score, you get two points for RLQ tenderness and 2 points for a leukocytosis over 10,000. You get an additional point for all of the following; rebound, temp over 99.1, migration of pain to the RLQ, anorexia, n/v, and a left shift. The max score is therefore 10. A score of 3 or less make appendicitis unlikely, 4-6 warrants CT imaging, and 7 or more a surgical consultation. Nachi: A 2007 study suggests that using the Alvarado score along with bedside ultrasound might allow for rapid and inexpensive diagnosis of appendicitis. Jeff: I don’t think we should change practice based on this just yet, but more ultrasound diagnosis may be on the horizon. If you want to start using the Alvarado score in your practice, MDcalc has a great easy to use calculator. Nachi: Let’s get to the final section. Disposition! Jeff: As we mentioned at the beginning of this episode, the diagnosis is less important than proper disposition. For patients with suspected ruptured AAA, torsion, or mesenteric ischemia - the disposition is easy - they need immediate surgical consultation and likely operative intervention. Nachi: For others, use the tools we outlined above - ct, us, labs, etc, to help support your decision. Keep in mind, that serial exams are a great tool and of little expense - so make sure to lay your hands on the patient's abdomen frequently, especially when the diagnosis is unclear. Jeff: For those that look well after a work up, with no clear diagnosis, it may be reasonable to discharge them home with prompt follow up, assuming prompt follow up is plausible. The key here is that these patients need good discharge instructions. Check out figure 2 on page 20 for a sample discharge template. Nachi: But if the patient is still uncomfortable, even after a thorough workup, there may be a role for ED observation units. In one study of 220 patients admitted for to ED obs units for serial exams, 39% eventually underwent surgery with only 5% having negative laparotomies. Jeff: This month’s issue wraps up with some super important time and cost effective strategies, so let’s see if we can quickly breeze through some of the most important points before closing out this episode. Nachi: First - limit your abdominal x-rays as they offer limited value and are rarely helpful except in the setting of perforation, when an early upright chest film should be used liberally. Jeff: Next - limit electrolyte testing especially in young adults with nausea, vomiting and diarrhea. In those 18 to 60, clinically significant electrolyte abnormalities occur in only 1% of those with gastro. Nachi: With respect to urine testing, urine cultures are rarely indicated for uncomplicated cystitis in young women. Along similar lines, don’t anchor on the diagnosis of UTI as other lower abdominal conditions often lead to abnomal urine studies. Jeff: In your alcoholic patients, although all should be approached with an abundance of caution, limit testing to repeat abdominal exams in your non-toxic appearing patient who is already tolerating PO. Nachi: For those with suspected renal colic, especially those with a history of renal colic, limit CT use and instead consider ultrasound to look for hydro. This approach is endorsed by ACEPs choosing wisely campaign. Jeff: But as a reminder, this is for low risk patients only. Anyone with signs of infection should also undergo CT imaging. Nachi: And lastly - consider incorporating bedside US into your routine. The US is fast and accurate and compares similarly to radiology, especially in the context of detecting acute cholecystitis. Jeff: Alright, so that wraps up the new material for this episode, let’s close out with some key points and clinical pearls. The peritoneum becomes less sensitive with aging, and peritonitis can be a late or absent finding. Be wary of early diagnostic closure and misdiagnosis with a mimic of a more severe and dangerous pathology. The elderly, immunocompromised, women of childbearing age, and patients with prior abdominal surgeries are all at a higher risk for misdiagnosis. Elderly patients can present without fever, leukocytosis, or abdominal tenderness, but still have surgical abdominal pathology. Consider diagnostic imaging in all geriatric patients presenting with abdominal pain. Consider plain film if you suspect a viscus perforation or for certain foreign body ingestions. Do not forget the pelvic exam, testicular exam, and rectal exam as part of your physical, when appropriate. Testicular torsion can present with abdominal pain only. If suspected, consult urology and consider manual detorsion. A normal white blood cell count does not rule out appendicitis or other intra-abdominal pathology. Serum amylase should not be used in your assessment of the abdominal pain patient. Lack of microscopic hematuria does not rule out renal colic. CT of the abdomen with IV contrast alone is enough for most surgical conditions including appendicitis. Oral and rectal contrast does not need to be routinely administered. The 2018 American College of Radiology (ACR) Appropriateness Criteria discuss concern for delay in diagnosis associated with oral contrast use and an increased rate of perforation. There is recent literature to support that IV contrast does not cause nephropathy. The ACR 2015 Manual on Contrast Media states that concern for contrast induced nephropathy is not an absolute contraindication, and IV contrast may be necessary in many situations. Ultrasound can be used to evaluate the aorta, gallbladder, kidneys, appendix, bowel, spleen, pancreas, uterus, and ovaries. Consider bedside ultrasound and emergency surgical consult for all unstable patients with abdominal pain. For stable pregnant patients with concern for appendicitis, start with an ultrasound. If inconclusive, order an MRI. Epigastric pain in an elderly patient should raise concern for ACS. An EKG and troponin should be considered. For analgesia in patients with gastroparesis or cannabinoid hyperemesis syndrome, haloperidol is considered first-line. Low-dose ketamine (0.3mg/kg over 15 minutes) may be a better choice than opiate analgesia for abdominal pain. Nachi: So that wraps up Episode 29! Jeff: As always, additional materials are available on our website for Emergency Medicine Practice subscribers. If you’re not a subscriber, consider joining today. You can find out more at ebmedicine.net/subscribe. Subscribers get in-depth articles on hundreds of emergency medicine topics, concise summaries of the articles, calculators and risk scores, and CME credit. You’ll also get enhanced access to the podcast, including any images and tables mentioned. PA’s and NP’s - make sure to use the code APP4 at checkout to save 50%. Nachi: And last reminder here -The clinical Decision Making in Emergency Medicine Conference is just around the corner and spots are quickly filling up. Don’t miss out on this great opportunity and register today. Jeff: And the address for this month’s cme credit is ebmedicine.net/E0619, so head over there to get your CME credit. As always, the [DING SOUND] you heard throughout the episode corresponds to the answers to the CME questions. Lastly, be sure to find us on iTunes and rate us or leave comments there. You can also email us directly at emplify@ebmedicine.net with any comments or suggestions. Talk to you next month!   Most Important References 18. Gardner CS, Jaffe TA, Nelson RC. Impact of CT in elderly patients presenting to the emergency department with acute abdominal pain. Abdom Imaging. 2015;40(7):2877-2882. (Retrospective study; 464 patients aged ≥ 80 years) 38. Kereshi B, Lee KS, Siewert B, et al. Clinical utility of magnetic resonance imaging in the evaluation of pregnant females with suspected acute appendicitis. Abdom Radiol (NY). 2018;43(6):1446-1455. (Retrospective study; 212 MRI examinations) 41. Lewis KD, Takenaka KY, Luber SD. Acute abdominal pain in the bariatric surgery patient. Emerg Med Clin North Am. 2016;34(2):387-407. (Review) 57. Wagner JM, McKinney WP, Carpenter JL. Does this patient have appendicitis? JAMA. 1996;276(19):1589-1594. (Review) 67. Magidson PD, Martinez JP. Abdominal pain in the geriatric patient. Emerg Med Clin North Am. 2016;34(3):559-574. (Review) 83. Macaluso CR, McNamara RM. Evaluation and management of acute abdominal pain in the emergency department. Int J Gen Med. 2012;5:789-797. (Review) 94. Bass JB, Couperus KS, Pfaff JL, et al. A pair of testicular torsion medicolegal cases with caveats: the ball’s in your court. Clin Pract Cases Emerg Med. 2018;2(4):283-285. (Case studies; 2 patients) 106. Kestler A, Kendall J. Emergency ultrasound in first-trimester pregnancy. In: Connolly J, Dean A, Hoffman B, et al, eds. Emergency Point-of-Care Ultrasound. 2nd edition. Oxford UK: John Wiley and Sons; 2017. (Textbook)

Dissect 3 interesting cases and improve your clinical reasoning skills! Time Stamps: New features in this episode [0:30] Case one: 66M w RUQ pain [1:09] Case two: 41M w Afib in RVR [9:26] Case three: 50M w Syncope [14:33] Reveal [19:57] Retrieving illness scripts [22:29] Typical versus Atypical presentation of diseases [26:12] For full transcript and show notes: https://www.coreimpodcast.com/?p=21028 Tag: medical education, clinical cases, expert clinicians, internal medicine podcast

阿拉伯书法源远流长，派系繁盛。而阿拉伯字母进入中国后，其书法艺术又产生了不同的演变与发展。今天，我们再次邀请到多文字字体的研究与设计者郑初阳，为我们梳理与解读中国的阿拉伯书法。 另，《字谈字畅》三周年庆线下活动，将于 7 月 25 日起开放售票，席位有限，售完即止。 第二十六轮抽奖活动开启，截至 7 月 30 日零时前。本期奖品为嘉宾初阳带来的「印度及周边文字演化图」海报。 参考链接 〈论哈密瓜种植与文化的关系〉，《字谈字畅》第三十三期 阿拉伯字母 小儿经，也称「小儿锦」「小经」等 阿拉伯书法 阿拉伯书法六大书体： 库法体（Kufic）‎ 纳斯赫体（Naskh） 苏鲁斯体（Thuluth） 卢格阿体（Ruqʿah） 波斯体（Nastaʿlīq） 学者体（Muhaqqaq） 迪瓦尼体（Diwani） 阿拉伯书法的「中国体」（Sini） 阿拉伯字母 و（瓦乌） 云南伊斯兰教经籍木雕版 中国现存最早的木刻版《古兰经》 Qalam，一种阿拉伯书法工具 马格里布体 Aisha 字体，设计受马格里布体的启发，Rosetta Type 出品 经字画 嘉宾 郑初阳：3type（三言）联合创始人；毕业于德国德绍包豪斯，初在柏林 MetaDesign 工作，深受 Livius Dietzel 影响；后回国，专注于多文字字体的研究与设计 主播 Eric：字体排印研究者，译者，Type is Beautiful 编辑 蒸鱼：设计师，Type is Beautiful 编辑 欢迎与我们交流或反馈，来信请致 podcast@thetype.com​。如果你喜爱本期节目，也欢迎用 PayPal 或支付宝向我们捐赠，账户与联络信箱一致：podcast@thetype.com​。

Author: Don Stader, M.D. Educational Pearls Common pathologies include cholecystitis, choledocholithiasis, and in concerningly ascending cholangitis. Cholecystitis is obstruction at the cystic duct leading to inflammation of gallbladder wall, while choledocholithiasis is a distal obstruction of the biliary tree, and ascending cholangitis is an ascending infection of the biliary tree secondary to obstruction. Risk factors for Cholecystitis are the 5 F’s (Fat, Forty, Female, Fertile, Family Hx). Classic symptoms seen in ascending cholangitis are Charcot’s Triad of fever, RUQ pain, and jaundice, or Reynold’s pentad which is more severe and has the addition ofaltered mental status and hypotension. Porcelain gallbladder is a radiographic finding showing calcification of the gallbladder that is associated with cancer of the gallbladder. References: Kimura Y, Takada T, Kawarada Y, et al. (2007). "Definitions, pathophysiology, and epidemiology of acute cholangitis and cholecystitis: Tokyo Guidelines". J Hepatobiliary Pancreat Surg. Strasberg, SM (26 June 2008). "Clinical practice. Acute calculous cholecystitis". The New England Journal of Medicine. 358 (26): 2804–11.

In this podcast General Surgeon, Dr. Michael McCall, will review some common causes of RUQ pain as it relates to the biliary system. After listening to this podcast you should be able to: Describe the presentation of Biliary Colic and Cholecystitis Review differential diagnosis and diagnostics Understand treatment of both Biliary Colic and Cholecystitis

Part II of II on gallbladder disorders finishing up with acute cholangitis. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_118_0_Final_Cut.m4a Download Leave a Comment Tags: Gallbladder, Gastroenterology, General Surgery, GI Show Notes Take Home Points Cholangitis is an acute bacterial infection of the bile ducts resulting from common bile duct obstruction and is potentially life-threatening (mortality 5-10%, acute bacterial infection of the bile ducts Diagnosis is based on clinical findings and while imaging can be supportive, it is frequently non-diagnostic. Look for RUQ tenderness with peritoneal signs and fever A normal ultrasound does not rule out acute cholangitis Treatment focuses on supportive care, broad spectrum antibiotics and consultation with a provider that can provide biliary tract decompression (IR, gastroenterology or general surgery) Read More Radiopaedia: Acute cholangitis Core EM: Cholangitis Read More

Part II of II on gallbladder disorders finishing up with acute cholangitis. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_118_0_Final_Cut.m4a Download Leave a Comment Tags: Gallbladder, Gastroenterology, General Surgery, GI Show Notes Take Home Points Cholangitis is an acute bacterial infection of the bile ducts resulting from common bile duct obstruction and is potentially life-threatening (mortality 5-10%, acute bacterial infection of the bile ducts Diagnosis is based on clinical findings and while imaging can be supportive, it is frequently non-diagnostic. Look for RUQ tenderness with peritoneal signs and fever A normal ultrasound does not rule out acute cholangitis Treatment focuses on supportive care, broad spectrum antibiotics and consultation with a provider that can provide biliary tract decompression (IR, gastroenterology or general surgery) Read More Radiopaedia: Acute cholangitis Core EM: Cholangitis Read More

This podcast takes a deep dive into the presentation, diagnosis and management of preeclampsia and eclampsia. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_113_0_Final_Cut.m4a Download Leave a Comment Tags: Eclampsia, Hypertensive Disorders of Pregnancy, Obstetrics, Preeclampsia Show Notes Take Home Points Suspect preeclampsia in any pregnant women presenting with epigastric/RUQ pain, severe or persistent headache, visual disturbances, nausea or vomiting, shortness of breath, increased edema or weight gain Evaluate for preeclampsia by looking at the blood pressure, urine for protein and obtaining a panel to evaluate for HELLP syndrome Severe preeclampsia and eclampsia are treated with bolus and infusion of MgSO4 Emergency delivery is the “cure” for preeclampsia and eclampsia. Consult obstetrics early for an evaluation for delivery Don't forget to consider preeclampsia and eclampsia in the immediate postpartum period Read More Core EM: Preeclampsia and Eclampsia LITFL:

This podcast takes a deep dive into the presentation, diagnosis and management of preeclampsia and eclampsia. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_113_0_Final_Cut.m4a Download Leave a Comment Tags: Eclampsia, Hypertensive Disorders of Pregnancy, Obstetrics, Preeclampsia Show Notes Take Home Points Suspect preeclampsia in any pregnant women presenting with epigastric/RUQ pain, severe or persistent headache, visual disturbances, nausea or vomiting, shortness of breath, increased edema or weight gain Evaluate for preeclampsia by looking at the blood pressure, urine for protein and obtaining a panel to evaluate for HELLP syndrome Severe preeclampsia and eclampsia are treated with bolus and infusion of MgSO4 Emergency delivery is the “cure” for preeclampsia and eclampsia. Consult obstetrics early for an evaluation for delivery Don’t forget to consider preeclampsia and eclampsia in the immediate postpartum period Read More Core EM: Preeclampsia and Eclampsia LITFL: Preeclampsia and Eclampsia

There are 5 key diagnoses classically associated with right upper quadrant (RUQ) abdominal pain. Cholelithiasis and Biliary Colic Cholelithiasis = Gallstones in the gallbladder Frequently seen on CT scan or RUQ ultrasound Present in 15% of the population Biliary colic = Intermittent episodes of pain if stone passes Classically colicky/crampy/spasmy pain in RUQ Frequently radiates […]

Hosts: Vincent Racaniello, Dickson Despommier, and Daniel Griffin The TWiP Trinity solve the case of the Peace Corps volunteer with diarrhea, and reveal how immunizing against a virus ameliorates exacerbated leishmaniasis. Become a patron of TWiP. Links for this episode: Viral vaccine prevents exacerbated leishmaniasis (PLoS NTD) For whom the trich tolls (TWiP 47) A virus in a parasite in a human (virology blog) Virologists in the mist (TWiV 128) Letters read on TWiP 126 This episode is brought to you by Blue Apron. Blue Apron is the #1 fresh ingredient and recipe delivery service in the country. See what’s on the menu this week and get your first 3 meals free - WITH FREE SHIPPING - by going to blueapron.com/twip. Case Study for TWiP 126 Another Peace Corps volunteer in Fiji. 24 yo male, several days of fever, headache, dry cough, rash. Feels poorly, starts diarrhea. No blood or mucus, no vomiting but abdominal discomfort. Heart rate over 100. At private nearby hospital for evaluation: no prior med probs or surgeries. Social history: MSM, not always protected, drinks every weekend. Home blown away by cyclone. Alcohol: drinks beer, a lot. White rice, split peas, bread diet. Fan of cava, also drank unfiltered water. He is admitted, continues to feel poorly. Continued fevers, localized abdominal pain RUQ. On exam he has tender palpable liver, elevated WBC 17.8, eosinopenia, 0 cells. AST/ALT slightly above normal. Dengue, chick, lepto, blood all negative. Ultrasound of liver: shows 8x8 cm mixed echogenic lesion in right lobe. HIV negative.  Send your case diagnosis, questions and comments to twip@microbe.tv

「文化就像种哈密瓜，最甜的哈密瓜一定是通过远距离的嫁接而形成。」西域维吾尔语的使用者，就是一个广泛吸纳了中东波斯文化、东欧俄罗斯文化及中国内地汉文化的族群。文化的糅合，也从维吾尔文字及其字体中折射出来。 今天，我们有幸邀请到多元文化设计师郑初阳，与听众分享维吾尔文字体的语言基础、历史变迁及文化背景。 此外，第二轮抽奖活动也将开始：本轮两位幸运听众，将获赠嘉宾精心准备的礼物，海报「丝绸之路上的百年字体」，截至 11 月 7 日零时前。 参考链接 坂本伸二著，刘庆译．《设计入门教室：设计的基本规则》．北京：中信出版社，2016 年 听众亦佳与我们分享的照片（1 / 2 / 3 / 4），来自 Phil Baines 教授字体兴趣组活动 初阳设计（Chuyang Design），由设计师主导，并与社会学家、人类学家、历史学家协同作业的设计工作室 郑初阳今年初在 Type is Beautiful 撰文介绍维吾尔字体近百年的历史 Nadine Chahine，黎巴嫩籍字体设计师，阿拉伯文字体设计专家，现于 Monotype 英国任字体设计总监 Frutiger Arabic 维吾尔语 阿拉伯字母 波斯字母 维吾尔字母 西里尔字母 / 基里尔字母 西里尔维文（USY） 《维吾尔之声》（Uyghur Awazi），一份哈萨克斯坦报纸 Murat Nasyrov（木拉提·纳斯洛夫；ULY：Murat Nasirow），俄罗斯歌手，曾发表过维语专辑 老维文（UEY） 新维文（UYY） 拉丁维文（ULY） 誊抄体 / 纳斯赫体（Naskh نسخ） 棱角体 / 库法体（Kufic كوفي）‎ 三一体 / 苏鲁斯体（Thuluth ثلث‎） 卢格阿体（Ruqʿah رقعة‎） 纳斯·泰阿利格体 / 波斯体（Nastaʿlīq نستعلیق） Zapfino Arabic Kashida Neifs，维吾尔文字体，郑初阳设计 《字谈字畅》抽奖程序，基于「梅森旋转算法」生成伪随机数序列，随机种子源自抽奖时刻以毫秒为单位的 Unix 时间 嘉宾 郑初阳：活跃在多种文化间的平面设计师，字体设计师 早年在柏林 MetaDesign 工作，深受 MetaDesign 的字体设计传统影响，与外文字体设计和理论研究结下不解之缘，对「多文字字体匹配」（Matchmaking）设计倾注了极大的热情和精力。郑初阳认为，字体设计不仅仅是外观的问题，更是折射背后文化的三棱镜。 字体作品包括拉丁、阿拉伯双文正文字体 Nefis、Dessau Sans，汉文字体 Livory Song，以及拉丁、西里尔、阿拉伯三文标题字体 Faustina 等。更多作品，可访问「初阳设计」网站。 主播 Eric：字体排印研究者，译者，Type is Beautiful 编辑 蒸鱼：设计师，Type is Beautiful 编辑 欢迎与我们交流或反馈，来信请致 podcast@thetype.com。如果你喜爱本期节目，也欢迎用 PayPal 或支付宝向我们捐赠，账户与联络信箱一致：podcast@thetype.com。

A Prisoner Poked, A Galleon Gorged, A Star searched for and Lieutenants Lathered! There's Jewelry traded, Brandy Stolen, Flintlock anesthesia and Ruckus from a Ruq! Don't miss it!