Carolinas case conference - Dr. S. Pecevich

Internal Hernias

• With patients status post gastric bypass, beware of the internal hernia and have low threshold to consult gastric bypass surgeon in abdominal pain!
• CT scan may fail to reveal internal hernia in up to 20% of cases, and the diagnosis can be missed on initial read.
• Abdominal pain in pregnancy? There’s more than just the uterus, so remain vigilant and keep a broad differential.
• Be wary of sending people home after repeat IV pain medication.
  

 
Osteomyelitis, MSSA bacteremia and pediatrics

• No great single test to diagnose osteomyelitis--keep a high index of suspicion.
• In pediatrics, lactate can be unreliable and should be used to rule in, not rule out.
• Pediatric populations can decompensate quickly, and a normal BP is likely the last vital sign to go in setting of shock. Track perfusion, as skin mottling, AMS and urine output will change before the patient’s BP will.
• MSSA toxic shock — PVL is a toxin seen in MSSA osteomyelitis with high morbidity.
• Vancomycin should be used as initial antibiotic when concerned for staph bacteremia. Vancomycin over Clindamycin -- May be up to 30% MRSA clindamycin resistance in Charlotte area,

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