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CMC Chief Case Conference - '15-'16 Chiefs

5/28/2015

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Sneaky Ectopic - Dr. Nichols

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  • Don't let a beta HCG lull you to sleep, if your suspicion is high, get an ultrasound and/or discuss with OBGYN.
  • Beta HCG assays vary significaltly between labs, for accurate results try to maintain the same testing assay.
  • Anchoring is a dangerous bias that places you at high risk to miss key and potentially life-threatening diagnoses.
  • To avoid anchoring, be judicious about a "diagnostic pause" and await diagnosing patients until all information is available.


GIB and Aortic Graft - Dr. Beverly

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  • History and physical is the foundation of medical decision making. Complete a good chart biopsy. Undress the patient fully. If not,  you may miss a crucial piece of information that will alter your decision making.
  • Aortoenteric fistula is a can't miss diagnosis. In a patient with a GI bleed and a known graft, this is your diagnosis until proven otherwise. 100% mortality if left untreated.
  • Consult vascular early of you suspect this diagnosis. Treatment involves early resuscitation and rapid operative intervention.


Pulmonary embolism + pleural effusion - Dr. West

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  • Up to one half patients with PE’s with have a pleural effusion on CT, one third if just looking at CXR
  • Usually unilateral and small
  • Usually exudative
  • If a patient has a small pleural effusion and pleuritic chest pain, think pulmonary embolus


Traumatic Ptx, Be Kind - Dr. Robertson

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  • Set your trauma rooms up ahead of time, know what to look for early in the patient's physical exam. 
  • Review the concepts of correct position and chest tube insertion techniques
  • Pigtail catheters are as efficacious as large bore chest tubes for traumatic pneumothorax
  • Keep an eye out for more data on Pigtails for blood in the chest. 
  • Large bore chest tubes remain standard of care for hemothorax, hemopneumothorax or concern for barotrauma in already vented patient's (even if pneumothorax is small). 

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Ovarian Torsion: Rocephin Won't Cure This ONe - Dr. Thacker

5/22/2014

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1.) Be concerned about ANY female presenting with acute, unilateral abdominal pain.

2.) Do not let a normal ultrasound dissuade you in a patient you are particularly concerned about.

3.) Torsion is a surgical emergency! Time to detorsion is crucial! 

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M&M - Dr. Bronner

5/1/2014

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Thyrotoxicosis and Cardiomyopathy

  • Hyperthyroid effects on the cardiovascular system are not the same as hyperadrenergic states
  • Direct effects on vascular smooth and cardiac tissue leads to:
    1. Decreased SVR
    2. Decreased diastolic BP = Decreased afterload
    3. Activation of Renin-Angiotensin-Aldosterone = Increased Preload
    4. Direct cardiac inotropy + chronotropy
  • Ultimately, increased CO (HRxSV) that can lead to HF and dysrhythmias
    1. May be catastrophically precipitated by stressors such as sepsis 
  • Treatment of Thyroid Storm
    1. B-Blockade
    2. Thyroid Inhibition
      1. Synthesis  -   PTU or Methimazole
      2. Release   -   SSKI
      3. Periph Conversion (T4 to T3)  -   Hydrocortisone
HIV and PID

  • Suspect HIV in any severe febrile illness without a source
  • Know emerging demographics - Minority, heterosexual, women
  • PID treatment in HIV+ patients has similar approach and outcome as HIV-
    1. HIV+ may be more likely to develop TOA
  • IUDs are do not predispose to PID after the first 3 weeks post-placement
  • Usual culprit : Actinomyces, but treat for GC/CT!

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TuboOvarian Abscess - Dr. Pinzon

1/30/2014

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TOA
    - Has same risk factors as PID
        - Multiple sexual partners
        - 15-25 yrs old
        - History of prior PID

2 forms 
    - Tobuovarian complexes (agglutination of pelvic organs +/- bowel)
    - Collection of pus

    - Often begins with DTD, but once abscess forms it is usually polymicrobial

  > Think about when you have suspicion for PID but are acutely ill, failure of treatment with normal therapy; diffuse abdominal pain

  > Imaging = US is 1st choice
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Pregnancy Complications - Dr. Jyothindran

1/23/2014

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Infection

      > 2-7 days post abortion - ascending infection; risk factors include operative intervention, retained POC             advanced gestation

     Retained POC = endometrial stripe >5mm on TVUS

      > Sx - history, fever (though common to not have a fever), abd pain, discharge, vaginal bleeding, tender         uterus, adnexa

      > Antibitoic regimens
            - Outpatient - levaquin, flagyl;
            - Inpatient - vanc, zosyn +/- amp/gent vs vanc and meropenam;
            Remember tetanus

Rh immunization - Rh negative mom, Rh positive fetus - with mixing of maternal and fetal blood; not a lot of great clinical evidence out there so unclear if our Rhogam dosage is correct, unclear how much maternal bleeding is required to have alloimmunization


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  • RESIDENCY
    • About CMC
    • Curriculum
    • Benefits
    • Explore Charlotte
    • Official Site
  • FELLOWSHIP
    • Fellowships at CMC
    • EMS
    • Global EM
    • Pediatric EM
    • Toxicology >
      • Tox Faculty
      • Tox Application
  • PEOPLE
    • Program Leadership
    • PGY-3
    • PGY-2
    • PGY-1
    • Alumni
  • STUDENTS/APPLICANTS
    • Medical Students at CMC
    • EM Acting Internship
    • Healthcare Disparities Externship
    • Resident Mentorship
  • #FOAMed
    • EM GuideWire
    • CMC Imaging Mastery
    • Pediatric EM Morsels
    • Blogs, etc. >
      • CMC ECG Masters
      • Core Concepts
      • Cardiology Blog
      • Dr. Patel's Coding Blog
      • Global Health Blog
      • Ortho Blog
      • Pediatric Emergency Medicine
      • Tox Blog
  • Chiefs Corner
    • Top 20
    • Current Chiefs
    • Schedules >
      • Conference/Flashpoint
      • Block Schedule
      • ED Shift Schedule
      • AEC Moonlighting
      • Journal Club/OBP/Audits Schedule
      • Simulation
    • Resources >
      • Fox Reference Library
      • FlashPoint
      • Airway Lecture
      • Student Resources
      • PGY - 1
      • PGY - 2
      • PGY - 3
      • Simulation Reading
      • Resident Wellness
      • Resident Research
      • Resume Builder
    • Individualized Interactive Instruction