Benign skeletal condition of increased focal bone resorption and disordered bone formation in age >50 years
Autosomal Dominant (with incomplete penetrance) related to SQSTM1 Mutations that are responsible for 50% of familial and 30% of sporadic cases
Asymptomatic initially in 70% of cases, incidental elevation of Alkaline Phosphatase and most commonly involves Pelvis, thoracolumbar spine, skull and proximal long bones
Preferred treatment is Zoledronic acid (Reclast) whose effect typically lasts >5 years
Home Visit (prevent, hme)
Overview of indications, approach, preparation, safety, efficacy, billing
Update Tetanus Vaccine at 5 years with Tdap or Td (or DTaP if age <7 years) if severe wounds, crush injuries, punctures or burns, or contaminated (dirt, feces)
ET3 is a Medicare Five year pilot program allowing EMS additional reimbursed transport options beyond the Emergency Department
In addition to ED transport, patients may be transported to appropriate medical facility (e.g. urgent care, clinic office, sober center, mental health facility)
EMS may also coordinate care by qualified healthcare practitioner or QHP (Medicare enrolled physician, PA or NP) on site or via Telemedicine
Initial trials of the program prior to ET3 release demonstrated safety and cost reduction for Medicare population
Major surgery results in fever in 15-40% on postoperative day 1 (most without infection), and it typically resolves in first 24-48 hours (if not infectious)
Atelectasis is coincidental, but not causative of fever (Atelectasis and fever are both caused by major surgery)
Analgesics should specifically target pain and should not be used for sedation; typically start with Fentanyl and wean to Acetaminophen and longer acting Opioids
Post-intubation sedation typically starts with Propofol, then transitions to Precedex for weaning, but consider Ketamine with or without Clonidine
Since 2011, CT Head was considered sufficient within 6 hours of acute onset severe Headache in neurologically intact patient
However, there has been growing evidence that even under 6 hours, Lumbar Puncture should still be performed after negative CT Head in high suspicion cases
Causes include Bacteremia including Endocarditis, contiguous spread from intra-abdominal infection or peritonitis and candiasis in Immunocompromised patients
May re-dose medication if medication taken within 15 minutes of Vomiting (or intact drug seen in Emesis)
May re-dose medication IF risk of missed dose outweighs risk of extra dose
Avoid re-dosing of medications at higher risk of toxicity (e.g. antiocoagulation), with rapid absorption (e.g. liquids) or little impact of one missed dose
Diuretics are for symptom control and not the primary CHF treatment
Start Furosemide (Lasix) 20-40 mg orally daily in AM (increase to 40 to 160 mg per dose, twice daily) and double the dose until Urine Output increases (exceeds threshold)
With prolonged use (years), causes Retinal damage (Pigmentary Maculopathy) with Retinal pigment changes that result in Blurred Vision and difficulty in adjusting to dim lighting
Whole cows milk is preferred for age 1-2 years, and unsweetend Fortified Soy Milk may be used as an equivalent to cow's milk
Other non-cow's milk (almond milk, rice milk, coconut milk, hemp milk) are not recommended since they are associated with decreased adult height and decreased Vitamin D
CF Transmembrane Conductance Regulator (CFTR) Modulatorsa are CF disease modifying agents that partially return function of chloride channels, resulting in less mucus accumulation
Trikafta (elexacaftor/tezacaftor/ivacaftor) is a new agent released in 2020, that targets gene mutation found in 90% of CF patients (contrast with 50% for other agents)
To maximize absorption, take with fat containing food such as peanut butter or avocado, and with Pancreatic Enzymes
Among the more complicated retained skin foreign bodies are broken needles, which may occur in IVDA, Subcutaneous Injections (e.g. Insulin) or acupunture
Along with the typical complications of retained foreign bodies (e.g. infection, Granuloma), needle fragments may also embolize
Consider especially in exclusively Breast fed infants of darker skin and reduced sunlight exposure (esp. winter)
Classic XRay Findings consistent with Rickets at metaphysis include Forearm/tibia cupping (scalloping) of metaphysis, fraying (tattered rope appearance) at metaphysis, widened metaphysis (splayed)
Risk of Radial Nerve injury (including posterior interosseous nerve which branches from Radial Nerve); perform a careful Hand Neurovascular Exam (esp. extension of thumb, wrist and MCP joint)
Effects up to 6% of children and is the most common cause of monocular Vision Loss in children and causes irreversible blindness in nearly 3% of adults
Early recognition and treatment is key (ideally before 3-5 years old) and Photoscreening with an iphone is an effective strategy
Ophthalmology referral indications have been expanded
After correction of primary eye disorders (e.g. Congenital Cataracts), patching, glasses and Atropine drops obscuring the good eye, are the main treatment strategies
In adults, substituted judgment is based on knowing a patient's opinions and values and the surrogate acts on what they believe the adult patient would want
However, younger children do not typically have the ability to understand their medical options and make decisions
Instead, parents and surrogates practice what they interpret as best interests of the child, although "Best interest" is often difficult to determine, and may reasonably vary from one surrogate to another
Nonmaleficence ("do no harm") may be a more manageable way to judge surrogate decision making, in which the clinician should consider whether surrogate decision making risks significant child harm
Although immediate cardioversion is indicated in unstable primary Atrial Fib RVR, it may be harmful in secondary cause
If Hypotension is due to Atrial Fibrillation with rapid rate, expect the patient to be cool; contrast with Sepsis with vasodilation, in which the patient's skin will be warm
Expect typical rates for Atrial Fibrillation rapid ventricular response (130-140 if younger, 110 if older); Heart Rate of 160 suggests compensatory Tachycardia for secondary cause (e.g. Sepsis)
CCTA is an option evaluation of Low Risk Chest Pain patients in the prediction of short-term significant coronary event (risk 0.2-0.3% or 2-3 per 1000)