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By: Jennifer Lynn Garst, MD

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  • Member of the Duke Cancer Institute

https://medicine.duke.edu/faculty/jennifer-lynn-garst-md

Evidence for the Use of Initial Care There are no quality studies incorporated into this analysis medications not to take with blood pressure meds purchase 100 ml duphalac free shipping. Of the zero articles considered for inclusion treatment varicose veins buy duphalac 100 ml on line, zero randomized trials and zero systematic studies met the inclusion criteria medicine dictionary pill identification buy duphalac 100 ml low cost. Of the 4 articles considered for inclusion medicine to stop runny nose cheap duphalac 100 ml amex, 0 randomized trials and 2 systematic studies met the inclusion criteria. Follow-up Visits Patients generally require from 1 to 6 appointments, depending on severity and need for workplace limitations. Greater numbers of appointments may be required for evaluating and treatment pain and monitoring function and work status over time. Frequency/Duration – Scheduled dosage rather than as needed is generally preferable. Indications for Discontinuation – Resolution of pain, lack of efficacy, development of adverse effects particularly gastrointestinal. These medications are not invasive, have low adverse effects for short-term use in employed populations, and are not costly. Evidence for the Use of Exercise There are no quality studies incorporated into this analysis. Of the zero articles considered for inclusion, zero randomized trials and zero systematic studies met the inclusion criteria. Strength of Evidence – Recommended, Insufficient Evidence (I) Level of Confidence – Low Rationale for Recommendation 173 Copyright© 2016 Reed Group, Ltd. However, in select cases with ulna positive variance and without resolution of considerable or incapacitating symptoms or lacking trending towards resolution, this procedure is recommended. This procedure is invasive, has adverse effects, may not be effective, but also may provide either cure or relief of symptoms and thus is recommended for select cases. Evidence for the Use of Surgery There are no quality studies incorporated into this analysis. Strength of Evidence – Recommended, Insufficient Evidence (I) Level of Confidence – High Rationale for Recommendation There are no quality studies evaluating the use of x-rays for crush injuries or compartment syndrome. However, x-rays are essential for evaluating the extent of injuries and identification of fractures. Evidence for the Use of X-rays There are no quality studies incorporated into this analysis. Strength of Evidence – Recommended, Insufficient Evidence (I) Level of Confidence – Moderate Rationale for Recommendation 174 Copyright© 2016 Reed Group, Ltd. Recommendation: Elevation and Relative Rest for Acute Crush Injuries or Compartment Syndrome Elevation and relative rest are recommended for treatment of acute crush injuries or compartment syndrome. Strength of Evidence – Recommended, Insufficient Evidence (I) Level of Confidence – Moderate 2. Recommendation: Splinting for Subacute Crush Injuries or Compartment Syndrome Splinting is recommended after initial treatment for moderate or severe acute and subacute crush injuries or compartment syndrome. Strength of Evidence – Recommended, Insufficient Evidence (I) Level of Confidence – Low 3. Recommendation: Self-application of Ice for Acute Crush Injuries or Compartment Syndrome Self-application of ice is recommended for treatment of acute crush injuries or compartment syndrome. Strength of Evidence – Recommended, Insufficient Evidence (I) Level of Confidence – Low 4. Recommendation: Self-application of Heat for Acute Crush Injuries or Compartment Syndrome Self-application of heat is not recommended for treatment of acute crush injuries or compartment syndrome. Strength of Evidence – Not Recommended, Insufficient Evidence (I) Level of Confidence – Low Rationale for Recommendations There are no quality studies evaluating rest/elevation, splinting, or self-application of ice or heat to treat crush injuries or compartment syndrome. However, elevation, rest, and ice are believed to be helpful for treatment of these conditions and in milder cases may be the principal treatments administered. These interventions are not invasive, have no adverse effects, and are not costly (other than repeated administrations of cryotherapies in hospital settings where monitoring is required); thus, they are recommended. Splints may assist in symptomatic relief, are not invasive, have few adverse effects, and are low to moderate cost. The type of splint required depends on the type of injury and subsequent debility. Splints are recommended particularly for patients with moderate to severe injuries. Evidence for the Use of Initial Care There are no quality studies incorporated into this analysis. Of the 5,739 articles considered for inclusion, zero randomized trials and 1 systematic studies met the inclusion criteria. Follow-up Visits Patients generally require multiple follow-up appointments with the number dependent on the severity of the injury. Severe cases of compartment syndrome or crush injuries that have major medical complications and activity limitations may require dozens of appointments to evaluate, treat, advance activity limitations and otherwise monitor and actively facilitate clinical progress. Moderate and severe crush injuries and compartment syndrome usually require occupational or physical therapy for teaching mobilization and strengthening exercises. Medications Over-the-counter medications may be helpful, but most patients require prescription medications for pain, particularly for moderate to severe injuries. Indications – Pain due to acute or subacute crush injuries or compartment syndrome. Frequency/Duration – Scheduled dosage rather than as needed is generally preferable. Indications for Discontinuation – Resolution of pain, lack of efficacy, development of adverse effects, particularly gastrointestinal. There is one trial with non-specific limb injury suggesting efficacy of diclofenac (Woo 05. These medications are helpful for numerous other musculoskeletal disorders and are believed helpful for these injuries. Of the 2 articles considered for inclusion, 1 randomized trials and 1 systematic studies met the inclusion criteria. Author/Year Score Sample Size Comparison Results Conclusion Comments Study Type (0-11) Group Woo 2005 5. Paracetamol Vs diclofenacover single group Diclofenac and paracetamol group nonsteroidal 35. Median patient satisfaction Follow-up at scores (out of baseline and at 5-8 days after initial 10) with the oral presentation. Evidence for the Use of Exercise There are no quality studies incorporated into this analysis. This frequently includes emergency fasciotomy for release of tension from compartment syndromes as well as other surgical procedures to address fractures and other remediable defects. Of the 8 articles considered for inclusion, 1 randomized trial and 5 systematic studies met the inclusion criteria. This frequently includes emergency fasciotomy for release of tension from compartment syndromes as well as other surgical procedures to address fractures and other remediable defects. Strength of Evidence – Recommended, Insufficient Evidence (I) Level of Confidence – High Rationale for Recommendation There are no quality studies evaluating surgeries for crush injuries or compartment syndrome of the hand or forearm and the clinical variability between patients is large. However, fasciotomies are particularly essential for treatment of significant neurovascular compromise from compartment syndrome and is a surgical emergency. Evidence for the Use of Surgery There are no quality studies incorporated into this analysis. Of the 7 articles considered for inclusion, 0 randomized trials and 1 systematic study met the inclusion criteria. Of the 3 articles considered for inclusion, 0 randomized trials and 2 systematic studies met the inclusion criteria. Kienbock Disease Diagnostic Criteria Patient has non-radiating wrist compartment pain, limited range of motion, and developed x-ray evidence of radiological collapse of the lunate. Strength of Evidence – Recommended, Insufficient Evidence (I) Level of Confidence – High Rationale for Recommendation There are no quality studies evaluating the use of x-rays to diagnose Kienbock disease. However, x-rays are used to confirm the diagnosis and are moderately costly, thus they are recommended. Evidence for the Use of X-rays There are no quality studies incorporated into this analysis. Strength of Evidence – Recommended, Insufficient Evidence (I) Level of Confidence – Moderate 180 Copyright© 2016 Reed Group, Ltd.

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Laboratory studies show: Serum + Na 138 mEq/L fi Cl 100 mEq/L Arterial blood gas analysis on room air: pH 7 treatment 3 cm ovarian cyst cheap 100 ml duphalac amex. A 67-year-old man is brought to the emergency department because of a 1-week history of nausea medicine wheel native american discount duphalac 100 ml amex, generalized weakness medicine that makes you poop purchase duphalac 100 ml on-line, and malaise treatment 1860 neurological buy generic duphalac 100 ml. Current medications include lisinopril, digoxin, isosorbide, spironolactone, and metoprolol. Laboratory studies show: Hematocrit 36% 3 Leukocyte count 10,000/mm Serum + Na 140 mEq/L + K 7. A previously healthy 19-year-old college student comes to student health services 24 hours after the onset of headache, stiff neck, and sensitivity to light. She received all appropriate immunizations during childhood but has not received any since then. A 64-year-old woman comes to the physician because of a 5-month history of increasing shortness of breath, sore throat, and a cough productive of a small amount of white phlegm. She has asthma treated with theophylline and inhaled fi-adrenergic agonists and corticosteroids. She has smoked one pack of cigarettes daily for 44 years and drinks one alcoholic beverage daily. There are right lower peritracheal, precarinal, right hilar, and subcarinal lymph nodes. A grade 2/6 systolic ejection murmur is heard along the upper left sternal border. Since returning, he has noticed that his stools have changed in size and consistency. Laboratory studies show: Hemoglobin 11 g/dL 3 Mean corpuscular volume 72 fim 3 Platelet count 300,000/mm Red cell distribution width 16% (N=13%–15%) Which of the following is the most appropriate next step in diagnosisfi A 22-year-old man comes to the physician for a routine health maintenance examination. Examination shows a 6-cm, soft, nontender left scrotal mass that transilluminates; there are no bowel sounds in the mass. A 27-year-old nurse comes to the emergency department because of nervousness, dizziness, palpitations, and excess perspiration for the past 3 hours. She has been drinking two alcoholic beverages daily for the past month; before this time, she seldom drank alcohol. A 38-year-old woman comes to the physician because of a low-grade fever and generalized rash for 4 days. Laboratory studies show: 3 Leukocyte count 10,800/mm Segmented neutrophils 60% Bands 8% Eosinophils 4% Lymphocytes 20% Monocytes 8% Serum Urea nitrogen 20 mg/dL Creatinine 1. A 25-year-old man is brought to the emergency department after being discovered semiconscious and incoherent at home. Three days after hospitalization for diabetic ketoacidosis, an 87-year-old woman refuses insulin injections. She says that her medical condition has declined so much that she no longer wishes to go on living; she is nearly blind and will likely require bilateral leg amputations. She reports that she has always been an active person and does not see how her life will be of value anymore. She accurately describes her medical history and understands the consequences of refusing insulin. She dismisses any attempts by the physician to change her mind, saying that the physician is too young to understand her situation. A 5-year-old boy is brought to the physician by his mother because of a 2-day history of a low-grade fever, cough, and runny nose. The physician refers to a randomized, double-blind, placebo-controlled clinical trial that evaluated the effectiveness of a new drug for the treatment of the common cold. The mean time for resolution of symptoms for patients receiving the new drug was 6. Which of the following is the most appropriate interpretation of these study resultsfi A 22-year-old man is brought to the emergency department 30 minutes after he sustained a gunshot wound to the abdomen. Abdominal examination shows an entrance wound in the left upper quadrant at the midclavicular line below the left costal margin. A 19-year-old man comes to the physician because of a 3-week history of malaise, generalized fatigue, swelling of his legs, and dark urine. A renal biopsy specimen shows a crescent formation in the glomeruli and immune complex deposition along the basement membrane. The most appropriate next step in management is administration of which of the followingfi A previously healthy 17-year-old girl comes to the physician because of a 2-month history of exercise-induced cough and nasal congestion. She plays field hockey and has noticed she coughs when running up and down the field. A 62-year-old white man comes to the physician because of an 8-month history of progressive pain and stiffness of his hands. There is mild tenderness over the second and third metacarpophalangeal joints bilaterally without synovial thickening. Heberden nodes are present over the distal interphalangeal joints of the index and ring fingers bilaterally. Laboratory studies show: Hemoglobin 16 g/dL 3 Leukocyte count 7700/mm 3 Platelet count 332,000/mm Serum Glucose 182 mg/dL Albumin 3. A 32-year-old man who is a jackhammer operator comes to the physician because of pain and swelling of his right arm for 3 days. A 4-year-old boy with asthma becomes limp during treatment with inhaled albuterol in the emergency department. Ten minutes ago, he received intravenous methylprednisolone for an acute exacerbation, and he was alert and oriented at that time. He received the diagnosis of asthma 2 years ago and has been admitted to the hospital for acute exacerbations eight times since then. The point of maximal impulse is 2 cm to the left of the midclavicular line in the sixth intercostal space. A 62-year-old woman comes to the physician for a routine health maintenance examination. On questioning, she has had fatigue, constipation, and a 9-kg (20-lb) weight gain during the past year. A previously healthy 32-year-old man is brought to the emergency department after being found unconscious on the floor at his workplace. After receiving intensive medical care for 6 hours, the patient develops decerebrate posturing and becomes hemodynamically unstable. During the meeting, they say that they were unaware of his willingness to be an organ donor and agree that he should not receive cardiopulmonary resuscitation. Which of the following is the most appropriate next step with respect to organ donationfi A 6-year-old boy is brought to the emergency department 2 hours after injuring his arm when he fell out of a tree. During the past year, he fractured his right tibia after falling off a trampoline and sustained a concussion after falling off his bicycle. She says that his teachers reprimand him frequently for running wildly in the classroom, talking excessively, and getting out of his seat; he often forgets to turn in his homework. Physical examination shows a dislocated left shoulder, healing abrasions over the elbows, and ecchymoses in various stages of healing over the knees. A previously healthy 18-year-old man is brought to the emergency department because of abdominal pain and nausea for 6 hours. A 42-year-old woman comes to the physician because of a 1-year history of vaginal bleeding for 2 to 5 days every 2 weeks. Menses previously occurred at regular 25to 29-day intervals and lasted for 5 days with normal flow. She is sexually active with one male partner, and they use condoms inconsistently. Her mother died of colon cancer, and her maternal grandmother died 2 of breast cancer. A 15-year-old boy is brought to the physician because of fatigue since starting his freshman year of high school 3 months ago. He urinates four to five times nightly and often has difficulty falling asleep again.

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Fernando Silva) shows how you can use the lung point to estimate the extent of a pneumothorax medications in carry on luggage order 100 ml duphalac otc. Again medicine vs engineering cheap duphalac 100 ml visa, research Pleural Effusion has shown not only is lung ultrasound comparable to chest radiography treatment internal hemorrhoids generic 100 ml duphalac with mastercard, it may be superior treatment qt prolongation order duphalac 100 ml without prescription. In addition to its diagnostic value, thoracic 4-6 ultrasound is able to assist in procedural guidance as well. This application takes advantage, again, of the ability of the wellaerated lung to scatter sound. When looking in the anterior or posterior axillary line in the longitudinal plane with a low frequency probe, the diaphragm should be identified. Pericardial effusions and pleural effusions can be differentiated based on position of fiuid. The lack of a mirror image artifact indicates that neously breathing patient 4. In this case, we have another way to identify pleural fiuid, which is Animation demonstrating the reverberation and reflection known as the spine sign. This, again, makes use of sounds ability to that takes place with a normal lung and the diaphragm. The spinous In this case, the ultrasound machine will assume the sound wave travprocesses and vertebral bodies are deep to the kidney and spleen/ eled in a straight line, and so liver tissue refiections will appear both liver when looking from the mid-axillary probe position. Left-sided effusions can be seen in the far field of a parasternal long axis cardiac image and taper to the descending thoracic aorta where pericardial effusions would cross anterior to the aorta (Movie 4. Right-sided effusions can be seen deep to the diaphragm in a subxiphoid cardiac view (Movie 4. Clinical correlation is imperative as interstitial thickening can be a process of pulmonary edema, pulmonary fibrosis, infection or tumor/scarring. In the right clinical scenario, however, pulmonary ultrasound has been shown to be superior to chest radiography 10 in identifying interstitial disease. The scanning technique uses the low frequency probe to scan in eight zones of the thoracic cavity to get a good sense of the distribution of disease 4. Ultrasound can be used to identify pulmonary edema, pulmonary fibrosis, and infection. In per zone is considered pathologic, and that zone is considered posigeneral, congestive heart failure and pulmonary edema are caused tive for interstitial disease. The more B-lines that are present, the by fiuid translocation, and so the pleural line in pulmonary edema more pathologic the interstitial process, and this holds true across the will remain thin and regular (Movie 4. In contrast, diffuse infecdisease spectrum including pulmonary edema, pulmonary fibrosis, tion or infiammation causing interstitial disease will tend to affect the 8,9,11 and infection. Patients with high initial B-line scores had a worse prognosis and higher event scores at 16 months than patients with low B-line scores. B-line scores outperformed other echo14 cardiographic variables as a univariate predictor. Lung ultrasound can distinguish between lung consolidation and atelectasis Video showing consolidation. This finding has been well correlated with areas of consolidation on chest radiographs and with chest computed tomography. Indeed, multiple studies have shown that lung sonography is as sensitive and specific as computed tomography for pneumonia, and it is a distinct 82 15-17 improvement over chest radiography. In fact, the spectrum of inesses, such as pneumonia or other infectious processes, the bronchi fectious pulmonary disease reliably progresses from focal areas of will be generally unobstructed, and because of the distinct difference interstitial disease. One interesting advantage of lung sonography is that it appears it can distinguish between lung consolidation and atelectasis, which is oftentimes a challenge for chest radiography. In contrast, atelectasis is a result of bronchial plugging, and so the air column within the consolidation is not mobile and is described as static (Movie 4. As observed in patients undergoing dialysis, the B21 lines of fiuid overload appear to resolve in hours. As observed in Function patients undergoing increases or decreases in the positive endexpiratory pressure settings on ventilators, the consolidation and B22 lines appear or disappear rapidly. This has led to a series of recent articles looking at whether or not lung sonography could, in fact, replace chest radiography for both emergency and critical care 10,18,19 patients. Traumatic pneumothorax detection with thoracic ultrasound: we d g e p re s s u re a n d ex t ra va s c u l a r l u n g wa t e r. Emergency thoracic ultrasound in the differentiapine chest radiography and bedside ultrasound for the diagnosis of tion of shortness of breath: sonographic B-lines and N-terminal protraumatic pneumothorax. Ultrasound lung comets in systemic sclerosis: a chest 86 sonography hallmark of pulmonary interstitial fibrosis. Real-time resolution of sonographic B-lines in a patient with pulmonary edema on 13. Sperandeo M, Varriale A, Sperandeo G, Filabozzi P, Piattelli continuous positive airway pressure. Prognostic value of extravascular lung water assessed with ultra2009;135:1433-9. Lung ultrasound is an accurate diagnostic tool for the diagnosis of pneumonia in the emergency department. Historically, there has been far less urgency to use ultrasound to evaluate the medical patient with hypotension or signs of shock. The main reasons for this discrepancy are the lack of a universally accepted name for the exam and a standardized sequence of views to obtain. This site may be sub-xiphoid, but more often it is on the anterior the parasternal long axis view and apical four chamber view are chest wall. Ultrasound-guided pericardiocentesis is safer than a blind used to assess for pericardial fiuid, which is best identified posterior 7 sub-xiphoid procedure. In the same parasternal long view, if lism is more likely to present with only indirect signs. Ideally, a large pocket of noses are massive pulmonary embolism and right ventricular infarcfiuid with a good amount of space between the pericardium and the tion. While more pressure will also be seen well on the parasternal short axis view, complicated procedures allow a numeric estimate of the ejection frac8 causing a D shaped left ventricle (see Movie 5. Enlargement of the right ventricle can also occur from right ventricuIn parasternal long view, at the level of the papillary muscles, a lar infarction. The exam outlined below Inferior Vena Cava is a dynamic evaluation of filling pressures based on respiration. The exam is conducted differently depending on whether the patient is spontaneously breathing or if the patient is on mechanical ventilation. This view is most easily obtained by first obtaining a subxiphoid four-chamber view of the heart and then, with the right atrium centered on the screen, rotating the probe 90 degrees on its axis. If the patient is intravascularly depleted in this setting, they will need agents to increase their inotropy or decrease their afterload before fiuids will be helpful. In addition, the ventilator 96 should be adjusted to deliver 10 ml/kg of tidal volume. Even in patients with acute lung injury, placing a patient on this tidal volume for the ~20 seconds of measurement will cause no ill effects. Unfortunately, these studies calculated their cut-off points using different formulae. Values greater than this predict an increase in cardiac output to a fiuid challenge. If there is not time to complete all of these views, an image of Morisons pouch with the patient in Trendelenburg position is sensitive for 14 significant intraperitoneal blood or fiuid. When performing the upper quadrant views, sliding the probe up to the thorax allows us to image the interface between lung and dia15 phragm for hypoechoic fiuid or blood in either hemithorax. We prefer to scan Aorta the aorta in transverse orientation at four levels: just below the heart, 16 suprarenal, infrarenal, and just before the iliac bifurcation. By sliding the probe down from the xiphoid to the umbilicus, these four views can be obtained in a continuous and rapid fashion (see Movie 5. Scan the anterior chest wall of both thoraces with probe held in a parasagittal orientation from the midclavicular second intercostal space to the last rib with a high frequency linear, microconvex or phased array probe. Normally apposed pleural surfaces will appear to slide against one another resulting in a shimmering effect. Pathognomonic for pneumothorax is the pleura, is observed, then pneumothorax is likely. When this lung point is found, you will stem bronchus intubation and on the ipsilateral side with bronchial see normal pleural sliding on one side of your screen with loss of slidobstruction. In these cases, identification of lung pulse (see Movie ing on the other (see Movie 5.

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