You diagnose a patient with benign paroxysmal positional vertigo (BPPV) based on the Dix-Hallpike maneuver. This is caused by otoliths and debris in the posterior semicircular canal. Now what? The patient still feels miserably nauseous and vertiginous.
Is your first-line treatment meclizine or benzodiazepines?
You diagnose a 35 years old woman with uncomplicated cystitis. She is not diabetic and not pregnant. Which antibiotics should you give? What if she had pyelonephritis?
Answer: It depends on your local antibiogram.
Today, go find out about your hospital’s local resistance rates for uropathogens to various antibiotics. For San Francisco General Hospital, I found our antibiogram publicly posted online. Urine isolates of E. coli demonstrate relatively high resistance rates to trimethoprim-sulfamethoxazole and ciprofloxacin:
So based on the new 2010 practice guidelines by the ID Society of America and the European Society for Microbiology and Infectious Diseases,1 I should give:
Adapted from [1]
Go to ALiEM (PV) Cards for more resources.
The Dix-Hallpike maneuver is used to help diagnose benign paroxysmal positional vertigo (BPPV).
I find 2 things challenging in this maneuver.
The key is to maintain about 20-30 degrees of neck extension to align the posterior semicircular canals with the direction of gravity. Placing several blankets under the patients’ shoulders can accomplish this same position without having to scoot the patient close to the gurney edge. I’m sure the patient would appreciate keeping their head movement to a minimum.
Contact dermatitis from poison oak
We see a variety of rashes in the Emergency Department. The first step is to accurately describe the rash. Is this a macule or nodule? Is this a vesicle or bulla? The next step is to quickly “profile” it to see if it fits any classic pattern by patient age, lesion distribution, or presence of hypotension. And finally, if you are still stumped, use an algorithm based on the rash type.
These figures are from March 2010’s Emergency Medicine Magazine. It’s not meant to be a comprehensive article on rashes but it sure does take the guesswork out of 90% of the rashes you see.
Go to ALiEM (PV) Cards for more resources.
Thanks to Dr. Hemal Kanzaria for including this idea as a PV card.
A 35 year old man presents with low back pain which radiates down his right leg to the level of the knee. Is this sciatica?
Low back pain is one of the most common chief complaints that we see in the Emergency Department. In addition to the examination of the back and distal neurovascular function, we also need to test for evidence of a radiculopathy (compression or inflammation of a nerve root typically from a herniated disk). Because most disk herniations occur at the L4-L5 and L5-S1 level, you should test for irritation of the L4-S1 nerve roots. This is the sciatic nerve.
Tachycardia is a common clinical occurrence in the ED. Most of the time the etiology can be discerned through the history and physical exam, but sometimes it cannot. This is problematic especially when we are about to discharge a patient home but his/her heart rate is still 115 beat/min. We can’t send this patient home yet. Do we then have to admit them for work-up of persistent tachycardia?
Attached is a list of common causes of tachycardia in the ED, as well as potential diagnostic and therapeutic considerations. Rather than a shot-gun approach, a limited and thoughtful method works best.
Can you think of other potential causes?
Go to ALiEM (PV) Cards for more resources.
This useful PV card was made by one of our new star faculty members at San Francisco General Hospital, Dr. David Thompson. Thanks, David!
One of the hardest bandages to apply well is one for auricular hematomas. After drainage, how would you apply a bandage to prevent the re-accumulation of blood in the perichondrial space?
Traditionally, one can wedge xeroform gauze or a moistened ribbon (used for I&D’s) in the antihelical fold. Behind the ear, insert several layers of gauze, which have been slit half way to allow for easier molding around the ear. Anterior to the ear, apply several layers of gauze to complete the “ear sandwich”. Finally, secure the sandwich in place with an ACE wrap, which ends up being quite challenging because of the shape of the head.