Trick of the Trade: Pediatric ear exam

Performing a physical exam on frightened pediatric patients can often be challenging. I am always thrilled to add more child-whisperer techniques to my arsenal of tricks. I have written in the past about:

Balloonimals iPhone app to grossly assess peak flow
Candleflame iPhone app to grossly assess peak flow
Eye Handbook iPhone app with pediatric fixation animation targets
Casting/splinting your buddy bear

What’s your trick on performing an otoscope exam of the ears?

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By Michelle Lin, MD|2019-02-19T18:08:03-08:00Sep 20, 2011|ENT, Pediatrics, Tricks of the Trade|

Paucis Verbis: Legionella pneumonia

Did you know that there was an unexplained spike in Legionnaire’s disease (pneumonia caused by Legionella pneumophila) during the 2009 H1N1 flu pandemic?

Since the flu season is rapidly approaching, I thought I would review what Legionnaire’s disease looks like. Yes, they will have a fever, cough, and pneumonia on CXR. These patients are generally pretty sick and almost always need hospitalization. What makes it unique? The trick is to look for extrapulmonary findings, which help to distinguish it from other atypical pneumonias. Relative bradycardia is a sure tip.

Why do we want to differentiate it from other pneumonias? Legionnaire’s disease requires reporting to your state’s health department to help track for outbreaks.

PV Card: Legionella and Legionnaire’s Disease

Adapted from [1]
Go to ALiEM (PV) Cards for more resources.

More information on Legionella from the CDC website.

Reference

Cunha B. Legionnaires’ disease: clinical differentiation from typical and other atypical pneumonias. Infect Dis Clin North Am. 2010;24(1):73-105. [PubMed]

By Michelle Lin, MD|2021-10-12T16:00:57-07:00Sep 16, 2011|ALiEM Cards, Pulmonary|

Trick of the Trade: Synovial lactate in septic arthritis

A 55 year old woman presents with rheumatoid arthritis presents with monoarticular joint pain in her left knee for the past 3 days. She has a low-grade fever of 100.2 F and a significantly warm and tender knee. “It feels different than my RA flare.”

Does this patient have a septic joint?

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By Michelle Lin, MD|2019-02-19T18:42:06-08:00Sep 13, 2011|Orthopedic, Tricks of the Trade|

Paucis Verbis: Distracting injuries in c-spine injuries

“Distracting injury” is a frequent cited reason for imaging the cervical spine in blunt trauma patients, per the NEXUS study. In the Journal of Trauma in 2005 and 2011, studies aimed to narrow the definition of “distracting injury”. Although both are studies at different sites, both conclude the same:

Chest injuries may be considered “distracting injuries” because of their proximity to the cervical spine.

Example

So let’s say you are caring for a non-intoxicated motor vehicle crash patient with an isolated tibia fracture (i.e. a “long bone fracture”), no chest injuries, and no neck pain/tenderness. Per the NEXUS criteria, you might consider this patient to have a “distracting injury” because of the long bone fracture. Instead, the literature now supports your clinically clearing the cervical spine without imaging.

Wait, let’s rethink this. Does this mean that you should get cervical spine imaging for ALL blunt trauma patients with ANY chest wall tenderness?! NO. That’s just crazy. You should still factor in the mechanism of injury, severity of pain, and your clinical gestalt.

So for me, these “distracting injury” studies are helpful such that:

If your trauma patient does NOT have chest trauma, it may help you avoid unnecessary cervical spine imaging, as suggested by the NEXUS criteria.
If your trauma patient DOES have significant chest trauma, I have a lower threshold to obtain cervical spine imaging despite the neck being non-tender.

PV Card: Distracting Injuries in Cervical Spine Assessment

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Go to ALiEM (PV) Cards for more resources.

By Michelle Lin, MD|2021-10-12T16:03:39-07:00Sep 9, 2011|ALiEM Cards, Orthopedic, Trauma|

Trick of the Trade: Epley maneuver

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?

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By Michelle Lin, MD|2019-01-28T22:37:25-08:00Sep 6, 2011|Neurology, Tricks of the Trade|

Paucis Verbis: Antibiotics for Cystitis and Pyelonephritis in Women

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.

San Francisco General Hospital 2010 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:

Trimethoprim-sulfamethoxazole resistance rate = 33%
Cefazolin or Cephalexin resistance rate = 12%
Ciprofloxacin resistance rate = 16%

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:

Cystitis: Nitrofurantoin x 5 days, or cephalexin / beta-lactam x 3-7 days
Pyelonephritis: Ceftriaxone 1 gm IV x 1 + (ciprofloxacin x 7 days or trimethoprim-sulfamethoxazole x 14 days)

PV Card: Antibiotics for Uncomplicated Cystitis and Pyelonephritis in Women

Adapted from [1]
Go to ALiEM (PV) Cards for more resources.

Reference

Gupta K, Hooton T, Naber K, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis. 2011;52(5):e103-20. [PubMed]

By Michelle Lin, MD|2026-06-16T16:03:02-07:00Sep 2, 2011|ALiEM Cards, Genitourinary|

Trick of the Trade: Dix-Hallpike maneuver variation

The Dix-Hallpike maneuver is used to help diagnose benign paroxysmal positional vertigo (BPPV).

Place the gurney’s head of the bed down flat.
Reposition the patient so that s/he is sitting another 12 inches or so closer towards the head of the flat gurney.
Rotate patient’s head 45 degrees.
Help the patient lie down backwards quickly.
The patient’s head should be hanging off of the gurney edge in about 20 degrees extension.
Observe for rotational nystagmus after a 5-10 second latency period, which confirms BPPV.

I find 2 things challenging in this maneuver.

The patient often does not like to be moved AT ALL while feeling nauseously vertiginous. This even includes trying to reposition the seated patient closer to the head of the bed. This requires them to look behind them to see what where they are going, which sets off more vertigo.
In some of our ED rooms and hallways, the head of the gurney bed is often abutting a wall, a portable monitor, or some equipment. It takes a little fancy shuffling to make room for the Dix-Hallpike maneuver.

Trick of the Trade: A modified Dix-Hallpike maneuver

Place blankets or a pillow under the shoulders for the Dix-Hallpike 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.

By Michelle Lin, MD|2020-01-07T23:52:15-08:00Aug 30, 2011|ENT, Neurology, Tricks of the Trade|