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Nov 20131) Magnets are stronger than ever as they now contain

neodymium. And they are around- magnetic earrings aresimulations for those who have not yet pierced their ears whodo not want to. wallowing magnets can !e devastating- theycan cause perforation and ulceration if another magnet oranother metallic o!"ect is concurrently ingested. A!dominal #ray is still used for diagnosis. $%ed &astro Nutr''$3)23(). on*twait for the +A guys to ma,e this diagnosis +A/ M/M/A&/ Magnet ingestion can !e dangerous.

2) A definite may!e. +his tiny study said that &a!apentin did helpwith post dural induced headaches. $Anest nten 4are50$5)615) +hese headaches were tough ones as some failed!lood patch. t wor,ed in '07 of patients which actually is notthat great. 8eing that &a!apentin is a ,nown pain reliever9 do

not ,now if using a cheaper one may wor, "ust as well. +A/M/ M/A&/ &a!apentin is another option in pain relief

3) 4: stuff- really did not ,now this $c*mon cott- tell me youdid). +hey present a case where they could not ventilate apatient who they intu!ated. +hey did all the %/ stuff$Dislodgement;O!struction; Pneumothora#; E

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than a 6 !ut in any case; !e careful = too much air is !ad = for/+ tu!e !alloons and politicians. $>esp 4are '6$?)1352). donot intu!ate many ,ids; !ut occasionally do use a @.' on petitadults; so this is good info. +A/ M/ M/A&/ o notoverinflate those /+ !alloons.

4) A word = actually too many words- on penicillin allergies. %4Nallergies are usually = not allergies !ut long ago reactions thatthat were never allergies or were out grown. Most patients whosay they have an allergy who undergo s,in testing do not havethe allergy and if you do this test and it is negative; it ispro!a!ly safe to give the stuff. esensitiation if it was everdone may not !e permanent. Bastly = and you all ,now thisalready from past /M:s- you can give cephalosporins in %4Nallergies- cross reactivity is low with the newer ones. $4lin >evAll mmun 53$1)?5) +A/ M/ M/A&/ %4N allergies are

usually not -and you can do a simple s,in test to determinethis. +his month*s

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Reality continues to ruin my life. I'm not

dumb. I just have a command of thoroughly useless information.

5) can summarie this fast and you pro!a!ly wish would.+oday*s wound care is moist; and do not distur!. &aue

macerates wounds so do not use it- use a petroleum !aseddressing or one that has a plastic side that doesn*t stic,. $C

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Dound 4are 21$?)3'() Calvin !here's no"roblem so a#ful$ that you can't add some guilt to it and ma%e it even #orse.

&) ere is a clinical ocephin and Aithromycin. e ta,esamlodipine and prednisone. e is !uc,ing the vent so thepropofol is increased and fentanyl is added.5? hours later- hisurine is green. e did not receive arsenic nor has the urine !ag

!een filled with spinach $yu,). o what happenedE % urineporphyrins were negative $Neth C Med 60$@)2?2). +he twoauthors were from NF = one from :NF :pstate and one form

364

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:NF downstate $do they neutralie each otherE) = Dhy theystretched to the Neth C of Med is un,nown !ut this is not thefirst report of this case. Dhat is going onE

+his statue is in%rague. &ives new meaning to a pissing contest; right Gather&regE

) %eople can have a stro,e while ta,ing 4oumadin and giving+%A is complicated under such conditions. +hey gave this fellowwith an elevated N> and a sign of a stro,e %44 and within 1'minutes the N> was 1H2 of what it was and he got his +%A.$4ere!ro is 33$@)'(6). +his is pretty

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%44 can reverse N> if you need to do so

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ucutaneous nodules; @ainless" irm collections o colla#en iersoer ones or tendons& 7he0 commonl0 a%%ear on the ac! o the/rist" the outside elo/" and the ront o the !nees&

>r0thema mar#inatum; lon#-lastin# reddish rashthat e#ins on thetrun! or arms as macules" /hich s%read out/ard and clear in themiddle to orm rin#s" /hich continue to s%read and coalesce /ith other

rin#s" ultimatel0 ta!in# on a sna!e-li!e a%%earance& 7his rash t0%icall0s%ares the ace and is made /orse /ith heat&

0denhamBs chorea 't& CitusB dance+; characteristic series o ra%idmoements /ithout %ur%ose o the ace and arms& 7his can occur er0late in the disease or at least three months rom onset o inection&

Minor criteria[

eer o 3,&2E3,&* FA '11E12 F+ rthral#ia; $oint %ain /ithout s/ellin# 'Aannot e included i

%ol0arthritis is %resent as a ma:or s0m%tom+ Raised er0throc0te sedimentation rateor A reactie %rotein .eu!oc0tosis >AG sho/in# eatures o heart loc!" such as a %rolon#ed @R

interal8,9 8*9 'Aannot e included i carditis is %resent as a ma:ors0m%tom+

@reious e%isode o rheumatic eer or inactie heart disease

Other signs and symptoms

dominal %ain =ose leeds

36?

http://en.wikipedia.org/wiki/Tendonshttp://en.wikipedia.org/wiki/Erythema_marginatumhttp://en.wikipedia.org/wiki/Rashhttp://en.wikipedia.org/wiki/Maculehttp://en.wikipedia.org/wiki/Sydenham's_choreahttp://en.wikipedia.org/wiki/Feverhttp://en.wikipedia.org/wiki/Arthralgiahttp://en.wikipedia.org/wiki/Erythrocyte_sedimentation_ratehttp://en.wikipedia.org/wiki/C_reactive_proteinhttp://en.wikipedia.org/wiki/Leukocytosishttp://en.wikipedia.org/wiki/Electrocardiogramhttp://en.wikipedia.org/wiki/Heart_blockhttp://en.wikipedia.org/wiki/PR_intervalhttp://en.wikipedia.org/wiki/PR_intervalhttp://en.wikipedia.org/wiki/PR_intervalhttp://en.wikipedia.org/wiki/PR_intervalhttp://en.wikipedia.org/wiki/Rheumatic_fever#cite_note-8%23cite_note-8http://en.wikipedia.org/wiki/Rheumatic_fever#cite_note-8%23cite_note-8http://en.wikipedia.org/wiki/Rheumatic_fever#cite_note-8%23cite_note-8http://en.wikipedia.org/wiki/Rheumatic_fever#cite_note-davidson617-9%23cite_note-davidson617-9http://en.wikipedia.org/wiki/Rheumatic_fever#cite_note-davidson617-9%23cite_note-davidson617-9http://en.wikipedia.org/wiki/Abdominal_painhttp://en.wikipedia.org/wiki/Epistaxishttp://en.wikipedia.org/wiki/Tendonshttp://en.wikipedia.org/wiki/Erythema_marginatumhttp://en.wikipedia.org/wiki/Rashhttp://en.wikipedia.org/wiki/Maculehttp://en.wikipedia.org/wiki/Sydenham's_choreahttp://en.wikipedia.org/wiki/Feverhttp://en.wikipedia.org/wiki/Arthralgiahttp://en.wikipedia.org/wiki/Erythrocyte_sedimentation_ratehttp://en.wikipedia.org/wiki/C_reactive_proteinhttp://en.wikipedia.org/wiki/Leukocytosishttp://en.wikipedia.org/wiki/Electrocardiogramhttp://en.wikipedia.org/wiki/Heart_blockhttp://en.wikipedia.org/wiki/PR_intervalhttp://en.wikipedia.org/wiki/PR_intervalhttp://en.wikipedia.org/wiki/Rheumatic_fever#cite_note-8%23cite_note-8http://en.wikipedia.org/wiki/Rheumatic_fever#cite_note-davidson617-9%23cite_note-davidson617-9http://en.wikipedia.org/wiki/Abdominal_painhttp://en.wikipedia.org/wiki/Epistaxis

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@recedin# stre%tococcal inection; recent scarlet eer raisedantistre%tol0sin < or other stre%tococcal antiod0 titre" or %ositiethroat culture& Gotta loe Dr& $ones irst name& hat did the0 call him

or short Iou are ri#ht- the0 called him red '0oudidnBt reall0 thin! ( /ould sa0 Duc!0 /ould 0ou+ 7J> H)>G>; RHD is around and can aect adults& Calvin: Moms andreason are like oil and water. Calvin: That's one of the remarkable things about life.It's never so bad that it can't get worse.

) Beu,otriene receptor antagonists do not reduce asthmaadmissions and there is not enough evidence to provide any!enefit in lung function +his is an /8M review $ %aed >esp >ev13$5)22@) Nice com!ination of !oth a patient and disease

oriented outcome. Are they steroid sparingE really do not careas steroids are really not that dangerous that would want tospend money on this med +A/ M/ M/A&/ Beu,otriene

36,

http://www.ncbi.nlm.nih.gov/pubmed?term=13%5Bvolume%5D+AND+4%5Bissue%5D+AND+226%5Bpage%5D+AND+2012/12%5Bpdat%5D&cmd=detailssearchhttp://www.ncbi.nlm.nih.gov/pubmed?term=13%5Bvolume%5D+AND+4%5Bissue%5D+AND+226%5Bpage%5D+AND+2012/12%5Bpdat%5D&cmd=detailssearchhttp://www.ncbi.nlm.nih.gov/pubmed?term=13%5Bvolume%5D+AND+4%5Bissue%5D+AND+226%5Bpage%5D+AND+2012/12%5Bpdat%5D&cmd=detailssearchhttp://www.ncbi.nlm.nih.gov/pubmed?term=13%5Bvolume%5D+AND+4%5Bissue%5D+AND+226%5Bpage%5D+AND+2012/12%5Bpdat%5D&cmd=detailssearch

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inhi!itors really do not wor, well. And may !e dangerous- thisis a series of aggressiveness that started with the medication!eing used and ceased when it was stopped. All occurred!etween the ages (-15H ncidence cannot !e ,nown as thearticle did not provide the denominator; !ut suicide does occurat 1 in 25000 e#posures $C nvest All 4lin mmun 22$@)5'2)Calvin: I don't need parents. All I need is a recording that says !"o play outside#!Calvin: $very time I've built character I've regretted it.

/0) /lectrical in"ury $that is low voltage) can cause chronicwea,ness parathesia and memory pro!lems. +his is !ecausethe nerves are such good conductors. $C Neuro Neuro %sych?3$() (33). +his reminds me of D4 Gields IMy Gather had achair in applied electricity at the tate %enitentiaryI

Calvin: As far as I'm concerned if something is so complicated that you can't

e%plain it in & seconds then it's probably not worth knowing anyway.

36*

http://www.ncbi.nlm.nih.gov/pubmed/23101197http://www.ncbi.nlm.nih.gov/pubmed?term=83%5Bvolume%5D+AND+9%5Bissue%5D+AND+933%5Bpage%5D+AND+2012/9%5Bpdat%5D&cmd=detailssearchhttp://www.ncbi.nlm.nih.gov/pubmed?term=83%5Bvolume%5D+AND+9%5Bissue%5D+AND+933%5Bpage%5D+AND+2012/9%5Bpdat%5D&cmd=detailssearchhttp://www.ncbi.nlm.nih.gov/pubmed/23101197http://www.ncbi.nlm.nih.gov/pubmed?term=83%5Bvolume%5D+AND+9%5Bissue%5D+AND+933%5Bpage%5D+AND+2012/9%5Bpdat%5D&cmd=detailssearchhttp://www.ncbi.nlm.nih.gov/pubmed?term=83%5Bvolume%5D+AND+9%5Bissue%5D+AND+933%5Bpage%5D+AND+2012/9%5Bpdat%5D&cmd=detailssearch

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//) mention these two articles !ecause of the :A*s great loveaffair with M> $while at the same time complaining a!outhealth care costs). n these patients with chest pain; elevatedtroponin and normal coronaries on %+4A- they then underwentM> as outpatients = much later- and 107 were found withevidence of myocarditis and 107 were found with an M. $8C>?'$101@)/5@1). +he ,ey point here is that M is still possi!leeven with clean coronaries- pro!a!ly from spasm- an issue wehave discussed !efore. owever; we also see the M> was notthat useful most of the time. Now also there are cases ofnursemaid*s el!ow that do not reduce and an M> can tell youthe reason- in this case report for e#ample- full entrapment ofthe annular ligament. $C %ed rtho 32$')/20) 4ould 4+ orultrasound have shown the sameE +A/ M/ M/A&/ M>can !e used for nursemaids el!ow and elevated troponin in the

face of a %+4A that is negative ; !ut the

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consider !enos. And of course- !e careful with overdosingpsych meds in patients with hypotension or failing ,idneyswhich are all so common in the 4: palace. $44M 50$()2@@2)

+A/ M/ M/A&/ %sych emergencies in the 4:- delirium;serotonin and NM syndromes and psych iatrogenic overdoses-here are the ways to deal with them. Calvin: $verybody I know needs acomplete personality overhaul

Calvin: "ive me the strength to change what I can the inability to accept what

I can't and the incapacity to tell the difference

/2) De 4+ everyone with a first time seiure !ut if they return tothem selves it really isn*t necessary in the /. n this Gam %ractarticle- they here recommend it only in focal seiures or thosewith developmental delay. owever they then say that those

with no structural !rain disease do not need anti seiure meds-well how do you ,now with out the 4+E Naturally; if !leeding issuspected then 4+ should !e performed. $AG% ?@$5)335) thin,the important point here is not doing the 4+ from the / andtruth !e told; never found any surprises on 4+ after a firsttime seiure in the /. +A/ M/ M/A&/ 4+ after a firsttime seiure- in the / is not necessary if it wasn*t focal andthe patient is normal now. n the clinic- pro!a!ly still need one.

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/4) elicate su!"ect- men refer to these

dierentl0 than

/omen however; things dogo wrong with the mammary glands and you should ,now

3612

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a!out them. Masses; pain anddischarge are the pro!lems. Masses- mammography is thestandard !ut ultrasound is more sensitive in the under thirtygroup $since ultrasound has no radiation; am not sure why

they don*t "ust ultrasound everyone). %ain is usually not due toa malignancy and medications can !e common causes whichinclude hormones; 4s; psych meds and some 4J meds.ischarge is more complicated. f it is one sided; associatedwith a mass or is spontaneous- that is suspicious. f it is!ilateral; chec, out + and prolactin $i!idp353) Note thatthey do not discuss trauma where fat necrosis can occur. 8ythe way; the !irds a!ove are a tufted titmouse; and a !luefooted !oo!y !ird. +here; we got that past the censors. +he last

!ird is a tunning Ginch it has nothing to do with our discussionand even do not ,now what it is doing here. +A/ M/

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M/A&/ 8reast disorders re

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you want to see the rashEE

/&) f you read /M: in the !athroom = and you should !e- then youmay fall asleep as this isn*t terri!ly useful. Bet me ma,e it

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a free /M: su!scription. My offer is still open Amal- thin, of allthe good "o,es you are missing +A/ M/ M/A&/ + waveinversions in the anterior and inferior leads can mean a %/.

Calvin: If you do the *ob badly enough sometimes you

don't get asked to do it again.Calvin: "irls are like slugs + they probably serve somepurpose but it's hard to imagine what

16) ne last clinical

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20) +heophylline- didn*t we put this med to sleep alreadyE Dell ifyou are a !eliever in meta analysis- and you shouldn*t !e- thanthis is the !est thing since sliced !read to prevent contrastinduced ,idney in"ury $AC @0$3)3@0). Dell; do not start givingthis dreadful drug yet- this helped only with creatinineelevations which is not a patient oriented outcome- mostpatients with !umps in creatinine do well with tincture of time.Also it didn*t help with patients who started with a creatinine of1.' = which is the population that most worries us. No longterm !enefits either. o you can return this medication to theshelf- hopefully at some point we will find a use for it. amegoes for me as well +A/ M/ M/A&/ +heophylline wasthought to help prevent contrast induced ,idney failure; !ut itdid not.

1/)+A/>- haven*t had any e#perience with this- neither on the

treating; receiving or distri!uting end. +his is a device thatshoots two sharp electrodes and delivers a high voltage lowcurrent shoc, to a person which temporarily immo!ilies them$from what remem!er from electricity = current is this themore damaging than voltage). According to hm*s law $JL>)the electricity will travel the path of least resistance and this isalong tissue layers; so the ris,s to hearts is minimal. owevermuscles can !e damaged and e#pect an increase in 4%- up to15@'. Nerves seem to !e preserved. +hey recommend that

only medical personnel remove the darts !ut that all dependson where they are. $C Gorensic cience '6$@)1'(1) +A/ M/M/A&/ +A/> seems to !e safe- !ut you should ta,e the

36?1

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darts out of the patient. r yourself if you are a ,lut. r even ifyou are not Calvin: I hate to think that all my current e%periences will somedaybecome stories with no point. Calvin ome#here in Communist Russia I'll bet there's alittle boy #ho has never %no#n anything but censorshi" and o""ression. ut maybe he's

heard of 6merica$ and he dreams of living in this land of freedom and o""ortunity7 omeday$

I'd li%e to meet that little boy...and tell him the a#ful !R8!( 6*8! !(I 9:6C;77

Calvin's ,ad Calvin$ be

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4are 2($@)5(6) "ust have two comments here- thin, a clergyperspective is critical here; !ut the authors of the articleapparently did not agree. Gurthermore; the

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anemia may !e worse than transfusions !ut sometimes the casemay !e vice versa. /specially since the safety of !loodtransfusions has improved significantly- !oth from leu,o reductionand from !etter storage which calls in ABwill ma,e you thin, twice a!out randomly giving !lood. +A/M/ M/A&/ &ive !lood to those who need it.

Fes guys; that is 8ella Bugosi in his role asracula.

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UPDATECalvin In my o"inion$ #e don't devote nearly enough scientific research to finding a cure

for jer%s.

Calvin @iss ,orm#ood$ I "rotest this C grade7 !hat's saying I only did an average

job7 I got 5A of the ans#ers correct$ and in today's society$ doing something 5A right is

outstanding7 If government and industry #ere 5A com"etent$ #e'd be ecstatic7 I #on't

stand for this artificial standard of "erformance7 I demand an 6 for this %ind of #or%7

Bne3t "anel)I thin% it's really gross ho# she drin%s @aalo3 straight from the bottle.

Calvin I understand my tests are "o"ular reading in the teachers' lounge

14) guess this is only relevant if you are sraeli; Cordanian or from:tah; !ut dead sea water into#ication can happen and isdangerous- even a swig of '0 cc can elevate your magnesiumand calcium significantly $%/4 2?$?)?1'). My hospital is thenearest to the ead sea and we see a lot of these9 my directorr. 4armi was ,ind enough to allow me to interview him on

how he treats this. 4alcium is generally easily treated withfluids and diuretics. Magnesium responds less well to diuretics.Girst aid includes fluids !ut then = if the level is eight or higher= or the patient is comatose you !etter consider dialysis. thin,Gather &reg can !e the first to tell you = you got to !e carefulwhat you drin, +A/ M/ M/A&/ hypermagnesemia canresult swallowing small amounts of ead ea water. Calvin *ne ofmy baby teeth came out7 I have to say$ I'm not entirely comfortable holding a "iece of my

o#n head.

Calvin Cigars are all the rage$ >ad. ?ou should smo%e cigars7

Calvin's Mom latulence could be all the rage$ but it #ould still be disgusting.Calvin I see.

,ad Dicely "ut$ dear

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2@) Fes; so it was !ac, in 1((3- was in &rand >apidsand a young man had arm pain after lifting weights. Fea;you ,now; arm pain; lifting weights- well; its a sprainand give it some ice and NA and life will !e rosy. Awee, later get called in !y the !oss- he got a dirtyletter that we missed an upper e#tremity J+. Dell;8oss; said; accept what you say; !ut don*t youremem!er that you saw him too and missed it a fewdays laterE +hen there was a strange

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M/A&/ :pper e#tremity J+ is safer !ut is oftenmissed.

Calvin (ey usie$ #hat's the ans#er to Euestion +

)usie ,erkins Imadoofus.

Calvin !han%s.

BCalvin reali=es usie has tric%ed him)

Calvin !he !ooth airy's gonna ma%e you rich tonight$ usie

Mom will you drive me into town? Reply Why should I drive you, Calvin? Its a perfect day

outside! What do you think people have feet for? To work the gas pedal.

- Calvin and Hobbes

1) islocations- there are three in the hand you !etter,now !ecause you may miss them on plain films. +his

article s on perilunate dislocations. +hey are highenergy outstretched hand things. +he can tether themedian nerve and cause aseptic necrosis fromcompromised !lood supply so this is a dislocation thatyou want to deal with immediately. ften there will !eassociated fractures such as of the scaphoid or theradial styloid. $8MC 35' e602@)

3623

http://www.ncbi.nlm.nih.gov/pubmed?term=345%5Bvolume%5D+AND+Navaratnam%5Bauthor%5D&cmd=detailssearchhttp://www.ncbi.nlm.nih.gov/pubmed?term=345%5Bvolume%5D+AND+Navaratnam%5Bauthor%5D&cmd=detailssearch

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7he irst %icture is a %erilunatedislocation& 7he second is a lunate dislocation&+hesedislocations are !est seen on lateral films. +he lastdislocation is a scaphoid lunate dislocation which yousee !est on A% = there is a large hiatus !etween thesetwo !ones- it can !e less pronounced than this picture

+A/ M/ M/A&/on*t miss dislocations in the hand. After Calvin nails Susie with asnowball he walks up to her and says I must say, the stinging snow makes your

cheeks look positively radiant. I have a hammer. I can put things together! I canknock things apart! I can alter my environment at will and make an incredible din all

the while! Ah, its great to be male!

- Calvin and Hobbes3624

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2?) ne last fun article which laments the preponderance offran,ly dum! a!!reviations in medical articles. $>adiolgy2@@$2)3?3). e !rings a funny N/CM letter from 1(?(320$16)11'2$would you !elieve those rats from N/CM want meto pay for the articleE Must !e friends of 8ill 8elichec,) 8utseriously spea,ing- many a!!reviations have you leafing !ac,through the paper to see what they are tal,ing a!out or can !econfused with other things- li,e M> can !e Magnetic >esonanceor Mitral >egurg or Mental >etardation $ ,now that is notpolitically correct !ut it is still in use in many countries) +A/M/ M/A&/ $+M) Avoid A!!reviations $AA)2() +hose who do not read the /M: for the centerfold often readthe letters only. /ven though /M: went out late last month; A#elwas ,ind enough to forgive me for it; although Gather &regre

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way you guys are going. 8ut did li,e the line a!out ma,ing thefuture. am no longer an /ast 4oaster; !ut drifted a littlefurther /ast. +han,s for the cogent comments- will definitelythin, of you ne#t time have a sandwich or get my head chewedoff. ey; what is a month without a letter from enE

(i ?osef

6gain$ great Dovember issue of ;@8. Jee" u" the fine #or%7

ince you #rote that you #ere e3"ecting me to #rite about scor"ions$ I #ont

disa""oint. In my e3"erience$ the diagnosis is usually made in children due to the acute

onset of bi=arre sym"toms. !hey thrash around$ have roving eye movements$ unusual

head and nec% movement$ mild cholinergic sym"toms and$ if they are verbal$ "ain at the

sting site. 6dults "rimarily have severe "ain Bsometimes rer. :eslie oyer B"ediatricianLto3icologist) at our 8niversity

of 6ri=ona #ent through the multiFyear "rocess of getting the @e3icanF"roduced

antivenom a""roved in the 8nited tates. he #on the (ero of @edicine a#ard for that.

ut$ #e need to remember that the @e3icans develo"ed the vaccine and have it in use.

Regarding the item on "hysical$ es"ecially the chest e3am$ I assume that #as a

jo%e. 6s emergency "hysicians #e routinely get unconscious "atients #ithout a history

and$ at least #here I often "ractice internationally$ I cant get a radiogra"hM

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UPDATEa vital "art of my armamentarium. I assume it does for you and most ;@8 readers$

also.

y the #ay$ my ne#est boo%$ !he Nlobal (ealthcare Kolunteers (andboo%

,hat ?ou Deed to Jno# efore ?ou No B###.galen"ress.com) #ent to the formatter

today. It then goes to the "rinter and should be out in Ganuary7 ?eah7

est #ishes$ Jen

+hat !oo, sounds very interesting. will give it a plug and vouchfor all of en*s wor,; while not !e a!le to accept a free copy;since can not accept any gifts. owever; if it was given tome. 8y the way; that guy was serious a!out the chest e#am-stand in the middle- am not going to diagnose any +> murmurs!ut it does help for wheeing and the li,e. +han,s for writing-interested in ,nowing where you can get a good sandwich inMichiganE +ry Glint.30) Num!er si# was a patient with respiratory al,alosis whichcauses propofol to !e meta!olied to pretty green urine. ere isthe for green urine form the article "ust in case youwondered why you have a su!scription to /M: Aimetidine;@romethaKine" (ndomethacin" )etoclo%ramide" lutamide" )eth0lenelue;s%ara#us; Alorets 'chloro%h0ll+; ilisan %ills 'Ahineseheralmedication+" Hartnu% disease" (ndicanuria" @seudomonas urinar0 tractinection" Lile ia esicoenteral istula" Green eer 'ather+" some #reen

d0es& Num!er 15 was guttate psoriasis which will respond tohigher potency steroids and :J8 treatments. would havethought this was a fi#ed drug reaction !ut there was no

36?2

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e#posure to any meds. included it !ecause if you aren*t agenius- and am not = at least you will thin, of this whenstandard anti allergy treatments do not wor,. h and of course-treat his strep throat please. Bastly num!er 1?; 1( and 20 was ofcourse a antavirus infection which comes from aerosolied dryfeces of a mouse. t can turn !ad; !ut treatment is supportive.Named anta !ecause of its discovery in orea. And it is a virus. made that one too easy.

EMU LOOKS AT: Looking great and breathingeasier7his month /e loo! at t/o su:ects that /e !no/ little aout 'at least ( do+@eriorital cellulitis 'Aurr

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UPDATE

3+ =on inectious causes- aller#0 is #oin# to e the leadin# cause& acialcreams" e0e dro%s and ma!eu% do the most dama#e" althou#h s0stemic

aller#ies can cause this as /ell& Guess/hat- the th0roid can cause this also" ut that doesnMt other me- theth0roid seems to cause eer0thin#& 7his /ill cause orital s/ellin# as /ell&

Do not or#et dermatom0ositis and lu%us& e /ill mention tumors" ut (do not thin! that /ill e that hard to dia#nose&4+ 7here is a /eird ird called le%harochalsis /hich is a disease o0oun# adults that comes and #oes or an aera#e o t/o da0s&5+ 7he article doesnBt sa0 this" ut ( use heat as hel%in# me ma!e thedia#nosis& ller#0 in onl0 one e0e is rarer" is usuall0 less hot and less red&(t ma0 e itch0&6+ He0 /hat aout meds (matini causes this oten ut /e use that onl0or A). and most o us /ill not see that& Li%hos%honates can cause this

as /ell as scleritis and uietis& H0aluronidase is oten a iller in cosmeticsand oten causes edema& =(D and some anti%0shotics do it as /ell&?+ @ost sur#ical causes can come rom the ears as /ell- cochleartrans%lants can do thisP

36*2

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,+ ( 0ou are aced /ith a case that 0ou are not sure o the cause" so thereis an al#orithm here /ith all sorts o lood tests" ut this is orin# enou#h&

.un# 7rans%lant >mer#encies;

1+ 7hese /iss docs are honest rom the outset- the0 sa0 this is/hat the0 do& Iou arenBt #oin# to see much science here" ut itat least ma!es some sense& Jee% in mind this article is not or%ost o% com%lications ur rather or the lun# trans%lant %atient

363

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UPDATE

that comes to 0our >D or clinic rom the communit0& Lut onethin# ( li!ed aout this article /as the irst authorBs name had t/oO in it 'chuurmans+& Jind o reminds me o this ello/- do 0ou

rememer him2+ Ies" that is O 7hant" the ormer ecretar0 General o the O=& =ot

Quite sure /hat %eo%le /ho didnBt !no/ his name said to him'he0" 0ouIes+

3+ ell" 0ou #uessed it- the lielon# ta!in# o sometimes three ormore immunosu%rressies causes most o their %rolems& -

(nection" #rat re:ection" and one marro/ su%%rsion& Lut do notsto% readin# 0et&

3631

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4+ Re:ection oten occurs ecause inadeQuate immunosu%rresion&7hese s0m%toms can e er0 sutle such as malaise" d0s%neaand lo/ #rade eer& ctuall0" the onl0 si#n ma0 e reduction ons%irometr0 Eso as! E most o these %atients !no/ ho/ tomeasure this themseles& Ho/eer do not #o reachin# ri#ht thenand there or the meds- e sure that 0ou are not loo!in# at a

res%irator0 inection irst& @rolems is that clinical assessment isnot enou#h and chest ilm ma0 e conusin# as ronchietasisand %leural eusion ma0 e %resent /hich can e seen inre:ection or inSSronchietasis and %leural eusion& A7 hel%s alot '/ithout (C contrast- the0 #et renal ailure too easil0+" utsometimes ronchosco%0 and io%s0 ma0 e necessar0 to rulein or out re:ection& or me as an >@" (Mll do a A7 and #o romthere i there is a ona ide inection& Hi#h acute eer and alous0 loo!in# %atient /ill hel%& A0clo%sorine #ets the !idne0s- so

!ee% an e0e on them /ith Ar and urea chec!s& @rednisone isoten ta%ered" ut :ust !ee% in mind that #ettin# this ri#ht ta!es0ears sometimes and des%ite all eorts" ronchiolitis oliteranss0ndrome can occur- 0ou /onBt e treatin# this" ut it is :ust aneam%le aout ho/ im%ortant #ood immunosu%rresion is here& (do not %ersonall0 eel comortale ad:ustin# immunosu%%resieson m0 o/n&

5+ Alarith0omi0cin ma0 cause the leel o c0clos%orine to #o u%" sothe0 %reer Kithro" Kole antiun#als are another %rolem" so

the0 use cas%oun#in& 7he0 neer use luconaKole& Le careul touse %ancreas enK0me re%lacement or A0stic irosis %atientsater lun# trans%lant& 7he0 hae a list o common medications

3632

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interactions that /ill cause re:ection or toicit0 or ne%hrotoicit0 inthe article& Le careul /ith metoclamide 'Re#lan" @ramin+ as thisis commonl0 used and can cause lo/er leels o c0clos%orine&

6+ .i!e stran#e names E here is a ecretar0 General o the O= rom

eore O 7hant& His name /asDa# Hammars!:old- #ood luc! tr0in# to %ronounce that one 'THe00ouU /ould %roal0 /or! here too+

?+ A0to%enia is airl0 common #ien the tonna#e o meds the0 ta!e&Do /atch the LA& ntiiotics do this es%eciall0 7)V-)W" and

la#0l& ome anti irals can do it too& Iou ma0 hae to mi andmatch the meds,+ o 0ou see this #u0 /ith a runn0 nose& 7he0 attac! him /ith

nasal iral and acterial cultures and then start moiloicin& ( it3633

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1+Here is another #reat name Ara%honso7hor%e& ( am not #oin# to attem%t to %ronounce that one

11+

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UPDATE

13+ Ies that is Ha Ha Alinton Di-a name onl0 rialed 0 the =e/ $erse0 7o/n

Hae a #reat 7han!s#iin# andHanu!ahP