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Latest Posts

Misdiagnosis Happens All The Time: Tips To Avoid It

Billionaire Teddy Forstmann has apparently been diagnosed with a serious form of brain cancer.  There’s a tragic twist to the story: according to Fox Business News, Forstmann believes that for more than a year, he had been misdiagnosed with meningitis.

ABC News wonders:

How could such a misfortune befall a billionaire —- a man able to afford the best doctors, best technology and the most sophisticated diagnostic tests?

They’re missing the point.  Misdiagnosis happens with shocking regularity – as much as Read more »

*This blog post was originally published at BestDoctors.com: See First Blog*

Interesting Neuro Case Requires ER Doc To Recall Forgotten Med School Knowledge

Yesterday, I presented the case of a woman with double vision and ptosis and challenged you all to a game of “spot the lesion.” To be honest, I found this stuff impenetrable as a medical student and it was only by sheer force of will that I was able to commit it to memory for exactly long enough to pass a test on it before immediately purging it from my memory. I did this several times for various board exams and such, but it never really “stuck.” Hated neuro beyond words, I did.

As mind-numbing as I found it all in the abstract, I get excited about these cases in application. I may not remember where exactly the internal capsule is or what it does, but when I see someone with an interesting neuro deficit due to a lesion there, all of a sudden it makes so much more sense, and is, dare I say it, cool. I know, kinda sad.

This case is as classic (and cool) as you will ever see. It’s a complete palsy of the Oculomotor Nerve (CN 3 for those keeping score at home).

So how do you approach figuring that out? Read more »

*This blog post was originally published at Movin' Meat*

Overwhelmed ERs Continue To Rise To The Challenge

Last night I was contacted by a physician in the local urgent-care.   I like him, and we made polite, but brief, conversation.  ‘So, are you guys busy?’

I gave him the status report.  ‘Well, yeah.  We have about 25 people waiting to be seen the waiting room is full and every patient room is full.  Also, we just received a gun-shot wound to the head by EMS.’

‘Wow, sounds terrible!  So, here’s what I need to send you…’

What he sent was, in fact, reasonable.  A young woman with signs and symptoms of meningitis (who was treated earlier in the day for and upper respiratory virus…with Amoxicillin, of course.)

She needed a lumbar puncture, which I performed and which was  negative.

But I had this thought.  I could probably have said, Read more »

*This blog post was originally published at edwinleap.com*

One Of The Most Common Infections Of Childhood: Otitis Media

A doctor examining the inside of a young girl's ear while her mother looks on.Ear infections are the bane of childhood and can spoil many outdoor adventures. One of the most common infections of childhood, they provoke long nights of miserable children, sleepless parents, and unhappiness all around. They may be recurrent, and can also progress (rarely) to more serious medical problems, such as meningitis.

What Are Ear Infections?

Acute otitis (inflammation of the ear) media (“middle”) infection is caused by bacteria or viruses. When it occurs, there is redness and inflammation of the eardrum, frequently with a collection of  blood, serum, or pus behind the drum. To know whether or not this has occurred, and to precisely determine the anatomic diagnosis and severity, one needs to see the eardrum, which is what the healthcare provider does with an otoscope.

With otitis media (middle ear infection), there is no drainage from the external ear canal (unless the eardrum ruptures, which is unusual in an adult and more common in a child) and the victim has a fever, sometimes with an accompanying sore throat. In many cases, the victim has a history of prior similar ear infections. Most often, otitis media occurs in children; when it occurs in an adult, it may be associated with a sinus infection or functional obstruction of the eustachian tube (the pressure-release mechanism from the middle ear into the throat).

It is interesting to note that children who chew Read more »

This post, One Of The Most Common Infections Of Childhood: Otitis Media, was originally published on Healthine.com by Paul Auerbach, M.D..

Do You Know How To Recognize Deadly Bacterial Meningitis?

MenactraOne of the most feared infectious diseases for outdoor travelers—particularly children and young adults—meningitis caused by the bacterium Neisseria meningitidis (meningococcus). The infection can appear in outbreaks, most commonly abroad, particularly in sub-Saharan Africa and China.

The infection is spread in the respiratory secretions of humans. The disease appears in many forms, the most common of which are meningitis, pneumonia, and disseminated bacterial infection. The typical presentation of meningitis is fever, headache, and a stiff neck. If the cause is meningococcus, the victim may develop a skin rash, which consists of red dots or bumps, or a flat, more patchy dark red discoloration.

If the dark red dots begin to enlarge and coalesce into large purplish bruise-like discolorations, this is a bad sign. In the worst cases, a victim can develop shock, respiratory failure, diffuse bleeding, and death. Approximately one in 10 victims of meningococcal meningitis dies. Read more »

This post, Do You Know How To Recognize Deadly Bacterial Meningitis?, was originally published on Healthine.com by Paul Auerbach, M.D..

Latest Interviews

How To Be A Successful Patient: Young Doctors Offer Some Advice

I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…

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How To Make Inpatient Medical Practice Fun Again: Try Locum Tenens Work

It s no secret that most physicians are unhappy with the way things are going in healthcare. Surveys report high levels of job dissatisfaction burn out and even suicide. In fact some believe that up to a third of the US physician work force is planning to leave the profession…

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Latest Cartoon

Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.

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Click here for a musical take on over-testing.

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Latest Book Reviews

The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

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Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

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Unaccountable: A Book About The Underbelly Of Hospital Care

I met Dr. Marty Makary over lunch at Founding Farmers restaurant in DC about three years ago. We had an animated conversation about hospital safety the potential contribution of checklists to reducing medical errors and his upcoming book about the need for more transparency in the healthcare system. Marty was…

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