J Emerg Med
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Acute aortic dissection is a life-threatening disease that is often a diagnostic challenge in the Emergency Department (ED). Patients with acute aortic dissection often have underlying hypertension and atherosclerotic disease, and commonly present with acute-onset severe chest or back pain in their sixth or seventh decades of life. Aortic dissection, however, can also be seen in patients < 40 years old and may present chronically, with symptom duration longer than 2 weeks. ⋯ Acute and chronic thoracic aortic dissections can occur in patients of all ages, as well as in patients with atypical signs and symptoms.
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Charles McBurney published a treatise on appendicitis in 1891, in which he described the exact point on the abdomen at which tenderness was maximal in cases of acute appendicitis--the point now known as "McBurney's point." He also described his approach to both the diagnosis and management of appendicitis, which at the time consisted of careful observation, total disuse of the stomach, and early laparotomy. Since 1891, many advances in the diagnosis of acute appendicitis have been made. Emergency physicians evaluating patients with abdominal pain may rely on laboratory studies, particularly the white blood cell count, and abdominal imaging with either ultrasound or computed tomography in addition to the history and physical examination. Despite these advances, tenderness to palpation over McBurney's point remains a key finding on abdominal examination in the assessment of patients with abdominal pain.
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The practice of avoiding cephalosporin administration to penicillin-allergic patients persists despite the low rate of cross reactions between both groups of antibiotics. ⋯ Although a myth persists that approximately 10% of patients with a history of penicillin allergy will have an allergic reaction if given a cephalosporin, the overall cross-reactivity rate is approximately 1% when using first-generation cephalosporins or cephalosporins with similar R1 side chains. However, a single study reported the prevalence of cross reactivity with cefadroxil as high as 27%. For penicillin-allergic patients, the use of third- or fourth-generation cephalosporins or cephalosporins with dissimilar side chains than the offending penicillin carries a negligible risk of cross allergy.
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Posterior fossa strokes, particularly those related to basilar occlusion, pose a high risk for progression and poor neurological outcomes. The clinical history and examination are often not adequately sensitive or specific for detection. ⋯ Head NCCT imaging is frequently insensitive for detecting posterior fossa infarction. Temporal evolution of strokes in this distribution, coupled with beam-hardening artifact, may contribute to this limitation. When a posterior fossa stroke is suspected and the NCCT is non-diagnostic, MRI is the preferred imaging modality to exclude posterior fossa infarction.
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Multicenter Study
Whole fentanyl patch ingestion: a multi-center case series.
Fentanyl is a potent synthetic opioid with large abuse potential. A common preparation of fentanyl is a sustained-release transdermal patch. To our knowledge, there are only two published case reports of whole patch ingestion. A case series of 76 patients with a history of whole patch ingestion is reported. ⋯ Ingestion of whole fentanyl patches may lead to prolonged and significant toxicity based on these poison center data.