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The Summary

Mizuho Morrison, DO and Mike Weinstock, MD
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HP -

Good topics.

Matt M., MD -

Always great stuff - this was not exception. Nursemaids elbow - like Miz, I usually do both...a brief hyperpronation, followed by the flexion/supination manauever with the olecranon supported, and a finger or thumb (depending on which side it is) applying some reduction pressure to the radial head. And like Mike, I have nearly 100% success rate over 30 years (estimating N appx 50), including my 2yo granddaughter a month ago (possibly the only situation in clinical medicine where it is absolutely OK to treat a relative). I can remember one case for sure with non-reduction (in the first few years of practice). The paper about IV antibiotics for CAP was certainly reassuring, and I absolutely agree with everything said - it just left me wondering with such a large number of patients, could a value for IV antibiotics in certain situations get "drowned out". Most of these patients do not have the specific culprit organism identified, and as we know, in a huge percentage, the organism is viral, Mycoplasma or Chlamydia where we would not expect a difference IV vs PO. This is likely also true for the group of patients with Strep pneumo, H. flu or M. cat. Where it might make a significant difference is in the population with Staph or gram negative bugs. Minor point in the urgent care setting, but just has me wondering. This study also gave me reassurance about a change I made recently as Chief Medical Officer at MedAccess - we had been stocking Ancef and Rocephin for parenteral use - I kept the Rocephin (thinking of respiratory and UT), dropped the Ancef and added Unasyn (GI and skin/ST), clindamycin (when there is high concern for anerobes) and PO Levaquin (which I will continue to use with probable increased frequency after hearing about this paper). That's what I did - would like to hear a segment about this...the elephant in this room is MRSA, but I think it is a moot point, since basically all of our UC MRSA patients do great with I&D and PO Septra.

Mike W., MD -

Thx Matt for your comments. All right on base! This is always a 'balance' - trying to walk the tightrope of appropriate outpt/UC mgmt and more intensive (IV) inpt mgmt. You are right, with MRSA abscess/cutaneous infection there is almost 100% sensitivity to tmp/smz but with pneumonia it is more complicated. I struggle with a specific pulse ox, usually admitting patients if they are in the very low 90s, but there are studies in children (with RSV) showing that the act ofeven using a pulse ox actually leads in inappropriate admissions. In the same way, some recs w adults allow for admission even below 90%. In summary, all of this needs to be used in the context of the patient in front of us.

The way it will change my practice is that I will be a little more likely to treat CAP (with very low suspicion for MRSA pneumonia) as an outpt. I am still checking pulse ox's! Thx SO MUCH for these comments and when I have a granddaughter, if she has a nursemaids elbow, I will probably reduce it at home also!! Take care

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You Broke It Where?? Full episode audio for MD edition 198:23 min - 93 MB - M4Ahippo Urgent Care RAP - March 2017 Summary 328 KB - PDF