Clinical Pearls

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Posted on 01/08/2009

At what age do permanent teeth erupt?

Answer

Permanent teeth erupt starting with at age 6 and proceed laterally to the second molars by age 12. Lower teeth generally erupt first. This age is important to remember because "baby teeth" should not be reimplanted while permanent "adult" tooth should be reimplanted as soon as possible. Periodontal ligamanets begin to die after 20 minutes and become essentially un-reimplantable after 1 hour.

Posted on 01/08/2009

What percentage of patients with syncope exhibit seizure like activity?

Answer

In a 1994 study involving induced syncope in 59 medical students, 90% exhibited or other seizure like activity lasting a mean of 6 seconds and as long as 16 seconds. Other studies have demonstrated 66% and 75% seizure like activity with syncope.

To induce syncope, 59 male volunteer medical students were made to squat and hyperventilate for 30 seconds followed by sudden standing and 10 seconds of valsalva. Subsequently, they were let go to wander the room and observed to see if they passed out forward or backward.

Rest assured, all volunteers were male and the rooms were well padded. Who said chivalry is dead. I hope all these geniuses got honors before completing their orthopedic residency.

References:
Lempert T, Bauer M, Schmidt D. Syncope: a videometric analysis of 56 episodes of transient.
Ann Neurol 1994:36:233–7

Posted on 01/08/2009

Which food allergies may result in reactions to propofol?

Answer

Propofol contains soybean oil and egg lecithin. Generic propofol contains sulfites as a preservative. Diprivan branded propofol does not contain sulfites but EDTA instead.

True allergies to propofol are uncommon.

Patients with sulfa allergies (bactrim, septra) are safe to take medications containing sulfites.

Generic propofol containing sulfites, however, may result in asthma exascerbation, particularly in women.

Posted on 01/08/2009

Which patients with an acute subdural hematoma can be managed non-sugically?

Answer

Assuming a GCS of 15 and a normal neuro exam, observation and repeat CT scanning may be appropriate if the subdural stripe thickness measures less than 10 mm and midline shift measures less than 5 mm.

Some authors recommend lowering the thickness threshold to 5 mm.

Posted on 12/19/2008

How long does BhCG remain elevated after an abortion?

Answer

BhCG clearance depends on the stage at which the pregnancy was terminated as well as the underlying reason for the loss.

In general, patients with induced abortions have hCG levels detectable longer than spontaneous abortions.

Patients with induced abortions have a detectable level for up to 2 months with a median of 1 month.

Spontaneous abortions and ectopic pregnancies may have detectable levels up to 1 month with a median of 19 days and 8.5 days respectively.

Posted on 12/19/2008

How sensitve is an upright chest xray for the detection of free air due to a perforated viscus?

Answer

CXR picks up free air only 38% of the time compared to CT scanning.

Stapakis JC, Thickman D. Diagnosis of pneumoperitoneum: abdominal CT vs. upright chest film.
J Comput Assist Tomogr.1992 Sep-Oct;16(5):713-6. CXR picks up free air only 38% of the time compared to CT scanning.

Posted on 12/19/2008

What findings on pleural fluid analysis are consistent with a diagnosis of empyema?

Answer

Grossly purulent pleural fluid

pH <7.2

WBC >50,000 cells/mm3

Glucose <60 mg/dL

Lactate dehydrogenase >1,000 IU/mL

Empyemas generally require chest tube drainage

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