Clinical Practice Points
This systematic review examines whether the route of administration and dosing of naloxone affect clinical outcomes in adults with suspected opioid overdose.
Ask your learners what the physical examination of a patient who has had an opioid overdose might reveal.
How should opioid overdose be managed? What needs to be done first? How is response evaluated, and for how long should patients be monitored? Which patients require intubation?
The authors of the review and the editorialists note substantial deficiencies in evidence for the optimal dose and route of administration of naloxone and the need for transportation to the hospital after out-of-hospital administration. What might be the barriers to performing randomized trials to address these issues?
How should patients who have had an opioid overdose be assisted after emergency care? What is the role of pharmacologic agents, such as methadone or buprenorphine? How are they initiated, and what are the regulations related to their use? How are patients followed? Invite a specialist in the use of these agents to join your discussion.
This synopsis of guidance from the Joint Task Force on Practice Parameters provides 3 recommendations for the initial pharmacologic treatment of seasonal allergic rhinitis.
Start a teaching session with a multiple-choice question. We've provided one below!
Ask your learners how they approach the evaluation of a patient presenting with nasal congestion and/or rhinitis. What should they ask? What should they look for on examination?
What interventions do your learners consider for patients with allergic rhinitis? Is allergen avoidance sufficient?
Do your learners ever prescribe leukotriene inhibitors? When? What does this guideline conclude about their use for allergic rhinitis? What if the patient has a concomitant diagnosis of mild persistent asthma?
Are your learners able to recognize nasal polyps? If present, how do they affect management? Should referral for removal be considered?
Improving Diagnostic Skills
Diagnosis is one of the most important and challenging tasks that a physician performs, particularly in internal medicine. The rate of diagnostic error is estimated to be 10% to 15% for internists. Unfortunately, these errors result in substantial morbidity and mortality for patients. Diagnostic errors are the leading type of paid medical malpractice claim and are nearly twice as likely to result in death as any other category of error. This unique case-based educational program provides tools to help improve your learners' (and your own!) diagnostic skills.
Use this unique feature to:
Start a teaching session by reading one of the brief case presentations with your learners. You can do one in a few minutes at the beginning of each of several sessions.
Discuss the possible answers with your team and then review the answer critique together. Did you get it right?
Ask what “illness scripts,” “diagnostic momentum,” and “diagnostic timeouts” are.
Claim CME and MOC credit for yourself.
Humanism and Professionalism
Dr. Gianakos and others have noticed worrisome changes in his colleague's behavior. At first, they may not have garnered attention, but he puts aside his overwhelming workload to pay attention.
Listen to an audio recording, read by Dr. Michael LaCombe.
Ask your learners whether Jane's behaviors would alarm them if a colleague displayed them or whether they would be seen as normal. Can you tell the difference?
What must we do if we suspect a colleague is struggling? What should we do if we're struggling ourselves?
How do we position ourselves physically to show others that we are really listening? Do we put away our cellphones? Do we come out from behind our computers? How does that help those in need of our ear? How does it help us?
Do your learners know what resources are available to them if they are struggling?
Do your learners know what to do when a colleague reaches out for help? What if your learners think the colleague needs assistance from others? What if the colleague refuses?
MKSAP 17 Question
A 42-year-old man is evaluated for a 3-month history of cough. He describes the cough as nonproductive and associated with sinus congestion. He also notes increased mucus production with frequent throat clearing. He has no shortness of breath, wheezing, hemoptysis, or chest pain. He does not notice any change in cough with exercise. He reports that he has had similar extended periods of cough in the past, usually in either the fall or spring. He has tried over-the-counter dextromethorphan and decongestants, alone and in combination, without noticeable improvement. Medical history is otherwise unremarkable. He is a never-smoker and takes no medications.
On physical examination, the patient is afebrile, blood pressure is 124/84 mm Hg, pulse rate is 68/min, and respiration rate is 15/min. Nasal turbinates are boggy. The lungs are clear to auscultation. The remainder of the examination is normal.
Which of the following is the most appropriate treatment?
B. Antihistamine-decongestant
C. Inhaled bronchodilator
D. Intranasal glucocorticoid
D. Intranasal glucocorticoid
Treat upper airway cough syndrome due to allergic rhinitis.
The most appropriate treatment for this patient is an intranasal glucocorticoid. This patient has chronic cough (cough of more than 8 weeks' duration) due to upper airway cough syndrome (UACS) associated with allergic rhinitis. UACS is associated with conditions that cause excessive mucus production in the upper airways and postnasal drip, triggering cough. Allergic rhinitis is a frequent cause of UACS and is likely in this patient with evidence of seasonal allergies (clear nasal drainage, postnasal drip) and symptoms that are worse in high allergy seasons (fall and spring). Patients with UACS due to allergic rhinitis respond well to intranasal glucocorticoids, and these agents are considered first-line therapy.
Antibiotics are not indicated in this patient who has no clinical evidence of acute or chronic bacterial sinusitis.
First-generation antihistamine and decongestant therapy is recommended for patients with UACS due to nonallergic rhinitis. Since this patient's presentation is typical of seasonal allergies, intranasal glucocorticoids are a better option. Additionally, the systemic side effects associated with oral medications do not occur with intranasal administration.
Although cough can be a manifestation of asthma, this patient had no reports of wheezing, even with exercise, and physical examination did not reveal the presence of wheeze or airflow limitation. Therefore, inhaled bronchodilators are not indicated.
Intranasal glucocorticoids are first-line therapy for patients with upper airway cough syndrome due to allergic rhinitis; antibiotics should not be used without clear evidence of bacterial infection.
Wallace DV, Dykewicz MS, Bernstein DI, et al; Joint Task Force on Practice; American Academy of Allergy; Asthma Immunology; American College of Allergy; Asthma and Immunology; Joint Council of Allergy, Asthma and Immunology. The diagnosis and management of rhinitis: an updated practice parameter. J Allergy Clin Immunol. 2008 Aug;122(2 Suppl):S1-84. Erratum in: J Allergy Clin Immunol. 2008 Dec;122(6):1237.
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