Nitrous oxide is used medically as an anesthetic agent; in the food industry as a propellant for condiments; and recreationally for its euphoric and dissociative effects. We report three cases of nitrous oxide misuse causing severe, symptomatic cobalamin (vitamin B12) deficiency in which signs of nitrous oxide use per se, as well as signs of toxicity, were observed, including characteristic palmar calluses over the metacarpal heads, and frostbite. These signs may assist clinicians in the recognition of nitrous oxide use and the timely diagnosis of nitrous oxide toxicity.

Internal medicine is the specialty with the most semiological training and it is taught that the combination of a complete clinical history with a thorough physical examination allows for a diagnosis to be reached in the majority of cases. We present a clinical case where an incomplete physical examination interfered with the course of hospitalisation. In a growing technological world where complementary diagnostic tests often allow us to see what is impossible to the eye, the physical examination is often neglected.
CONCLUSIONS: Reinforce the importance of thorough physical examinations in a digital era.Encourage critical reflection on cases for continual improvement.

In this comprehensive review, we delve into the significance of the ocular fundus examination in diagnosing and managing systemic infections at the bedside. While the utilization of advanced ophthalmological diagnostic technologies can present challenges in bedside care, especially for hospitalized patients confined to their beds or during infection outbreaks, the ocular fundus examination often emerges as an essential, and sometimes the only practical, diagnostic tool. Recent discussions have highlighted that the role of an ocular fundus examination might not always be advocated as a routine diagnostic procedure. With this context, we introduce a decision tree tailored for assessing the ocular fundus in inpatients with systemic infections. We also present an overview of systemic infections that impact the eye and elucidate key signs detectable through a bedside ocular fundus examination. Targeted primarily at non-ophthalmology clinicians, this review seeks to offer a comprehensive insight into a multifaceted approach and the enhancement of patient clinical outcomes.

OBJECTIVE: The gastrointestinal (GI) physical exam provides critical information about underlying disease states. However, since assessment of physical examination skills is rarely conducted as part of internal medicine residency training, little is known about resident performance on the GI physical exam.
METHODS: During a clinical skills assessment that took place between November 2019 and February 2020, internal medicine interns examined the same patient with chronic liver disease while being observed by faculty preceptors. We compared the exam maneuvers performed with those expected by the faculty evaluators. We noted which maneuvers were performed incorrectly, whether physical exam technique correlated with identification of physical exam findings, and if performance on the physical exam was associated with building an appropriate differential diagnosis. This four-hour assessment was required for internal medicine interns within two different residency programs in the Baltimore area.
RESULTS: More than half of the 29 participating interns (n=17, 58.6 %) received a \"needs improvement\" score on their physical exam technique. Technique was highly correlated with identifying the correct physical signs (r=0.88, p<0.0001). The most commonly excluded maneuvers were assessing for splenomegaly and hepatomegaly. The most commonly missed findings were splenomegaly and hepatomegaly. Most interns included chronic liver disease as part of their differential diagnosis even if they received \"needs improvement\" scores on physical exam technique or identifying physical signs.
CONCLUSIONS: Internal medicine interns would benefit from learning an organized approach to the gastrointestinal exam. This would likely lead to increased identification of important gastrointestinal findings.

UNASSIGNED: Colorimetric reagent dipstick (CRD) for leukocyte esterase (LE) has shown potential for diagnosing and ruling out bacterial meningitis. Potential advantages over traditional cerebrospinal fluid (CSF) analysis include the small quantity of CSF required, rapid results, and easy interpretation. Our study aimed to determine whether clinicians in LMICs could accurately diagnose bacterial meningitis using CRD at the bedside.
UNASSIGNED: A convenience sample of 143 patients requiring lumbar puncture for possible meningitis were enrolled from 1 October 2018 to 31 December 2019 at three hospitals, one each in rural Burundi, the Democratic Republic of Congo, and Kenya. CSF was analyzed using CRD followed by traditional laboratory-based analysis by technicians blinded to bedside results. Results were analyzed for concordance rates, sensitivity/specificity, positive and negative predictive values and impact on clinical decision-making.
UNASSIGNED: One hundred and one patients were included in the analysis. The prevalence of bacterial meningitis in the convenience sample was 35% (35/101) as defined by microscopy or positive Gram stain. Using a threshold of \"any positivity\" for LE on the CRD, bedside testing correctly identified 33/35 cases (sensitivity 94.3%) and had a NPV of 92%. When only a clearly positive (≥ \"+\" for LE) CRD criterion was used, sensitivity and NPV were 77.1% and 86.2%, respectively.
UNASSIGNED: Despite considerable promise, in our study, color reagent dipstick analysis of CSF did not perform well enough to rule out meningitis or screen samples for the need for microscopy. The development of a CSF-specific dipstick should be considered.

Deep cutaneous fungal infections including deep dermatophytosis are responsible for significant morbidity and mortality, especially in immunocompromised patients. Variable and longer turnaround time on tissue culture results delay diagnosis. We sought to seek the fast bedside diagnosis for disseminated deep dermatophytosis by direct microscopy using a blunt scalpel or needle aspiration before biopsy. This is a 6-year retrospective review of patients with a diagnosis of disseminated deep dermatophytosis seen at a single tertiary care institution. Trichophyton rubrum was isolated in four patients, and T. mentagrophyte complex in one patient. All the dermatophyte isolates can grow at 37 °C. Microscopy of purulence sampling from intact nodules demonstrated abundant septate hyphae, and also isolation from purulence was concordance with skin tissue culture. Ultrasound-guided sampling from non-eroded can yield purulence, and direct microscopy of purulence may facilitate rapid diagnosis of deep dermatophytosis and serve to prevent disease progression and dissemination.

In this article, we report a patient with new-onset dyspnea and symptoms suggestive of heart failure, who had an unexpected diagnosis of a large left atrial myxoma with diastolic protrusion into the left ventricle. We further underline the role of cardiac Point-of-Care Ultrasound (POCUS) in the initial evaluation of patients with cardiac complaints in the emergency room setting. It can help to differentiate the patients\' symptoms in order to achieve a more accurate diagnosis and thus increase the efficacy of the established therapy. In some cases, as with this patient, it can help to establish a diagnosis which needs prompt therapy.

BACKGROUND: Over the past decade, point-of-care ultrasound (POCUS) has been performed increasingly in pediatric emergency medicine for a variety of indications. POCUS is a focused, limited, goal-directed examination at the bedside performed and interpreted by a physician trained in POCUS with the purpose of answering a specific question. Applying POCUS for immediate evaluation of specific emergent complaints may allow for faster and safer management of ill patients in the pediatric emergency department (ED).
METHODS: A 5-year-old female presented to the pediatric ED with fever, vomiting, and back pain. Based on the real-time gray scale and color Doppler POCUS findings, a diagnosis of an acute lobar nephronia (ALN) was made by a pediatric emergency physician and the patient was admitted to the hospital before laboratory and urinalysis findings were resulted. This case report illustrates how POCUS and knowledge of the sonographic characteristics of an ALN were beneficial for shortening the time to decision for admission, rapidly ruling out hydronephrosis (which may have required other interventions), and conveying important information to the admitting team. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Performing a kidney POCUS and knowing the sonographic characteristics of an ALN can assist in its diagnosis, especially in patients where pyuria is absent. In addition, performing a kidney POCUS in patients with a suspected upper urinary tract infection may shorten the time to decision for admission and improve communication with the pediatric admitting resident regarding diagnosis and indication.

Gait disorders in the elderly may be based on a neurologic deficit at multiples levels, or may be secondary to nonneurologic causes. The physiology and pathophysiology of gait problems are reviewed and bedside examination and investigative tools are discussed. The reader will have an excellent working knowledge of the subject and will know how to diagnose and treat gait disorders and falls.

Viral, bacterial, and fungal infections are frequently encountered in clinical practice, resulting in numerous cutaneous manifestations. Although diagnosis of these infections has changed over time because of technological advancements, such as polymerase chain reaction, bedside diagnostic techniques still play an important role in diagnosis and management, enabling rapid and low-cost diagnosis and implementation of appropriate therapies. This 2-part article will review both common and infrequent uses of bedside diagnostic techniques that dermatologists can incorporate into daily practice. This article examines the utility of bedside tests for the diagnosis of viral, bacterial, and fungal infections. The second article in this series reviews the use of bedside diagnostics for parasitic and noninfectious disorders.