Paucis Verbis: Asthma classification

Emergency physicians have the opportunity to educate patients and prescribe chronic inhaled corticosteroids to patients who should be on these medications chronically. Patients may be more receptive to education and advice given immediately after an asthma exacerbation, managed in the ED.  Using the National Institute of Health/ National Asthma Education and Prevention Program classification system, physicians can quickly determine if the patient is a candidate for inhaled corticosteroids and initiate therapy accordingly.

In short, patients can be classified into one of four classes: intermittent, mild persistent, moderate persistent, and severe persistent asthma. Patients in these classes should receive either Step 1, 2, 3, or 4/5 medications, respectively. I remember that patient using daily short-acting beta agonists (SABA) belong to the moderate persistent asthma category.

[MS Word] [PDF]

See other Paucis Verbis cards.

For the complete report from the 2007 National Heart, Lung, and Blood Institute Guidelines, go to:

www.nhlbi.nih.gov/guidelines/asthma.

Video: On being wrong

Always question whether you are wrong. Step back and rediscover the possibilities. Don't be afraid to admit that you are wrong.

This is great philosophy to live by in both your personal and work life.

This is a fascinating 18-minute TED video by Kathryn Schulz, a "wrongologist" and author of "Being Wrong: Adventures in the Margin of Error.

Specifically in Medicine, many instances of medical error occur when physicians just can't admit to themselves that they may be wrong in their assumptions. So in the Emergency Department, when I encounter a challenging or perplexing case, I step back and challenge what I assume is true. Maybe my assumptions that the patient is clinically intoxicated or malingering are wrong. Maybe my bedside ultrasound of the gallbladder was falsely normal.

Step back.
Reassess.
Repeat the exam or test, if necessary.

Such questioning has often saved me from going down a completely wrong path.

An especially funny anecdote was the speaker's insight about how one psychologically processes the fact that someone else thinks you are wrong:

• The ignorance assumption
• The idiocy assumption
• The evil assumption

Do any particular consultants come to mind?

Trick of the trade: Nebulized ... orange juice?

In my theme of detoxifying malodorous smells in the ED (see Toxic Sock Syndrome and abscess drainage), I recently learned of a new way of masking odors. Imagine the stress on your olfactory nerves from the combined effects of urinary and fecal incontinence from a nursing home patient.

An ingenious nurse proposed nebulizing actual coffee within the room. Unfortunately, our ED was out of coffee at the moment.

Trick of the Trade:
Nebulized orange juice

I only learned of this trick after walking into the patient's very subtly foggy room. About 4 cc of orange juice had been nebulizing for a few minutes. The room smelled a little like a Jamba Juice (a smoothies/ juice shop). Quite pleasant actually. I was shocked to find that it masked the odors quite well. I just HAD to take a photo and share this great trick.

Addendum: This trick really is a more subtle de-odorizer approach. So it only works in an enclosed room, such as a patient's room. You need time for the scent to build up. If your patient is in a common area or hallway, the scent gets too dispersed. You're outta luck.

Professional poster templates for free

If you are in academic medicine , you are familiar with making posters for research forums. Based on the dimensions allowed, the content is usually in 3-4 columns. Everyone has a slightly different approach.

This year SAEM is offering a unique opportunity for poster presenters at this year's Boston annual meeting. They have a a professional printing service where you can upload your poster online, have it printed in Boston, and then pick it up at the meeting site. You'll have to carry it back home though.

Even if you aren't using their printing service, this is a great way to see how professional posters look. There is a menu of various templates that anyone can download for FREE:

Powerpoint-based templates

Live blogging from annual UCSF Education Day

Today UCSF's Academy of Medical Educators (AME) and Office of Medical Education host the 10th annual Education Day. It is free to the public and features many of the big-hitters in medical education at UCSF. I'm hoping that my brain will absorb some of the good education ju-ju at the conference.

The schedule can be found here, featuring the keynote speaker Dr. Diane Wayne (Associate Professor and Vice-Chair of Education in the Department of Medicine at Northwestern University) discussing the "Use of Medical Education Research to Improve Patient Care Quality".



The last time I live-blogged (CORD Academic Assembly 2011), I embedded a Google Docs spreadsheet. The plus was that I had a lot of flexibility in how I could format the layout. The minus was that I needed a wireless internet connection and I couldn't do this from an iPad (doesn't allow Google Docs editing). So this time, I'm embedding a Twitter feed, knowing that I'll be limited to 140 characters. The up side is that I can do this on 3G or wireless and can more easily post photos on-the-fly. If you reply on Twitter, I'll try to respond in as real-time as possible. Let me know what you think.

Paucis Verbis: Dental infections

Periapical abscess

To follow up with the wildly popular Paucis Verbis card made by Dr. Hans Rosenberg (University of Ottawa), here is his card on Dental Infections. This card summarizes common dental infection complaints that we see in the Emergency Department.

Feel free to download this card and print on a 4'' x 6'' index card.

[MS Word] [PDF]

See other Paucis Verbis cards.

Reference
Nguyen DH, Martin JT. Common dental infections in the primary care setting. American family physician. 2008, 77(6), 797-802. PMID: 18386594

The article can be downloaded for free from American Family Physician [Download PDF].

A call for peer-reviewed lectures in Academic EM journal

In an interesting announcement this week, Academic Emergency Medicine announced that it will be publishing Peer-Reviewed Lectures (PeRL) in video format. The journal has had success with its Dynamic Emergency Medicine video section, and it appears that it is now looking to branch out. The PeRL videos will really shatter the old-school model of journals traditionally focusing on original hypothesis-driven research. This is the first that I've heard of a journal thinking "outside the box" and publishing peer-reviewed lectures in addition to traditional research.

Having personally created videos for teaching in the past, I can only imagine how great and utterly challenging this project will be. It will be interesting to see how they handle making the content AND video editing high quality and consistent in tone and formatting. It's the little things like professionally lighting the speaker and getting a good quality microphone which screens out ambient noise that'll make good video lectures great.

According to the SAEM Facebook page announcement:
"Prospective authors should consider contacting the PeRLs editorial board (through John Burton, MD, Senior Associate Editor) for a discussion before starting on video production of a lecture for a determination of topic suitability. Videos can be complex to produce, and given the effort involved, having a discussion with an editor either by e-mail or phone before producing it, is recommended."

Trick of the Trade: Corneal reflex test

The corneal reflex test (blink test) examines the reflex pathway involving cranial nerves V and VII. Classically the provider lightly touches a wisp of cotton on the patient's cornea. This foreign body sensation should cause the patient to reflexively blink.

This maneuver always makes me a little worried about causing a corneal abrasion, especially if you are examining a very somnolent patient. You are wondering -- Is there no blinking because you're not touching the cornea hard enough? You apply harder pressure but still no blink. You repeat the test and now the patient finally blinks. That's 3 times you've just scraped against the cornea.

What's an alternative approach?

Trick of the Trade: 
Apply drops of sterile saline on the eye.

When a patient presents with a low GCS, you want to perform rapid neurologic exam. I've been seeing our neurologists do a quick simple test for corneal reflexes. Grab a pre-filled sterile saline syringe, typically used to flush IV's, and squirt a few drops on the eye. Look for the patient to blink.

This seems much safer and definitive of a test of the corneal reflex.

First annual Medical Apps Awards: Vote now

The polls for the first annual Medical Apps Awards is now open. Voting closes April 21, 2011 @ 12:00 AM EST.

• General instructions (you can win various prizes)
• Go directly to the polls

There are 3 categories that you can vote on:


1. Best Medical App for Healthcare Professionals

• MediBabble - a medical translation tool
• Doximity - a professional networking tool
• Medscape - comprehensive guide to drugs, interactions, diseases, & procedures
• Epocrates - comprehensive guide to drugs, interactions, identifying pills, & calculators
• DrChrono - the first EMR for the ipad

2. Best Medical App for Patients

• iHealth BPM w/ cuff - the first medical app to take your blood pressure & keep track of it
• Asthma Maze - know which food additives & cosmetic ingredients can trigger an asthma attack
• Mayo Clinic Diabetes Type 2 Wellness Solutions - comprehensive guide to diabetes
• Free RX iCard - get discounts on prescription drugs at participating pharmacies, easy locater
• Calorie Tracker by Livestrong - keep track of your daily calories and weight loss progress

3. Most Innovative Medical App

• Airstrip - monitor your patient's vitals, waveforms, labs, I/Os, meds, & allergies from home
• Webicina - a comprehensive online medical resource for both patients & healthcare folks
• Fooducate - scan any barcode in the grocery store to instantly see product health highlights
• PocketCPR w/cradle - real-time feedback so that anyone can do CPR correctly
• Google Translate - speak into your phone and it will speak out the translation

I thought I would mention this since Medibabble was created by recent graduates from the UCSF School of Medicine. It's a creative, well thought-out, free medical translation app. I had highlighted the app back in Feb 2011 and deserves to be on the list of impressive apps.

The downside of voting is that you are required to enter your email and snail-mail address in case you win the prize. Good luck to all the nominees!

I do not have any financial ties with any of these apps.

Article review: What's wrong with self-guided learning?

There is a constant tug-of-war between self-guided learning and supervised learning. With the advances in technology for medical education such as asynchronous learning modules, simulation, there has been a movement away from traditional, instructor-led teaching and towards more independent, self-guided learning. There is less supervision of learning.


But left unsupervised, are learners learning the right things and doing so optimally? The authors, in this review, say yes and no. 

How can learners optimize the practice of self-guided learning? 
The authors delved into the educational psychology literature. The trick is to use under-appreciated cognitive tools in the learning process. 

• Self-monitoring: Keep a record of and be cognizant of the learning process. An example is keeping a record of learning behaviors or personal performance while learning about a particular skill or topic. This reflective approach has been shown to increase self-awareness and improves learning outcomes.
• Selecting what to study: Metacognition research shows that learners are only average at being able to identify learning needs. Interestingly without any time pressure, learners focus first on difficult concepts and then easier concepts later. WITH time pressure (which is pretty much all of medical education), learners focus first on easier items or most proximal topics.  
• Self-testing: Frequent "retrieval practice", or self-testing, has been shown to improve learning retention. Many learners don't do this because subconsciously it's natural to want to avoid being wrong.

Why do we even need instructor supervision then?

Expert instruction is still vital in education. Instructors can...

• more accurately identify and learner's skill/knowledge level and set appropriate learning goals. It's the instructor's job to constantly challenge and push the learner to learn more.
• challenge learners in a different way than learners can challenge themselves. This includes teaching which dispels any false illusions of competence on the part of the learner. This may include scheduling class time to do self-tests, practicing random (instead of a focused) skills, providing summary rather than more real-time feedback. 
• provide support in challenging learning environments.

The authors advocate for a hybrid learning approach called "directed self-guided learning" where the instructor has a behind-the-scenes presence in the independent learning experience. This presence may include designing a structured, step-wise curriculum which the learner can progress through at his/her own pace with multiple checkpoints on learner competency. More studies need to look into the good and bad habits of self-guided learning, how to incorporate external resources into self-guided learning, and the best approach to challenge our learners.

This article is worth a read, although I had to read it a couple of times to really let the content sink in. It's a pretty densely packed article.

Reference
Brydges R, Dubrowski A, Regehr G. A new concept of unsupervised learning: directed self-guided learning in the health professions. Academic Medicine. 2010, 85(10 Suppl): S49-55. PMID: 20881703
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Paucis Verbis: Dental trauma

How cool is this -- I have talented emergency physicians contributing Paucis Verbis card content!

This week features excellent pearls on Dental Trauma by Dr. Hans Rosenberg (University of Ottawa). Here's his recent article in Annals of EM on reimplantation of avulsed teeth (Emergency management of a traumatic tooth avulsion).

By the way, take a look at his recent article in Annals of EM on a rare case of ischemic colitis from blunt abdominal trauma ("Jujitsu kick to the abdomen: A case of blunt abdominal trauma resulting in hematochezia and transient ischemic colitis").

Feel free to download this card and print on a 4'' x 6'' index card.

[MS Word] [PDF]

See other Paucis Verbis cards.

Foiling a thief - high tech Dropbox style

In the past, I've talked about how amazing the cloud-based software Dropbox is. I use it to share my Paucis Verbis cards and share large files with others instead of attaching the whole file in an email. Here's one way I hadn't even imagined but love how stealthy this is.

In the LifeHacker blog (a general, tech-focused Tricks of the Trade website), a reader described how he used Dropbox to recover his stolen laptop.

How did he do this?
In a nutshell, Dropbox maintains a list of all the active devices which are sync'd to your Dropbox account. When you go the Dropbox website, you can log into your account and view all the devices affiliated with your account. For me, my laptop, iPhone, and iPad all have the Dropbox app. If you roll over the blue "i" next to the date of last activity, it will tell you the IP address of where it last sync'd. Because the synchronization takes place automatically, you can track where your laptop was in use most recently.

This led to the capture of the person who stole the reader's laptop. I love how sneaky and resourceful the reader was.

Just something to remember if you get your laptop or peripheral device stolen...

Trick of the Trade: Oblique CXR to look for pneumothorax

CT chest demonstrating a large left pneumothorax

Supine chest xrays have an extremely low sensitivity (12-24%) in detecting pneumothoraces. Because a pneumothorax layers anteriorly on an AP CXR film, the xray beam is perpendicular rather than tangential to the pneumothorax edge. This makes visualizing a small to moderate sized pneumothorax extremely difficult. So you are left to look for indirect signs such as a deep sulcus at the costophrenic angle or subcutaneous air. I'm often surprised at how large of a pneumothorax can be missed on CXR based on CT imaging.

What if you have an equivocal bedside ultrasound result in looking for a pneumothorax, and the patient is too unstable to go to CT?

Trick of the Trade:

Oblique CXR

Matsumoto et al in Annals of EM just reported this great tip. Position a film plate oblique to the patient's chest as shown in the above diagram from the article. "OPX" designates an Occult PneumothoraX. The x-ray beam is now more tangential to the edge of the anterior pneumothorax. This allow us to detect free air more easily.

Supine CXR, oblique view

Thanks to Dr. Fabio De Iaco and Dr. Gemma Morabito from MedEmIt for this CXR image.

Reference
Matsumoto S, Kishikawa M, Hayakawa K, Narumi A, Matsunami K, Kitano M. A method to detect occult pneumothorax with chest radiography. Ann Emerg Med. 2011, 57(4), 378-81. PMID: 20864214
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Blogger has new Dynamic Views

Blogger is always trying to reinvent itself with newer designs and layouts. Recently they released 5 Dynamic View options (above is the Flipcard view). They all have some really visually-appealing features. You can access all of these views by typing "/view" after any blogspot URL link:

http://academiclifeinem.blogspot.com/view

After browsing the layouts, I realized that I would have to delete the content in the current right sidebar:

• Chat box
• 3 most recent comments
• Most popular posts in past 30 days
• My Twitter feed
• Blog archive
• Labels
• My blog reading list

The lack of customizability at this point makes it difficult for me to adopt the new templates. Still kudos to Blogger for working towards making professional-looking layouts for novice bloggers like myself.

Article Review: Medical education can learn from the neurobiology of learning

The brain is a mysterious thing. 

How do we learn? 

Can we apply what we know about the neurobiology and sociology of learning towards medical education? This review article in Academic Medicine presents 10 strategies to improve teaching and curricular development.

1. Repetition
Revising topics from varying perspectives helps to solidify learning. Currently much of medical school education focuses on non-overlapping curricular material to cover the gamut of clinical information. For the purposes of medical school, residency, and lifelong learning, we need to determine when it is best to revisit concepts to improve knowledge retention.

2. Reward and reinforcement
Gold star! Whether we consciously are aware of it or not, the brain has an intrinsic reward system that reinforces learning. Rewards can come in the form of money, praise, or self-realization that one has successfully accomplished a goal. Curricula and educators should incorporate some short-term rewards to encourage and reinforce learning. 

3. Visualization
Visualization, or a mental rehearsal of a process, triggers "neural circuitry in sensory, motor, executive, and decision-making pathways of the brain". This is a great skill to encourage learners to employ, especially after they have gained more experience and witnessed actual procedures or clinical practices. 

4. Active engagement
Learning occurs more when the learner is actively engaged in the process. This is the driving force behind why more large-group traditional lectures are being replaced with small-group workshops where the educator becomes more of a facilitator than an actual teacher.

5. Stress
A little stress is good. Stress helps to potentiate synaptic connections in the formation of memory. Small-group workshops, which put more accountability on the learners, adds stress... in a way which reinforces learning.  

6. Fatigue
Physiologically, the brain needs to recharge periodically. A period for rest/sleep is just as important as a period of formal active learning in the solidification of memory.

7. Multitasking
Today's medical learners are multitaskers. In a classroom setting, learners are constantly barraged by information from various electronic media. These cognitive distractions are often unrelated to the learning material at hand. The trick is to incorporate multimedia into the curricula. Instead of diluting the learning experience, real-time technology (eg. Twitter, Pubmed literature searches, Google Docs sharing of documents, YouTube videos) can enhance it.

8. Individual learning styles
It's known that there are different types of learning styles (approaches to learning). Some do better with one style over others. Generally, there are 3 types of learning styles: Auditory, visual, and tactile/kinesthetic learners. Educators should incorporate teaching styles to match the various learning styles.

9. Active involvement
This item focuses specifically on learning skills, such as procedures. "Doing is learning, and success at doing/learning builds confidence." This provides a strong argument for simulation-based teaching.

10. Revisiting concepts through multimedia/sensory processes
Teaching concepts redundantly through different sensory processess helps to retain knowledge more long-term.

Reference
Friedlander MJ, Andrews L, Armstrong EG, Aschenbrenner C, Kass JS, Ogden P, Schwartzstein R, Viggiano TR. What Can Medical Education Learn From the Neurobiology of Learning? Acad Med. 2011, 86(4), 415-20. PMID: 21346504
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Paucis Verbis: AMI and EKG Geography

(click to see enlarged view) 

Sometimes a picture is worth MORE than a 1000 words. Such is the case of the above illustration that I saw on the Life In The Fast Lane blog. When I first saw it, I knew that I immediately had to find out who made the graphic. It turns out it is the multitalented Dr. Tor Ercleve, who is an emergency physician at Sir Charles Gairdner Hospital and an established medical illustrator.

This graphic demonstrates the EKG findings for the various types of acute MI's as broken down by coronary vascular anatomy (right coronary artery, left circumflex artery, left anterior descending artery). This detailed illustration won't be readable in print form but is great in digital format on your mobile device.

Thanks, Tor!

[MS Word] [PDF]

See other Paucis Verbis cards.

Practical Teaching in EM - Second edition coming in 2012

For educators in Emergency Medicine, there is a great handbook called "Practical Teaching in Emergency Medicine" by the super-star team of Drs. Rob Rogers, Amal Mattu, Mike Winters, and Joseph Martinez. While I don't have any financial relationship with the publisher, I do have a chapter on "Teaching Off-Service Residents".

In the upcoming second edition of the book, I'll be co-authoring with a friend Dr. Amer Aldeen who has recently published articles on this topic. He's also the lead author on the paper describing the NURRC videos.

Should be a fun chapter to revise.

Trick of the Trade: Check pupillary constriction with ultrasound

In some trauma patients with head and face trauma, you will need to check their pupillary response to light. Severe periorbital and eyelid swelling, however, make this difficult. You want to minimize multiple attempts to retract the eyelids because of the risk of a ruptured globe.

What's a minimally painful and traumatic way to check for pupillary constriction?

Trick of the Trade:
Use an ultrasound with a linear transducer.

• Apply generous ultrasound gel on the patient's closed eyelid.
• Have the patient look straight ahead (with eyelids closed).
• Gently position the transducer obliquely on the eyelid in either a sagittal or transverse plane.
• Shine a light into the other eye. If the other eyelid is swollen, you can actually shine a light through a closed eyelid. The pupil can sense light through the thin upper eyelid.
• Watch for pupillary constriction on the screen.

Thanks to Dr. Miss for this tip and Drs. Kornblith and Hensley for demonstrating.

Academic EM's Education Supplement: Deadline 4/22/11

I can't seem to find any posting anywhere online, but I know for a fact that if you want to submit a manuscript for publication in the CORD-CDEM Education Supplement in Academic Emergency Medicine, the deadline is April 22, 2011.

It's a great opportunity to feature your educational research or innovation. Take a look at last year's table of contents:

• 2010 Council of Emergency Medicine Residency Directors (CORD) Selected Abstracts
• It’s Time: An Argument for a National Emergency Medicine Education Research Center
• The CORD Academy for Scholarship in Education in Emergency Medicine
• Critical Appraisal of Emergency Medicine Educational Research: The Best Publications of 2009
• Emergency Medicine in the Medical School Curriculum
• Anatomy of a Clerkship Test 
• Inaccuracy of the Global Assessment Score in the Emergency Medicine Standard Letter of Recommendation 
• Emergency Medicine Quality Improvement and Patient Safety Curriculum 
• Curriculum Design of a Case-based Knowledge Translation Shift for Emergency Medicine Residents
• Rotating Resident Didactics in the Emergency Department: A Cross-sectional Survey on Current Curricular Practices 
• Incorporating Evidence-based Medicine into Resident Education: A CORD Survey of Faculty and Resident Expectations
• An Evaluation of Resident Work Profiles, Attending–Resident Teaching Interactions, and the Effect of Variations in Emergency Department Volume on Each
• A Core Competency–based Objective Structured Clinical Examination (OSCE) Can Predict Future Resident Performance
• Direct Observation Evaluations by Emergency Medicine Faculty Do Not Provide Data That Enhance Resident Assessment When Compared to Summative Quarterly Evaluations 
• Optimizing Resident Training: Results and Recommendations of the 2009 Council of Residency Directors Consensus Conference
• Scholarly Tracks in Emergency Medicine
• Guiding Principles for Resident Remediation: Recommendations of the CORD Remediation Task Force
• Best Educational Practices in Pediatric Emergency Medicine During Emergency Medicine Residency Training: Guiding Principles and Expert Recommendation

Article Review: Reframing research on faculty development

Every once in a while, an education article makes me pause and rethink things.


Faculty development is a concept which I have always taken for granted. Sure, our institution has a multitude of faculty development workshops such as:

• Giving effective feedback
• Educator's portfolio
• Team-based learning

But are these workshops effective? What evidence is there on whether faculty development workshops even make a difference to the educator, learner, or patients? 


This article was written by two of our education gurus at UCSF (Dr. Pat O'Sullivan and Dr. David Irby), who challenge academic institutions to rethink and pursue more research on faculty development. It is a fairly dense read, but it's only because they packed so much goodness in the 8-page commentary.

What are the take-home points?

• To conduct valuable research on faculty development, we need to rethink how we define faculty development. The framework should focus on 2 communities: the Faculty Development Community and the Workplace Community. Teaching faculty shouldn't focus entirely on their skills in isolation and outside of their workplace. Societal and environmental factors impact their teaching approaches and effectiveness. 
• The Faculty Development Community consists of the facilitator, program (curriculum and content), organizational context (eg. classroom vs clinical setting), and participants (teachers and affiliated staff). These components are inextricably linked with the greater Workplace Community.
• Faculty development is a "social enterprise" rather than a focus on just the individual teacher. That means that perhaps workshops not only include skill development but also working on applying these concepts in the actual workplace with the rest of the organizational team. 
• Research can look at the interactions between and among the various links in the model above.
• Educational research should be held to a different standard as traditional outcome-based research because while outcomes are important, process-oriented relationships are just as important. The authors make an eloquent argument on why educational research is unique and should viewed as such. 

The authors make 6 recommendations about faculty development:

• Promote high-quality, thematic, sustained, and cumulative research programs using various methods/models/paradigms in medical education.
• Embrace the use of an incremental and cyclical approach to research, as advocated by Bredo, in order to develop a deeper understanding of how faculty development actually works.
• Test this expanded model of faculty development examining all the components and interrelationships with an emphasis on studying processes to better ascertain their impact on desired outcomes.
• Test the application of the expanded faculty development model to various learners and career paths.
• Establish a National Institute or Center for Health Professions Education Research with associated training, career development, investigator-initiated research, and centers of excellent funding mechanisms.
• Advocate state, local, and private funding to support educational research and faculty development.

I redrew their new enhanced model on faculty development, partly because I have a secret desire to be a professional medical illustrator. Check out this upcoming Friday's Paucis Verbis card where you can see what a real medical professional illustrator can do.


Reference
O'Sullivan PS, Irby DM. Reframing research on faculty development. Acad Med. 2011, 86 (4), 421-8. PMID: 21346505
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Paucis Verbis: Post-exposure prophylaxis (non-occupational)

You know how chief complaints present to the ED in multiples? In one week, I had several cases where patients were asking for post-exposure prophylaxis treatment NOT in the content of a sexual assault. I haven't had to manage such cases in a long time and so needed to look up the recent guidelines from the CDC.

The trick is not to forget about all the co-existing problems and infections beyond just HIV. Specifically, don't forget about gonorrhea, chlamydia, and trichomonas. The 2010 CDC website on STD treatment and sexual assault is here:

www.cdc.gov/std/treatment/2010/sexual-assault.htm

[MS Word] [PDF]

See other Paucis Verbis cards.

Reference

Landovitz RJ, Currier JS. Postexposure Prophylaxis for HIV Infection New England Journal of Medicine. 2009, 361(18), 1768-75. This article is free to the public: http://www.nejm.org/doi/full/10.1056/NEJMcp0904189