How should adderall be handled in a patient with asymptomatic tachycardia?

I have an 11 y/o male with history of ADHD diagnosed at age 5 who presents to establish care. The patient has been on Adderall 20 mg ER for several years, and the mother states the medication and dosage is working well for him at school and at home. Upon examination, patient is found to be tachycardic at 112. Patient denies any cardiac symptoms. No tachycardia reported by previous PCP that mother or patient is aware of. No family hx of heart disease at an early age in the family. I ordered initial labs (TSH, CBC, BMP) and an EKG and scheduled follow-up in 1 month. 

Labs wnl, and EKG- sinus tachycardia. 

On follow-up visit, tachycardia persists. 

I suspect the tachycardia is due to adderall use. Do I refer this patient to cardiology to rule out a cardiac etiology? Or do I decrease the dose of adderall, but what if the lowered dose is not as effective for the patient? Or do I continue to monitor and refer the patient only if he becomes symptomatic?

Should anticoagulation be started in a patient with Factor V Leiden deficiency prior to undergoing venous radiofrequency ablation?

I have a patient with a history of Factor V leiden deficiency, but no prior history of DVT. He is not on anticoagulation regularly. He is scheduled for a great saphenous vein (GSV) radiofrequency ablation. I am trying to decide if he needs to be started on an anticoagulant prior to, during, or after treatment.

How long before a lumbar medial branch nerve radiofrequency ablation (or other equivalent pain procedure) should lovenox (enoxaparin) be stopped?

I have various patients on lovenox/enoxaparin (or being bridged with lovenox) who need pain procedures as described above. ASRA guidelines call for the med to be stopped 12 hours prior for prophylactic dosing and 24 hours prior for therapeutic dosing [Interventional Spine and Pain Procedures in Patients on Antiplatelet and Anticoagulant Medications]

They note that some prophylactic doses increase to 1.5mg/kg/day for obese patients. And I had a patient being bridged with 120mg/day. Considering this was a bridge I’m guessing this was a therapeutic dose but by the recommendation this could be a prophylactic dose, making it difficult to decide when to stop a dose like this?

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Is one fitness device better than another for weight loss?

I have some motivated patients who are trying to lose weight. They've asked for advice. I gave them some usual diet and exercise advice but one person in particular asked if one health tracking device is better than another… ie Fitbit, under armour, smart watches, etc.
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If my patient has an egg allergy do I need to get a preoperative anesthesia evaluation?

I have heard that an egg allergy can cause a problem receiving propofol. I sent patients for preoperative evaluations which proved unnecessary in one case. Is this a waste of time for the patient or could it be important?
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Are there differences in the types of needles used for lumbar punctures?

The lumbar puncture kits I have used usually have quincke spinal needles. I didn’t think much of it but I noticed that some anesthesia colleagues don’t use quincke needles when they do spinals, which are essentially the same procedure. Why is this? And why aren’t they used in lumbar puncture kits?

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Why is thiosulfate mixed in with nitroprusside in some formularies?

At our institution’s pharmacy, thiosulfate is mixed in with nitroprusside infusions. However, I know that this isn’t done by all institutions. Why is this done and how is dosing of the thiosulfate determined?
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Up to what INR can a peripheral joint injection be done safely?

My clinic frequently sees many patients who could benefit from peripheral joint injections. Unfortunately, many of them are on coumadin and are somewhat high risk for stopping anti-coagulation.

In these higher risk patients I want to know under what circumstances can I safely perform joint injections while remaining on coumadin?
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Is adderall associated with coronary artery disease of any kind?

We have a 31 year old patient with a history of hypertension, tobacco use and ADHD on adderall who presented with ST elevations in leads II, III, aVF, V5, V6 and an elevated CK, CKMB and Troponin T. Catheterization indicted distal occlusions of the apical portion of the posterior descending artery and posterior left ventricular branch and an ejection fraction of 60%. The cardiologist performing the catheterization felt that there was likely thrombus in the right coronary artery causing showering thrombi which caused the occlusions above. He denied cocaine use and his toxicology screen was negative. No family history of early CAD. His HDL/LDL were 47/108. His A1c was 5.3%. Although he is a smoker and has hypertension he is only 31. His only medication is adderall for ADHD. Is adderall associated with any coronary events like that described above?

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Is it okay to do a lumbar epidural steroid injection in a patient with a schwannoma or neurofibroma?

I have a 51 year old female with chronic low back pain with radicular pain down the left lower extremity. Her MRI within the last few months shows some non-specific degenerative changes except for a T2 signal in the right lateral recess of L3-L4 which is likely a schwannoma or neurofibroma. Interestingly, note the pain is mostly left but the lesion is on the right. Her pain appears to be coming from other degenerative changes.

The lesion has been stable for years and she elected a while ago to not undergo surgery. To treat the left sided pain I was thinking of an epidural steroid injection (possibly via the transforaminal approach on the left). But I’m not sure if the lesion is a contraindication?
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