RED FLAG FRIDAY: Don't Blow Off Anemia

In a population-based study, 9 percent of adults older than 65 years with iron deficiency anemia had gastrointestinal cancer. Yikes! I know, nine percent doesn't sound like a lot. But think about how many geriatric patients we see each year with anemia! In fact, older adults with anemia had gastrointestinal cancer 31 times as often as adults without anemia. (REFERENCE: Ioannou GN. Am J Med 2002;113:276-80).

Diagnosing Dizziness

Since dizziness can be cause by anything from BPPV to brain tumor, diagnosing the cause of dizziness can be a hugh challenge! This is an algorithm (or map) that I made to help simply the process. Hope it helps! A much higher quality PDF version of this algorithm is available by clicking here.

Depression Medication Chart

Here is a chart that I adapted from UpToDate. It lists the most commonly used antidepressants and their side effects, cost, and other random note. Hope it helps...

Algorithm for Work-up of Pediatric Anemia

Here is a simple algorithm for the workup of pediatric anemia. Hope it helps. This handout is from a lecture that I recently presented at the 2012 AAFP Scientific Assembly. (NOTE: Click on the "simple algorithm" link above to download the algorithm. The image below is low resolution).

Diagnosing Diabetes

The ADA guidelines for diagnosing diabetes are not always straight forward—there is a barrage of random numbers to memorize. See if this handout which has an easy pneumonic that I made up for the residents helps to ease some of the pain. Also I have included a handout explaining how to use the Homeostatis Model Assessment (HOMA) to determine whether a diabetic patient has an insulin production problem, a peripheral resistance problem, or both. (NOTE: Don't click on the image below since it will only give you a low quality image; click instead on the "this handout" link above).

Finally, I want to give Dr. George Guthrie profuse thanks for his help in putting together these handouts, and for lending his expertise at the 2012 AAFP Scientific Assembly. Thanks George, you are a blessing. He also added feet and toes and eyes to the pneumonic (to help us remember to do our diabetic feet exams and eye exams). Cool!

Tips on Neonatal Jaundice

(SOURCE: Wikipedia)

Neonatal jaundice! Should I start bili lights or not? AHHHHHHH! Nomograms! Charts! Calculating lab draw times! Assessing risk factors! There has to be an easier way to do this. We are in a technological age aren't we? For goodness sake, we have computers that can calculate the prime derivative of thirty billion electrons playing hop scotch in Andromeda! All I want is for the computer to do some pretty basic math and plot it on a simple nomogram! Ok...

Check this website out: www.bilitool.org. Makes all the calculations MUCH easier... And... You're welcome!

Lice! Lice! Lice!

What do you do when the Nix (1% permethrin) does not get rid of the patient's lice? Well... Assuming that you are doing all the other stuff (using the lice comb, treating family members, etc.), consider using Elimite cream. "But Dave, the patient doesn't have scabies!" you say. Well Elimite cream is 5% permethrin which is 5 times more concentrated than the permethrin in Nix. And, for me, this tip usually does the trick.

Of course there are many other Lice tips and tricks and medications (and some are quite flammable!). This is just what works for me.

Refills on Albuterol Inhalers

Each albuterol inhaler has 200 puffs. And since we advised patient to give themselves TWO puffs per treatments. There are about 100 "treatments" in one inhaler. Knowing this, I rarely give out more than 1 inhaler at a time (and I rarely give refills). The reason is that I can use the patient's refill history to give me a rough estimate of the patient's asthma control. If the patient is requesting a refill of their albuterol inhaler every three months, that means they are using their inhaler on the average 1 to 2 times a day (definitely not in control). And if they are requesting their refill only after one month, that means that they are using their inhaler at least three times a day! Yikes!

Imaging for Chronic Sinusitis

Do you have a patient with "chronic sinusitis" and you want to order some imaging?

• Order a limited CT scan of sinuses (without contrast)
• This costs about the same as a sinus x-ray
• But it gives way better images!

Women's Health Screening Recommendations

The Florida Academy of Family Medicine published a Women's Health Screening Recommendations (last edited 4/23/12). It's an interesting read that summarizes the recommendations made by various organizations such as the USPSTF. Here is the official New Release.  (NOTE: Don't click on the image below to see the recommendations—you will only see the first page of the recommendations—click on the link above instead).

Testing for Celiac Disease (Celiac Sprue)

Here are some tips regarding Celiac Disease:

• All patients with history of "irritable bowel syndrome" should be tested for celiac disease
• Testing should be done on a HIGH gluten diet
• These test have the highest diagnostic accuracy (better than IgG):
• Endomysial IgA 
• Tissue transglutaminase IgA 
• Diagnosis needs to be confirmed with small bowel biopsy

ASPIRIN Use: A Simple Reminder

Here are the USPSTF guidelines on aspirin use for protection against cardiovascular disease: 

Here are the original recommendation:

The USPSTF recommends the use of aspirin for men age 45 to 79 years when the potential benefit due to a reduction in myocardial infarctions outweighs the potential harm due to an increase in gastrointestinal hemorrhage.
Grade: A recommendation.

The USPSTF recommends the use of aspirin for women age 55 to 79 years when the potential benefit of a reduction in ischemic strokes outweighs the potential harm of an increase in gastrointestinal hemorrhage.
Grade: A recommendation.

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of aspirin for cardiovascular disease prevention in men and women 80 years or older.
Grade: I statement.

The USPSTF recommends against the use of aspirin for stroke prevention in women younger than 55 years and for myocardial infarction prevention in men younger than 45 years. 
Grade: D recommendation.

Radiation Risk from X-rays and CT Scans

Have you ever wonders who much radiation your patients are getting from a single chest x-ray or from a CT scan? Here is an awesome website that helps us calculate the risk. It is informative AND fascinating. Enjoy!

Simvastatin at 80 mg Dose No Longer Recommended

The FDA recently put out this recommendation regarding simvastatin at the 80 mg dose. I rarely ever go that high anyway (since going from 40 mg to 80 mg rarely helps to bring down the LDL very much). But it's still good to know.

Recurrent Yeast Infections (Vulvovaginal Candidiasis)

This is an awesome tip that I learned from Dr. Jennifer Keehbauch (who is the Associated Director here at Florida Hospital Family Medicine Residency). This tips was given as part of our "Learning Center" teaching series which our faculty personally do for our residents. Enjoy!

Recurrent vulvovaginal candidiasis (VVC) is defined as infections that occur greater than 4 times a year. The most common agent is C. Glabarata which causes 40% of the infections and is associated with increased burning and older aged females. There is usually less discharge and burning with candidiasis caused by C. Glabarata. Also, this organism is less susceptible to "azoles".

The treatment for recurrent VVC is with:

1. Induction - which is 2 x normal therapy. Can use Diflucan 200 mg on day #1 and #3. Or you can use Topical azoles for 7-14 days.
2. Maintenance - which is weekly dose for 6 months. You can use Diflucan 100 mg weekly or clotrimazole 500 mg PV weekly. 

The difference between glyburide and glipizide?

Both medications are common sulfonylureas use to treat type II diabetes. However, glipizide has a shorter half-life compared to glyburide (12 hours versus 22 hours). And glipizide has a lower incidence of hypoglycemia. Although the pharmaceutical companies want us to prescribe their newer oral agents (which are not part of the ADA guidelines), sulfonylureas like glipizide are considered "well validated" and "Tier I" medications for the treatment of type II diabetes (after metformin).

Booster Now Recommended for Menactra

This is an awesome tip that I learned from Dr. Ernestine Lee (who is the Assistant Director here at Florida Hospital Family Medicine Residency): A booster is now recommended for Menactra at age 16. Here is an excerpt of the CDC's recommendations:

All 11-12 years olds should be vaccinated with meningococcal conjugate vaccine (MCV4). Now, a booster dose should be given at age 16 years. For adolescents who receive the first dose at age 13 through 15 years, a one-time booster dose should be administered, preferably at age 16 through 18 years, before the peak in increased risk. Adolescents who receive their first dose of MCV4 at or after age 16 years do not need a booster dose.

RED FLAG FRIDAY: Headaches

This is an awesome tip that I learned from Dr. Jennifer Keehbauch (who is the Associated Director here at Florida Hospital Family Medicine Residency). This tips was given as part of our "Learning Center" teaching series which our faculty personally do for our residents. Enjoy!


      S     =     Systemic Signs (such as fever, meningismus, or weight loss)


      N     =     Neurologic Signs or Symptoms (slurred speech, double vision, abnormal neuro exam)


      O     =     Onset Sudden ("worst headache of life", thunderclap)


      O     =     Onset < 5 years or > 50 years (don't forget about temporal arteritis)


      P      =    Progression of Existing Headache (increased severity or frequency or change in quality)


If a patient has any of these symptoms, consider imaging to look for a secondary cause of the headache. 

RED FLAG FRIDAY: Subungual Melanoma

Most melanomas are evident on plain site. But sometimes they can also be "hidden" or they can look like something else. For examples, a melanoma underneath a nail looks very much like a hematoma. And often the only way to tell a subungual melanoma from a hematoma to do a biopsy. Thankfully, melanomas in general are pretty rare. But it's good to remember that in non-caucacians, about 30% of melanomas are subungual.

RED FLAG FRIDAY: Shingles on Tip of Nose

Herpes Zoster (shingles) is not typically "dangerous". But when the rash presents on the tip of the nose (Hutchinson's Sign), we have to worry about possible eye involvement. Refer those patient's immediately to an ophthalmologist.