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.

Vagisil Cream and Manliness?

Ok... I admit it. Vagisil cream is not the most manly thing a guy can pick up at the neighborhood Walgreens. Heck, I'd rather pick up a box of tampons! But, the stuff does relieve minor topical pain. The main ingredient is benzocaine, a local anesthetic. I've used it on patient's with shingles, minor first degree burns, etc. It's much cheaper than the Lidoderm Patches. And I don't have to fill out a prior auth form only to have the Lidoderm Patch denied because I'm using it off-label!

BUT I do recommend that the wives purchase the Vagisil for their man. Real men do NOT purchase Vagisil... NOT EVER!

Making Your Own Jeopardy Game

Have you every wanted to make your own custom Jeopardy Game for a lecture or class or your daughter's 10th birthday party? Why of course you do! Why doesn't? "But it's too hard!" you say. Well fear not! Here's an online tutorial that I did for the STFM Spring Conference on just this topic. It's really easy (and quite fun) with some FREE online tools!

Make Custom Game Shows for Education from David Koo on Vimeo.

When to start medications for osteopenia?

Consider medications in osteopenia if the 10-year probability of hip fracture ≥ 3% or a 10-year probability of a major osteoporosis- related fracture ≥ 20%. These percentages can be calculated using the online FRAX calculator.   Enjoy!

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.

Typical STABLE (and unstable) Follow-up Intervals

Here are some typical follow-up intervals we use at our residency. Note that these intervals are obviously not set in stone (and the clinical context will dictate the right thing to do):

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.

Commonly Prescribed Anticholinergic Medications

Yesterday we discussed the classic anticholinergic side effects. Today we are going to list some commonly prescribed medications in primary care with anticholinergic side effects:

• Muscle relaxers (flexeril, robaxin)
• Incontinence medications (Detrol, ditropan)
• Atrovent inhaler and Spireva
• Tricyclic antidepressants (amitryptyline)
• Benadryl
• Antispasmotic medications (Bentyl, Levsin, trihexphendyl)
• Atropine
• Cogentin
• Antidiarrhea medications (Lomotil)

Classic Anticholinergic Side Effects

• Blind as a bat (blurred vision, mydriasis)
• Mad as a hatter (hallucinations, psychosis, delirium, memory loss, coma)
• Red as a beet (flushing)
• Hot as heat (fever, hyperthermia)
• Dry as a bone (dry mouth, dry eyes)
• The bowel and bladder lose their tone (constipation, urinary retention, ilius) 
• And the heart runs alone (tachycardia, hypertension)

To remember this pneumonic, the first two rhyme with "bat", the next two rhyme with "beet", and the last three rhyme with "bone." Some of this pneumonic doesn't really make any sense since "bowel and bladder lose their tone" suggests diarrhea and urinary incontinence when, in fact, the opposite is the case.