Prolonged QT Syndrome

With patients complaining of palpitations, I have made it a habit to check the QT interval. I just wish there was a quick way to do it. Right now, I am using a program called MedMath on my cellphone that seems to do a good job. But I don't know that I would say that that method was quick. I suppose that that I should get an EKG machine that automatically calculated the QT interval.

Anyway, the reason that this tip is helpful is because prolong QT may increase the risk of Torsades. As a resident, I had a young patient who had multiple short runs of VTACH. Her QT ended up being prolonged and we did a cardiology referral.

Early MI and peaked T-waves

Not that I see a lot of acute chest pain in my office—but sometimes, the only EKG sign for early acute MIs are peaked T-waves. If I remember correctly, this is caused by cellular injury resulting in a transient rise of potassium (with is the most abundant intercellular cation). Ischemic and injury patterns such as inverted T-waves and ST changes may take some time to develop. I learned this tip many years ago as a resident when I was evaluating my first patient with an acute MI in the ER.

Children with vague abdominal pain and fever

Strep throat often presents atypically in young children. Sometimes, the only symptom that I will get is some vague abdominal pain. Other common symptoms such as fever, sore throat, or headache are frequently absent. On exam, the abdomen is benign and the throat may only be mildly inflamed. For these kids, I usually check a rapid Strep test and send a throat culture to the lab. I have been surprised many times!

Obviously, a urinary tract infection is also in the differential.

RED FLAG FRIDAY: Backpain

Although the vast majority of acute low back pain is benign, here are some "red flags" that I learned long ago to screen for:

1. FEVER—Consider infectious etiologies. After a spinal procedure such as epidural, consider spinal abscess. Also consider pylonephritis and pneumonia if pain is higher. I suppose rheumatic etiologies should be entertained (but patient should have other symptoms as well). 
2. PREVIOUS HISTORY OF CANCER—consider metastatic disease.
3. PARANEOPLASTIC SYMPTOMS—such as weight loss, night sweats, fever, etc. Also consider metastatic disease or even multiple myeloma.
4. FALL or TRAUMA or RISK OF OSTEOPOROSIS—consider fracture. 
5. CAUDA EQUINA SYMPTOMS—never seen a case in the last 15 years in medicine. And these patients would unlikely present to my office. The ER seems way more likely. But I suppose like all things, it's good to keep in mind.
6. PULSATILE MASS ON ABDOMINAL EXAM—consider abdominal aortic aneurysm. Again, I have never seen a case of this present as isolated low back pain. But I suppose someone has. 

I'm sure that there are other "red flags" for back pain. These are just the ones that come to mind off the top of my head. Does anyone else have other "red flags" to add? 

Renal Insufficiency and Metformin

Because of concerns of lactic acidosis (and subsequent high risk of mortality), metformin should not be used in patients with renal failure or severe renal insufficiency. When I get lab results back showing an elevated creatine, I have made it a habit to check 1) what the last creatine was, and 2) if the patient is currently taking metformin.

Warts and Low Self-Esteem (of Doctors)

Sometimes, the treatment of warts can cause doctors "low self-esteem" (especially when treating plantar's warts). No matter what we throw at that verrucous lesion—we can try to freeze it, pare it down with a sharp scalpel, and try to suffocate it under duct tape—it just laughs at us, menacingly, like this:

At that point, the time has come to get out the big guns:  DNCB (dinitrochlorobenzene). Our practice has found DNCB to be highly effective. But treat the stuff with utmost respect! And don't ever spill it in the office! That would be an environmental nightmare! And prepare the patient for multiple visits.

Warts and Duct Tape

My billing for cryosurgery for warts has gone down considerably since advising my patients to keep their warts covered with either duct tape or band-aids. This tip doesn't always work. But it works sufficiently well enough that I only get out the Cryo Gun about 2 times a week. That's too bad since using the Cryo Gun is kind of fun...

Alcoholism and high HDL in men?

There seems to be a high correlation (at least in men) between high HDL and alcoholism in my practice. I often ask about alcohol use (and sometimes ask the "CAGE questions" to screen for alcoholism) in men with very high HDLs. This correlation is not always true since many other factors can raise HDL. But the correlation occur frequently enough for me to do a minor screening for alcoholism in my population.

Patients ask the HARDEST questions!

After graduating from residency, I was proficient with managing strokes, working up new onset atrial fibrillation, treating severe congestive heart failure, managing a ventilator, placing central lines, doing lumbar punctures, and treating severe diabetic ketoacidosis in the ICU. BUT, I couldn't answer these simples questions:

1. Why do people hiccup?
2. Why do I get so many cramps in my legs?
3. What do I do if the Nix doesn't get rid of my lice?
4. Why do babies spit up so much?
5. How do I burp a baby?
6. What do I do if my 8 month old baby doesn't poop in two days?

It amazes me how family practice residencies can train young doctors to be so proficient in handling complicated medical problems, and yet new graduates know so little about the intricacies of burping!

The Pain of Prior-Auths

I hate filling out medication prior-authorization forms! Luckily I don’t have to do it much since I usually prescribe generics. However, sometimes using name brand medications is unavoidable. For instance, I have one patient who is on Celebrex for osteoarthritis. She had serious GI side effects with traditional NSAIDs. And because NSAIDs may reduce the efficacy of aspirin (which the patient is taking), we decided to stick with Celebrex. SO EVERY STINKING YEAR FOR THE PAST FIVE YEARS, I go through the same song-and-dance with her insurance company. It is an unnecessary AND time-consuming AND irritating job. This last round, I wrote this on the bottom of the form:

PLEASE APPROVE HER CELEBREX FOR MORE THAN ONE YEAR!!!!! HER HISTORY DOES NOT CHANGE FROM YEAR TO YEAR!!!!  AND THIS IS AN UTTER AND COMPLETE WASTE OF MY TIME!!!! STOP BOTHERING ME!!!!!

My MA looked at me with some skepticism before faxing the form. Two weeks went by with no reply. Then I got this faxed back from the prescription management company:

CONGRATULATIONS! We have approved your patient’s Celebrex for 6 MONTHS!

Nice!!!!! I must admit though—instead of being fuming mad—I thought this was a brilliant response. Six months! That must be the best passive-aggressive response I have ever heard! I showed the fax to my partner who just laughed. I should have kept it. Then, I could frame it. Actually I should have kept faxing back the same form! Maybe I could get it down to 6 days!

Tinea capitis NEEDS systemic anti-fungals!

I have seen two cases where other doctors prescribed topical anti-fungal creams for tinea capitis. The result: I have to manage the unfortunate treatment failures which, in these particular cases, resulted in large, purulent, disgusting kerions on the patients' scalp. So this post is just a simple reminder: the treatment of tinea capitis requires systemic anti-fungal agents! I like using griseofulvin with french fries.

Child dies from hypotonic fluid bolus!

When I was in residency, an ER doctor gave a child hypotonic fluid (½ NS) as a fluid bolus. The child developed cerebral edema, had status seizures, and died. It was such a sad case for everyone involved (including the doctor). But I definitely learned an unforgettable lesson from this: hypotonic fluids should never be given as a bolus in anyone (especially children).

Being Confident About Ignorance

When I started working after residency, I laughably thought that I had to know everything. And I also imagined that patients expected me to know everything. Boy, how quickly I learned! Now I know that there is absolutely no way I can know everything, and that my patients most definitely do not expect me to know everything. But they do expect this: that I ought to be extremely confident in stating what I do and do not know. In other words, when I do know somethings well, I should be able to communicate it confidently and clearly. And when I do not know something, I should be able, with equal confidence, to admit my ignorance. They don't want "half-baked" responses. And they can sniff out when I am floundering for an answer a mile away! It is much better to simply say, "I don't know." Here are some ways that I have said that:

         "That is an excellent question! And I have absolutely no idea!" 

         "In my 10 years of practice here, I have never heard anyone ask me that question before!"

         "I really don't know. But if you give me one second, I can look it up for you."

         "I'm going to have to think about this one. Give me until our next appointment to sort this out. I want to do some research on this."

         "If you don't mind, I am going to have my partner look at this also. Sometimes two minds are better than one." 

         "That is not something that I am good at evaluating, if you don't mind, I'd like to refer you to a specialist to see if they can help us figure this out."

         "I'm not sure what is causing your symptom, but I will do my very best to help you find out. We will make of list of some possibilities and start crossing them out as the tests come back."

Over the last ten years, I have found that I have needed to say these things less often. But it's still good to remember that no matter what questions may come up, simply saying "I don't know" is nothing to be ashamed or embarrassed about. On the contrary, I have found that when I am brutally honest about my ignorance, patient will trust me more about the things that I do know. 

Why won't this jock itch go away?

Have you ever been frustrated with the treatment of tinea cruris? I have! Once I went through several rounds of topical anti-fungals and the stick'in rash still wouldn't go away! In my case, the reason was because the patient did not have tinea cruris. Rather, it was erythrasma which, honestly, can be extremely difficult to differentiate from tinea cruris. Doing a KOH slide would have helped I suppose! Live and learn! I've also heard that a wood's lamp will make erythrasma glow, but I think that some forms of tinea will do the same.

The treatment for erythrasma is simple: erythromycin 333 mg, one tablet by mouth 3x/day for 10 days.

Glycohemaglobin and Average Plasma Glucose

A glycohemaglobin of 6% correlates with an average plasma glucose of about 120. And every 1% increase in glycohemaglobin will cause approximately a 30 point rise in the average plasma glucose. So if we charted it out, it would look something like this:

Just remember 120 at 6%. And 30 rise with every 1%. Remember that these are just rough estimates (and they are probably on the conservative side).

Funky TSH Results

When treating hypothyroidism, sometimes I get unexpected TSH results. Before making another adjustment to a patient's levothyroxine dose, I always double check 1) compliance with taking the levothyroxine, and 2) if they are taking their levothyroxine with vitamins, antacids, iron, or calcium supplementations (which can all decrease levothyroxine absorption in the gut).

The Walmart $4 Generic List

Here is the link to the Walmart $4 Generic List. Here are some interesting things that I noticed:

1. Albuterol premixed nebulizer solution is on the list (25 vials for $4). That's pretty amazing considering that Proventil HFA costs around $55! Not that I'm advocating that doctors give all their asthma patients nebulizer machines, but the price of a basic nebulizer machine is around $55. This could be an interesting option for our self-pay patients who are really strapped for cash. Too bad there are no inhaled steroids on the list!
2. Terbinafine (Lamisil) is also a $4 med. I can remember a time when it was well over $150. 
3. Metformin ER is generic. Having an extended release metformin may help some of my patients who complain for GI issues from the regular metformin. 
4. Antipyrine/Benzocaine otic drops are on the $4 list. That's good to know for my kids with simple but painful otitis media. 
5. Sprintec and Tri-Sprintec are the only $4 birth control pills on the list. 
6. Fosamax 70 mg is on the list. I had no idea! 

There rest of the list is mostly common knowledge. I'm just waiting for simvastatin to go on the list. 

Tips for Residents: Make your SOAP note NARRATIVE

For new doctors just graduating from residency (or even entering residency), here is my advise regarding documentation. I hope you find it helpful...

As you document your assessment and plan, TALK TO YOURSELF! Here is one time where talking to yourself is not considered insane! Tell yourself what you are thinking in the encounter (“I’m not sure exactly what is causing her fatigue, but either sleep apnea and/or depression is highly likely”). Tell yourself what are some of the things that you want to “rule out” in the future if your current work-up comes back negative (“Consider ordering an EGD if cardiac work-up comes back negative”). Tell yourself what your treatment plan is over the next few appointments (“If patient does not improve with home stretching and NSAIDs, consider starting physical therapy next visit”). Tell yourself the plan for the followup visit (“Consider repeating Chem 7 next visit since we increased her dose of HCTZ”). Tell yourself why you don’t think certain dangerous things are in the differential (“I don’t think that her chest pain is cardiac in nature since there is a strong correlation with spicy foods and laying down at night”). Tell yourself interesting facts about the patient (“She is going with her sister to Maui next week.”)

All these little tidbits are an important part of the “narrative” aspect of good physician documentation. As medicine slowly transitions to EMR, don’t forget this “narrative” aspect of documentation. It is important for medical-legal reasons. It is important for simply being a good doctor!

Is EMR destroying “the narrative”?

Many ERs in my area recently transitioned to electronic medical records. And so far, this has been a terrible step backwards in physician documentation. Instead of getting a concise SOAP note that gives me a reasonable idea of what the ER doctor thought (or even did), I get a vomitus of essentially meaningless word-salad (which is generated, no doubt, from doctors checking off boxes on their computers). Here is a sample which I have transcribed almost verbatim (without the patient's actual name of course):

Have reviewed chart of JOHN DOE and it is ready for final disposition. Condition at discharge—stable. Patient discharged from department. Verbalized understanding of discharge instructions. Verbalized understanding of need for followup and how to access followup care. Verbalized understanding of signs and symptoms to return to ED. Patient discharged from department. Discharge home. Verbalized understanding of discharge instructions [haven’t we heard this already?]. Verbalized understanding of need for followup and how to access followup care. A disposition has been done for JOHN DOE.

What a complete waste of paper! All I want from the ER is something like this: “Johnny has a mild otitis externa. I have prescribed cortisporin otic drops for him. Follow up with Dr. Koo in 2-3 days.” Instead, I literally get five pages of tree-killing faxes that doesn’t even tell me what was prescribed! Nice!

Now I’m sure that some of the kinks of EMR will eventually get worked out. And to be fair, there have been some small improvements recently. However, because EMR relies on doctors typing and clicking on a computer rather than dictating into a voice recorder, I’m afraid that most of the “narrative” aspect of physician documentation will go by the way of the Dodo Bird. And I am saddened that I probably will no longer get something as simple as this from the ER:

“Mr. Johnson has some dizziness. I think this is probably just from some dehydration. I have instructed him to drink more fluids and to decrease his lisinopril from 20 mg to 10 mg a day. He was advised to followup with Dr. Koo in 3 days to recheck his blood pressure. Consider repeating a Chem 7 at that time to reassess his mild renal insufficiency.” 

Now that kind of dictation is HELPFUL, but will likely become increasingly rare in our new era of check-boxes and computer-based templates.

Oxycodone and Urine Drug Screens

Oxycodone (Percodan, Percocet, Roxicodone, Oxycontin) does not show up on most urine drug screens (but at high levels it may show up as positive opoids). To screen for diversion, I specifically order a urine oxycodone quantitative level (NOT qualitative level) for those patient who are taking oxycodone products for chronic pain.

ACE Inhibitors and Birth Defects

As family doctors are diagnosing diabetes and hypertension earlier and earlier, the use of ACE Inhibitors in younger patients is becoming more common. However, it is good to be reminded that ACE Inhibitor may be associated with an increased risk of birth defects (and currently this is a black-boxed warning). For woman of childbearing age, options other than ACE Inhibitors should be considered. So when we get that fax from the insurance company urging us to start an ACE Inhibitor for our young, diabetic, female patient, we should feel free to tell them to bugger off.

Practice Management Tip #2: Cutting Medications Saves Money

Some medications such as Lipitor and Crestor are very effective but expensive. To help patients save money, I often have them cut their tablets in ½. The reason why this technique saves money is because different strengths of a medication are typically priced the same. Therefore, by cutting the tablet in half, patients are getting twice the amount of medications for the same price. But there is a caveat to this tip. If you write your script like this:

      Lipitor 20 mg
      Take ½ tablet by mouth 1x/day
      #30

Guess what! The pharmacy will only give the patient #15 tablets instead of #30 for a month. And that will really annoy your patients! Not only do they have to pay the same price for their Lipitor, but now they also have to cut all their tablets in half! To get around this ridiculous problem, here's how I write my scripts:

      Lipitor 20 mg
      Take 1 tablet by mouth per day or as directed by your physician
      #30

My patient and I have an understanding that the phrase "or as directed by your physician" is our secret code for "cut the tablet in half". This obviously requires that 1) you have excellent communication with your patients and 2) you have a good way of documenting the correct dose in your chart. Also, be prepared to get irritating faxes from the insurance company stating that your patient has not been compliant with their medication. These notifications I promptly place in the shredder.

Obviously, not all medications are amenable to this tip (i.e. capsules, tablets with special time-release coatings, or tablets that are oddly shaped). However, that still leaves quite a few medications that can take advantage of this tip.

Practice Management Tip #1: Give Enough Medications

Always give patients enough refills until their next appointment. In fact, make sure that you give them one extra month so that if they are a little late for their followup, they do not have to call your office for refills. For example, if I start a patient on simvastatin for hyperlipidemia and I want to see them back in 2 months to recheck their cholesterol, I will write for #30 tablets with 2 refills (for a total of 3 months). This simple tip significantly reduces the number of callbacks.

Asprin use in Diabetic Patients

Hmmmmm... It looks like aspirin use in diabetic patients is not as "cut and dry" as we once thought. But still, most of my diabetic patients seem to meet the criteria since they are typically older patients with multiple risk factors for cardiovascular events:

The organizations state that only men older than 50 and women older than 60 who have one or more additional major risk factors should be treated with aspirin for primary prevention of cardiovascular events.

Surviving Medical School Tip #2: The Last Graduate

QUESTION: What do you call the medical student who graduates last in his class?

ANSWER: Doctor

This is not an excuse for slacking. But there is something amazing to be said about simply graduating from medical school. Also, there are some doctors who graduated from the top of their class who I would never refer my patients to. And there are others who graduated near the bottom who are intelligent, conscientious, and excellent physicians. It goes to show that MCAT scores, medical school grades, and board scores do not solely define a good doctor. Non-quantifiable traits such as common sense, a good bedside manner, being a good listener, compassion, the ability to set firm boundaries, discernment, organizational skills, communication skills, and integrity are arguably as important as medical knowledge in the making of a good family doctor.

Proper Inhaler Technique Revisited

Now this is the proper (although less funny) technique...

These are the key points that I stress to my patients:

1. Press inhaler after start of inhalation
2. Do a slow inhalation (NOT the quick gasp that you see people do on TV)
3. Hold breath for ten second (or as long as comfortable)
4. Repeat in 1 minute if needed

Proper Inhaler Technique

This a good reminder for those of us who treat asthma...