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.

Hypertension Treatment Goals

For most people, the medication treatment goals is less than

140/90

For patients with diabetes and chronic renal disease, the goal is less than

130/80

Teenage Shot Schedules

Here is how I manage my teenage shots to cut down on the number of visits to the doctor:

Visit 1:
   HPV #1
   tDaP
   Follow-up in 2 months

Visit 2:
   HPV #2
   Hep A #1 (if not already given)
   Follow-up in 6 months

Visit 3:
   HPV #3
   Hep A #2

RED FLAG FRIDAY: Headaches

For patients over the age of 50, don't forget about temporal arteritis.

REVISIT: Glycohemaglobin and Average Plasma Glucose

In a previous post, we discussed a quick tip to calculate the A1C, here is an EVEN QUICKER tip provided by Dr. Eddie Needham (in which Dr. Carlos Dumois started the entire discussion):

Ave Glucose = (A1C — 2) x 30

So a patient with an A1C of 10 would have an average glucose = (10 — 2) x 30. Or 240. Simple awesomeness. 

RED FLAG FRIDAY: The Dangers of NORMAL Iron Studies

Normal iron studies (i.e. ferritin, total iron, TIBC, percent saturation) in an anemic patient CANNOT be used to rule out CANCER causing a bleed. IRON STUDIES can be falsely normal and trick you into thinking that the patient is not iron deficient (from a bleed), when in fact he really is! YOU STILL NEED TO LOOK FOR (or at the very least consider) cancer causing blood loss from every anemic adult patient!

For example, check a UA to rule out hematurea caused from renal cell carcinoma or bladder cancer.
Order a colonoscopy (or possibly a set of 3 stool guiacs) when appropriate.
Do a work-up for abnormal vaginal bleeding when clinically warranted.

Testing for HSV

This tip is from one of our esteemed residents Dr. Jennifer Stuart:

According to UpToDate, to diagnose an acute herpes infection, viral culture on an unroofed lesion is only about 50% sensitive in diagnosing HSV. A much better (and expensive) test is to order the

HSV PCR 

of the mucosal specimen. The HSV PCR is especially helpful in detecting asymptomatic HSV shedding.

So where does serology fit in? To be honest, I'm not sure. I don't check HSC IgG since I  don't typically care about testing for an previous infection (which may not reoccur). Testing for HSV IgM may be helpful, but in the setting of a very early initial or reactivated infection, it may be falsely negative. 

Testing for Mononucleosis

In day to day practice, I order a monospot to screen for mono. But sometimes, the monospot can give a false negative reading (especially early in the disease). For those times where I need something more sensitive (and more expensive), I will order this:

EBV VCA IgM

Which affectionately stands for Epstein-Barr Virus, Virus Capsid Antigen IgM.

Urine Drug Screens

BEFORE ordering a urine drug screen, make sure to ask when your patient last took EVERY controlled medication that you prescribe. And document that conversation in the chart. It is impossible to interpret the drug screen if we don't know what to expect.

Tips on Inpatient Geriatric Delerium

This is an awesome tip that I learned from Dr. Mina Zeini (who is also faculty 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!

     1. Use the CAM (Confusion Assessment Method)

           1. Must have acute onset and fluctuating course  AND
           2. Must have Inattention

               PLUS

           3. Disorganized thinking

               OR

           4. Altered level of consciousness

     2. Find out the CAUSE!

     3. Do NOT RESTRAIN!!! (increases delirium)

     4. Haldol at low dose (0.25 to 0.5 mg IV) is the first line therapy (discontinue as you find out cause)

     5. TRY TO AVOID BENZOS (it worsens delirium)

Detecting Fentanyl on Urine Drug Screen?

This is an awesome tip that I learned from Dr. Carlos Dumois (who is also faculty here at Florida Hospital Family Medicine Residency)... 

Like oxycodone, fentanyl will not typically be detectable on a standard urine drug screen (i.e. opioids will likely be negative). According to the Mayo Clinic Proceedings: it is undetectable not because it has no metabolites (it does), but because the chemical structures of fentanyl and its metabolites differ radically from those of opiates (ie, morphine and codeine).

To screen for diversion, specific confirmatory testing needs to be orders. Confirmatory testing needs to be ordered for oxycodone also.

An Algorithm for Low Back Pain

Here is an algorithm for low back pain that I made for a recent lecture. Nothing really original here (except for maybe the graphics and layout). It is basically a mishmash of various recommendations. Hope you find it helpful. Please note that this algorithm is simply an educational tool. It is not the Bible!  And it is not suppose to replace sound clinical judgement.

Maximum dose of HCTZ

The maximum dose of HCTZ for the treatment of hypertension is typically listed as 50 mg per day. However, there is minimal "bang for the buck" for doses over 25 mg. In some studies, increasing the dose from 25 mg to 50 mg only reduced the systolic blood pressure by 4 mm. In my private practice, I typically max out HCTZ at 25 mg per day for the treatment of hypertension. If the patient is still not at goal at that dose, I typically add another medication.

Blood Pressure Medications

Most blood pressure medications, even at maximal dose, will only bring down the systolic blood pressure by 10-15 mm. So the tip of the day is this: consider starting TWO blood pressure medications (i.e. lisinopril and hydrochlorothiazide) for patients who are newly diagnosed with hypertension AND who have a systolic blood pressure > 160.

How to Order Compression Stockings

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

Itchy After Seeing Scabies?

Is it me just me—or do other doctors get really itchy after diagnosing a really bad case of scabies?

Treating Scabies

FIVE simple tips for treating SCABIES... 
#1.  SCABIES CAN LOOK LIKE ALMOST ANYTHING. 

And the classic presentation of furrow lines between the fingers is rare (especially for norwegian scabies). In fact, scabies can accurately be described as "the great imitator". Here are some examples of the "non-classic" presentation of scabies:

#2.  SCABIES REALLY ITCHES. 

When you see a really itchy rash, scabies needs to be high in the differential. Other things in the differential include rhus dermatitis (i.e. from poison ivy), dyshidrotic eczema, and insect bites. I'm sure that are other itchy rashes in the differential but my mind is dull today.

#3.  THE ENTIRE HOUSEHOLD NEEDS TO BE TREATED. 

If one person has it, then it is likely that other people in the household have it. Dogs and cats in the home may need to be treated also.

#4.  THE RASH TAKES UP TO 1-2 WEEKS TO RESOLVE

Although the mite is dead, it's poop "lives on" under the skin! So unless you want an angry phone call the next day from the patient wondering why the rash did not spontaneously resolve after an overnight application of Elimite Cream, make sure you inform the patient that the rash takes a while to resolve. Also, it's not a bad idea to retreat the household in 1-2 weeks.

#5.  OTHER HOUSEHOLD MEMBERS DO NOT HAVE TO HAVE SCABIES FOR YOU TO MAKE THE DIAGNOSIS

Although the likelihood of scabies increases if other members have an itchy rash, that negative historical finding does not rule out your patient having scabies. It's all in the timing. Your patient may be the first in the household to demonstrate symptoms. Also some people also seem to develop a more rigorous allergic reaction to scabies than others. For example, five kids playing in a field of poison ivy will not all develop rhus with the same intensity—some who have never been exposed to poison ivy will likely not develop a rash at all.

A Quick Way of Estimating a Normal QT Interval

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

 In a busy practice, calculating the QTc (if your EKG machines doesn't do it for you) can be a chore. A quick way of estimating the normal QT interval is this:

The QT interval should be less than ½ the RR interval

This tips only works if the QRS complex is not widened. I haven't gone through the formal calculations yet to see how accurate this method is compared to directly calculating the QTc. But if sound logical since the QTc is the "corrected" QT interval which takes into consideration the RR interval. If someone does the calculations, please let me know! Cool!

RED FLAG FRIDAY: A NORMAL Urine Culture

Let's say that you treat a patient for a urinary tract infection and the initial UA which showed the following:

1+ protein, 1+ blood, 3+ LE, and POS nitrite

Then, several days later, the urine culture comes back normal:

NO GROWTH FOUND.

That result should not provoke rejoicing! It should cause some stress and worrying! Why? Because if the patient did not have a urinary tract infection, then what caused the 1+ blood in the initial UA? Could it be bladder cancer? Could it be renal cell carcinoma?

Whenever, I get a normal urine culture, the first thing that I do is to check the initial UA. If there is blood on the initial UA, I have the patient see me again to repeat another UA with a urine microscopy. If there are more than 3 RBC per high powered field, then I do a urology referral to work-up hematurea.

Direct Patient-Care Face Time (DPCFT)

Most doctors see one patient every 15 minutes. The economics of our medical system dictate this. In order to pay salaries, malpractice, benefits, rent, electricity, and general supplies, we needs to see patients at this pace. But what does that mean to us practically in terms of time management? Let's think about it... Because we all have responsibilities outside of our direct patient-care face time (DPCFT)—typing up a SOAP note, filling out prior authorization forms, reviewing home nursing orders, answering telephone messages from patients, refilling medications from pharmacies, reviewing notes from specialists, reviewing labs from the prior day, calling patients, doing referrals, and so on—those 15 minutes of DPCFT really get cut down to about 10 minutes. TEN MINUTES! That's all we get folks! No jibber-jabber here! No shooting the breeze about Mrs. Johnson's grandson. Although we want to spend more time talking about family, fishing, and fun with our patients, the truth is that we don't have much luxury to do so. And this can be stressful!

So here are three imperfect solutions that I have come up with:

1. Just run late—Honestly, I'm not good at this one. My patients expect to see their doctor on time (since I'm usually on time). But every once in a while, it good to throw efficiency into the wind, take a deep breath, and truly enjoy looking at Mrs. Jone's photo album of her pet pig (true story). 
2. Schedule 30 minute appointments—I judiciously set up 30 minute appointments. They offer a breather for me with complicated followup visits. But obviously, if I set up too many 30 minute appointments, I will not be able to pay for the overhead of our office. 
3. Split up the visit—I do this especially if the patient has multiple complicated medical problems. I often feel like a heel for doing it. But patients are generally understanding. 

Other than those three tips, I can honestly say that I don't know how to increase my DPCFT. People are constantly complaining about how the U.S. medical system is broken. And from my perspective, the most broken aspect of medicine is that I have so little time with my patients. In a traditional practice, doctor who only see 2 patients an hour get themselves fired for being unproductive or bankrupt for not meeting their overhead. It's a strange predicament that we are in.

Iron Deficiency Anemia

Although the gold standard for diagnosing iron deficiency anemia is a bone marrow biopsy (which is understandably unpopular), serum ferritin has largely replaced this in day-to-day practice. In fact, a serum

Ferritin < 40

is about 98% specific and 95% sensitive in diagnosing iron deficiency anemia. The problem, however, is that ferritin acts as an acute phase reactant (like the sedimentation rate). So any inflammatory process can falsely elevate the ferritin and fool you into believing that your patient does not have iron deficiency anemia (when she really does).

The "Rule of 20" for Pediatric Amoxicillin Dosing

The Rule of 6 for dosing amoxicillin, which we discussed in a previous post, is probably outdated since amoxicillin is typically dosed 80 to 90 mg/kg/day instead of 40 mg/kg/day for children (max 1000 mg per dose). So lets update this rule. For 90 mg/kg/day of amoxicillin, use the following calculation:

   Weight in Pounds  x  20   =   mg dose of amoxicillin per dose

The other change is that this calculation is assuming 2x/day dosing (instead of 3x/day dosing). Let's go through an example. Assuming that you have a 10 pound child in your office, the calculation would look like this: 10 x 20 = 200. So this child would need 200 mg of amoxicillin 2x/day. Since amoxicillin comes in 400 mg per teaspoon, the child would need ½ teaspoon by mouth 2x/day.

The important thing to remember is that this calculation is PER DOSE (and NOT per day). Also, remember that this calculation only works for dosing amoxicillin 2x/day. Double check this calculation with your normal method of calculating the amoxicillin dose. I think you will find that they are pretty close!

The Miracle of Insulin

Have you ever stopped to wonder what a miracle insulin is? Before 1922, the death rate from type I diabetes was 100%. It wasn't until 1922 when Frederick Banting discovered insulin that hope arrived. Can you imagine that? 1922! That was not that long ago!

As doctors, we take insulin for granted. Right now, I'm going through the book The Discovery of Insulin by Michael Bliss. It's a great read! Full of suspense and intrigue! It's amazing how far we have come since the early days of Frederick Banting's discovery.