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.