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.

RED FLAG FRIDAY: Snuff Box Tenderness

Assume that all snuff box tenderness is a scaphoid fracture! Even in the presence of a normal x-ray! These injuries usually require immediate splinting with with thumb spica splint and an orthopedic surgery consultation to rule out a scaphoid fracture which if not healed correctly can cause chronic hand pain from non-union and avascular necrosis.

RED FLAG FRIDAY: Joint Swelling

Joint effusions are common. Most often they are related to injury. But if a patient presents with joint swelling AND fever, that combo is a septic joint until proven otherwise. I usually do a STAT referral to an ER who will then do a STAT orthopedic surgery consult! Although other conditions can cause joint swelling and fevers, this is not one to miss or blow off.

The "Danger" of Epipen

Epipens are great! They can be a life saver!  BUT, they only buy patients about 20 minutes of time. And then guess what? That's right!—the wheezing, throat edema, tongue swelling, and chest tightness comes right back again (but this time without an Epipen).

Over the years, I have made it a habit to warn all my patients who carry an Epipen, "If you ever need to use it, GO TO THE EMERGENCY ROOM RIGHT AWAY. If you don't, you will be up a creek without an Epipen."

Fungus Loves Baby Bottoms

Fungus love moist environments (i.e. a baby's bottom). Most diaper rashes will go away simply by leaving the diaper off (which is my recommendation for really bad diaper rashes). I still use anti-fungal creams (like Lotrimin), but keeping the bottom dry work wonders.

Send a culture on EVERYTHING that oozes!

I send an aerobic cultures on EVERYTHING that oozes. I have been surprised many times at what grows out of even innocuous looking infections. The benefits are: 1) if it is MRSA, I can place the entire family on prophylaxis 2) I get to see what kind of resistance patterns are developing in my community, 3) it give me an opportunity to know if my initial choice of antibiotics are correct, and 4) it's easy to do.

RED FLAG FRIDAY: Sore Throats

When someone comes in for a sore throat, I look especially for a peritonsilar abscess. And when I do NOT find one, this is how I document a normal exam: Tonisilar pillars are symmetric and uvula a midline. If there is a peritonsilar abscess—which happens about once a year in my practice—I send the patient immediately to the ER who then consults an ENT doc to do an incision and drainage of the abscess. (I'm not about to stick a scalpel near someone's carotid artery!)

Pediatric Bactrim Dosing

Bactrim suspension is dose at approximately 1 teaspoon for every 22 pounds. This is given twice a day. For example, a 45 pound kid would get about 2 tsp by mouth twice a day. Just be aware of the maximum dose. Pretty cool eh? And no calculators involved!

Bilateral Pedal Edema

When a patient presents with new-onset bilateral pedal edema (especially with elevated blood pressure), I make it a habit to check a UA looking for proteinuria. Every once in a while, I catch a new case of nephrotic syndrome that way—since peeing out your albumin (and other proteins) will definitely cause extra-vascular edema from reduced inter-vascular oncotic pressure.

The "Think About It" Technique

Sometimes patients need some time to "mull" over things. And the idea of getting certain tests (i.e. colonoscopy) or starting certain medications (which they will have to take for the rest of their lives) is stressful to them. I have learned that for some patients, it is best simply to "bring up the idea" before prescribing an intervention. Here are some of the things that I might say:

Mr. Jones, at your next visit, we should schedule your screening colonoscopy. You've been putting it off for a while now.

Mr. Williams, the treatment of diabetes requires as least 4 different medications: your diabetic medication, something called an ACE inhibitor, aspirin, and a cholesterol medication called a statin. I'm telling you this now because I don't want you to be shock in the future. Today, we'll just start the metformin. As you come back, I'll talk to you more about the benefits of the other medications. 

Mrs. Stevens, your cholesterol is still really high. We should consider starting a cholesterol medication at our next visit in 3 months if it is still elevated.

Treating blood pressure frequently requires 3 or more medications. Most blood pressure medications at their maximum dose will only bring down your blood pressure by 15 points. So don't be alarmed if we have to add more medications in the future.

Guess what Mr. Reed, we need to do your rectal exam at our next visit!

Preparing patients mentally like this, especially for those who are typically against medical intervention, seems to "soften the blow" when the time comes. 

Don't Be Fooled by a Negative C. Diff. Toxin Test

As family doctors, we are typically pretty good at screening for C.Diff. But just because someone has a negative C.Diff. Toxin Test does not mean that they do NOT have C.Diff. Remember that this test is imperfect and frequently needs to be repeated. Often it is better just to start empiric treatment while waiting for the workup.

Just a fever, doc, nut'in else!

For folks who present with only fevers or malaise, check for a urinary tract infection. In the elderly, UTIs commonly present as just malaise. For children, fever is frequently the only symptom.

"For The Rest of Your Life!"

This conversation occurs frequently:

"Mr. Jones, your cholesterol has gone back up. Are you taking your simvastatin everyday?"

"No... Was I suppose to?"

This is usually followed by an awkward silence.

"Ummmmm... Yeah.."

"Well, my last cholesterol was good and so I thought that I could just stop the medication."

For medications that need to be taken chronically, I have made it a habit to say something like, "You will likely need to take this medication for the rest of your life. If you make some dramatic changes to your lifestyle or you lose a lot of weight, we can talk about stopping the medicaiton. But don't stop the medication unless we talk about it or you are having a side effect." 

RED FLAG FRIDAY: Diarrhea

Just like back pain, the vast majority of diarrhea is self-limiting and benign. But here are some "red flags" that I typically screen for:

1. RECENT ANTIBIOTIC USE—consider Clostridium Difficile.
2. RECENT CAMPING (or drinking water form a lake, pond, or stream)—consider Guardia. I once had a man who maintained fountains in ponds who we diagnosed with Guardia. My only case in the last 10 years. 
3. CHRONIC WEIGHT LOSS—consider looking for colon cancer or inflammatory bowel
4. ABDOMINAL PAIN or BLOODY STOOLS—Consider invasive organism such as salmonella. Also entertain other infectious causes of abdominal pain.

Again, those are just some of the "red flags" off the top of my head. Do you have any others?

Encouragement is Sometimes the Best Medicine

I have a patient who we recently diagnosed with diabetes. During our visits, I have tried to explain the importance of reducing simple carbs in his diet, but I don't think that he ever "got it." At our last visit, I noticed that he lost 30 pounds over the past 3 months (and I didn't need a scale to tell me that). He was proud of the progress that he had made with he weight and his improved diabetic control. When I asked him how he did it, he told me that he was eating a lot of rice. At that moment, the thought briefly entered my mind of discussing carbs again. But you know what? I didn't say a word! That day was not the right time for that discussion? He was doing well, losing weight, and his glycemic control had improved. That day was the time for simple encouragement. That day was the time to celebrate his success.