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)