Clinical Pearls

FORWARD
This section is a collection of clinical pearls, “tricks of the trade”, and words of wisdom from experienced Family Physicians.  Individual doctors interviewed for this book had up to 55 years of experience in medicine.  Interestingly, I discovered on pilot testing this idea that some retired physicians who were no longer actively seeing patients daily had difficulty remembering specific pearls and most younger physicians (<5 years of experience) had yet to develop these “tricks”.  I discovered that physicians with 15 to 25 years of experience seemed to have developed the most pearls and had the desire to share this wisdom with the next generation of learners.

Over 100 board certified Family Physicians from almost every area of the United States were identified using a targeted, convenience sampling technique.  One person (the author of this book) interviewed every physician.  Their clinical pearls are in this book in no particular order and do not link directly to the listing of contributing physicians.  The majority of these “tricks of the trade” have not been tested using evidence-based methodologies.  In fact, few have ever been the subjects of random controlled trials.  Some of the medications suggested for certain treatments are “off-label” for that medication.  These suggestions would have to be viewed as evidence class C or “expert opinion”.  They may not work well for practice populations that differ from the contributing physician’s patients.  The reader is advised to review these clinical pearls with skepticism and to use them at their (or their patients’) own risk.

-Rick Ricer, MD  2003

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SECTION LINKS
Skin
Physical Exam
Musculoskeletal
Respiratory
Heart and Blood
GI Tract
Procedures
Children
Women
Psychosocial
Neuro
HEENT
Elderly
Philosophy of Practicing Family Medicine
Add your own Clinical Pearl

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SKIN
DIAPER RASH
• When treating contact dermatitis diaper rash caused by contact to diarrheal stools or urine, one of the cheapest and easiest treatments is regular white Crisco(TM).  This gives an extremely good water resistant barrier over the skin and does not irritate the skin.  It can be applied after each diaper change and cleaning.
• Wash the baby’s bottom after each bowel movement and put oil on the bottom and in the creases to prevent diaper rash.
• A mixture of nystatin, hydrocortisone cream, and zinc oxide can be used to treat almost any diaper rash.
• Mix cod liver oil and flour into a paste and paint onto the skin with each diaper change.
DRYING A WEEPING LESION
• One of the best ways to dry a weeping skin lesion is to apply Domeboro’s solution® (aluminum sulfate, calcium acetate) at every opportunity and allow to air dry.  This is an OTC product. Mix one pouch or tablet in a pint of tap water (2 in a quart).  Use a jar with a replaceable lid, such as an old mayonnaise jar with a screw on lid.  Place the solution on the kitchen counter or other area of high traffic.  Whenever the patient passes that area, have them shake up the solution, dab it on the lesions, and allow to air dry.  This is good for poison ivy, chicken pox, and other weeping lesions.
CONTACT DERMATITIS / ALLERGIC DERMATITIS
• If a patient develops a contact dermatitis to a piece of jewelry but wants to continue wearing that piece of jewelry, they can paint the back of the watch, bracelet, or ring with clear nail polish.  After this is dry, it creates a barrier between the jewelry and the skin, which prevents contact with the skin and the reaction.  The nail polish needs to be reapplied whenever it begins to wear off.
• An easily overlooked cause of dermatitis is the formaldehyde in wash-and-wear clothing.  It can cause a rash under new clothing.
POISON IVY
• The pharmacist can concoct a mixture of Cetaphil® cleanser with 0.1% menthol and 2.5% hydrocortisone cream.  This can be used TID.
• Use a spray if touching the skin is very uncomfortable.
DERMATITIS
• Gold Bond® powder absorbs moisture and soothes the skin.  It can be used for dermatitis under breasts or in the skin folds and for a perianal rash.
PRURITIS
• Oatmeal baths are helpful in softening skin and reducing itching.  A cup of oatmeal mixed into the bath water helps soothe the skin.  Remind the patient to completely flush all the oatmeal down the drain and through the trap. Dried oatmeal in plumbing can act like concrete.  A way to avoid the oatmeal going down the drain is to place it in a cloth bag and placing that in the tub.
• Adding baking soda to bath water can decrease itching.  Make the water milky.
PRURITIS WITH NO RASH
• This may be scabies.  Persons who shower daily are not likely to produce retrievable mites.  Eurax® (crotamiton) is an anti-itch cream and scabicide.
BLISTERS
• Many times patients will develop blisters on their feet from running increased distances or in new shoes.  If they want to continue running before the blisters heal, debride the top of the blister, dry the base, then apply tincture of benzoin over the base and allow to air dry.  Several coats may be needed.  This creates a “second skin” over the blister so the patient can resume activity.  The procedure may need to be repeated prior to each activity.  Placing benzoin on the base of the blister can be painful for the patient.
• Place Duoderm® over denuded blisters for protection and relief.
DECUBITI AND STASIS ULCERS
• Place Amino-Cerv® or similar product in the crater to promote epithelialization and nitroglycerin cream or ointment on the edges to increase circulation.  Too much nitroglycerin can cause a headache.
• Mix Betadine® and table sugar into a paste, apply this into the wound, then wash it out and repack every 8 hours.  Cover the wound with regular gauze.
HAIR LOSS
• Losing more hair than normal may be a sign of a masked depression.
ALOPECIA AREATA
• Anthraderm ointment® can be applied twice daily to bald spots.  This is an irritant that may help stimulate hair follicles and gives the patient something to do while waiting to see if hair growth will return.  Steroid injections might be tried after a 3-month trial fails.
FOOT ODOR
• For patients with sweaty, stinking feet, a combination of alum, isopropyl alcohol, and formalin can relieve the problem.  Saturate the alcohol with powdered alum, then add 1-2 tablespoons of formalin. Pat the feet with cotton balls dipped into the solution nightly.  The alum is an antiperspirant, the alcohol is a drying agent, and the formalin “pickles” dead skin.
BRITTLE NAILS
• Even if the patient is not anemic, supplemental iron may help. Treat for at least a month.  Oral gelatin may also be beneficial.
PRURITIS ANI
• One of the most common causes is the phenolphthalein dye in pink toilet paper.  Discontinue all colored paper.
ATHLETE’S FOOT
• Use vinegar soaks (1/2 cup vinegar in a bucket of warm water for 15 minutes BID), then apply antifungals.
ECZEMA
• Ask your local pharmacist to fabricate a mixture of liquor carbonis detergens 2% solution in a steroid cream and apply BID.
• In a dry climate, frequent showering can still be done if the amount of soap used is greatly decreased.
• After bathing, take at least 2 minutes to pad dry and then apply oil or moisturizer.
• Crisco(TM) placed on the skin and wrapped with Saran Wrap(TM) can be a good treatment for eczema.  A low potency steroid cream can even be applied under the Crisco(TM).
SKIN FISSURES
• Cracked skin is usually worse in the winter.  Covering the fissure with Vasoline(TM) and then covering that with a bandage can soften the skin and correct the problem.  This can also work for localized contact dermatitis or hand dermatitis.
ALLERGY TO WOOL
• Patients with eczema who react to wool shouldn’t use baby oil or mineral oil since this is derived from lanolin and they can react to that as well.
SKIN ANTIBIOTICS
• Use Polysporin® or Bactroban® instead of Neosporin® to decrease sensitivity reactions.
MELANOMA
• Smooth and well circumscribed skin lesions are almost never melanoma.  Melanoma has irregular borders.
• Any non-healing skin lesion needs biopsied.
ATOPIC DERMATITIS
• The most important treatment is to moisturize the skin.  Apply lotion immediately after taking a bath or shower.
SKIN LESIONS
• Put paper tape or scotch tape over a lesion you want to follow, trace the lesion, and then place the tape in the chart.
SPLIT NAILS
• Super glue can help hold split nails together while they are healing.
• Some patients with onychomycosis do well with twice a day application of Vick’s VapoRub (TM) on the involved nails for several months.
VENOUS STASIS ULCERS
• Bag Balm(TM) (8 hydroxy quinolone sufate 0.3% in petroleum lanolin) can help moisten, soften, and heal venous stasis ulcers. Bag Balm(TM) also works well for chapped or dry hands.
• Silvadene® cream can help keep the wound moist and will prevent the dressing from adhering to the wound.
LOCAL SKIN REACTION
• Applying a baking soda paste can help soothe a local reaction such as a bee sting.  An antiperspirant deodorant (aluminum) sprayed on the sting can also reduce symptoms.
• Put clear nail polish over chiggers or bug bites to decrease the itching.
CALLOUSES
• Covering callouses with Crisco(TM) and then saran wrap overnight will help soften them for pain relief and easier paring.
FUNGAL RASH
• If a rash itches only when the patient is hot or sweaty, think fungal cause.
WARTS
• When all else fails or prior to using a painful procedure, attempt to help the patient “visualize the warts away”.  Have them trace or draw the affected area complete with every wart, then have them perform a ceremony where they burn the paper and “burn the warts away”.  They can also do relaxation techniques, then imagine their white blood cells are Pac-Man(TM) like cells that “eat up” the warts leaving only a beautiful and wart free area.  This can be done nightly.
• To get a never ending supply of liquid nitrogen for cryotherapy in your office, contact a local cattle farmer and find out who supplies the sperm for his cattle insemination.  This is delivered to the farmer in liquid nitrogen.  You can get on their route inexpensively by renting a 20-liter flask from them.
• There is a gas vent available for cryo guns that screws in just behind the pinhole orifice.  This has a very small capillary tube that will vent out gas.  This allows a steady stream of liquid to be delivered to the orifice and will greatly decrease the “sputtering” effect of most cryo guns.

PHYSICAL EXAM
ABDOMINAL EXAMINATION / ABDOMINAL PAIN
• When a patient complains of abdominal pain and the examiner is confused as to whether the pain originates in the abdominal wall or deeper in the abdominal contents, have the supine patient lift both legs a few inches off the examining table while the examiner palpates the abdomen.  This contracts the rectus muscle.  If the pain is worse during this contracted examination, then the pain stems from the muscles of the abdominal wall. If the pain is absent during this contracted examination, then the process is intra-abdominal.
• Carry on a conversation with the patient while you’re examining the abdomen to distract them.
• If you suspect that abdominal pain is actually not present, place the stethoscope over that area of the abdomen, then press down on the stethoscope.  If this doesn’t elucidate pain, but there is pain when palpating without the stethoscope, the pain is probably not present.
• The size of the liver is the best 2 of 3 when using palpation, percussion, and the scratch test.
• Many times, mothers are concerned about appendicitis whenever their children have vomiting or any abdominal pain.  Have the child jump up and down on one foot. If they can do this without pain, they don’t have appendicitis.
RED REFLEX EXAM
• Sometimes it is difficult to examine the red reflexes of a newborn if they will not open their eyes.  The examiner can use the non-dominant hand to support the baby’s chest and central body.  Lifting the baby directly above the examiner’s head usually causes the baby to open their eyes and look down at the examiner.  The eyes can then easily be examined using the ophthalmoscope held in the dominant hand.
• You can use the otoscope to look for a red reflex in an infant or child.  Simple slide the magnifying lens off to the side.  You will be looking down the beam of light at zero diopters and can see a beautiful red reflex.
EAR EXAMINATION
• The otoscope is a light source and magnifier only.  The tip of the otoscope does not need to be buried into the ear canal.  This is painful for the patient.  Because the tips are tapered, a false impression is perceived that the tip should be pushed far into the canal.  This is not necessary and is uncomfortable.  The tympanic membrane can be visualized using only a penlight as long as the canal is straightened properly.  Place the tip of the otoscope just far enough into the canal to be able to visualize the tympanic membrane, then move yourself into a position to visualize the entire TM.  If a seal is needed for a pneumatic exam, clip 2 to 3 mm of the rubber or plastic tubing that connects the bulb to the otoscope and place this small piece over the end of the otoscope tip.  This gives a good seal without having to ram the tip deep into the ear canal.  Use the largest caliber tip that can easily be placed just inside the ear canal.  It can be very difficult to visualize anything through a tiny opening of a pediatric tip.  These are somewhat of a misnomer.
• Practice insufflating the tympanic membrane in order to be able to differentiate normal from abnormal.
HYPERTENSION
• A more accurate BP reading in massively obese individuals can be found at the wrist.  Put the cuff on the forearm where there isn’t as much adipose tissue to distort cuff efficiency.  Of course, the proper size cuff is still necessary.
• For chronic hypertensives, have them get their own BP cuff and bring it to the office so you can check with your BP cuff to see if the home device is accurate.
PELVIC EXAM
• To avoid changing gloves when doing a pelvic exam and a rectal exam (checking for heme positive stools), especially in the presence of any vaginal blood, do the internal vaginal exam with only the index finger and the rectal exam with the middle finger (or vice-versa).
• To be most comfortable, the patient needs to keep her bottom on the table and her knees as far apart as she can.
• In a patient in which you cannot insert a speculum (frightened patient, MR/DD, after an assault), insert your index finger into the vagina, find the cervical os, then slide the brush over your finger into the os to get the sample.
• When preparing for a bimanual exam, spend 30 seconds spreading the lubricant around the fingers.  This provides less friction during the exam and allows the examiners fingers to warm up the lubricant.
• When doing a pelvic exam, use a separate sheet to drape the patient from the abdomen down and always keep the legs covered.
• When a patient has very loose vaginal walls, cut a finger off a rubber glove, then cut the tip off that finger.  Place over a speculum.  This will keep the walls from intruding into the speculum when opened.
• For the first pelvic exam, explain it to the patient prior to undressing and show all the instruments.  Explain how to relax and make sure the knees are wide apart.
• When you are having trouble finding the cervix, close the speculum, push it deep into the vagina aiming for the sacrum, open slightly and pull back slowly.  It should pop into view.  If this fails, find the cervix with you finger first and aim the speculum there.
• Use the intravaginal finger(s) to push the organs up to the lightly pressing lower abdominal hand.
EXAMINING CHILDREN’S EARS
• To keep a child still during an otoscopic exam, tell them there’s a bird in their ear and to listen for the bird to whistle.  You whistle when you can see the TM.
• Another way to distract them is to let them play with your retractable tape measure while you examine their ears.
• Yet another way to distract kids for the otoscopic exam is to massage the tragus while talking to them, which desensitizes and reduces reactions.
• The examiner can whisper to the child and have the child concentrate on hearing the whisper while the examiner searches for the TM.
• Have the child hold the otoscope and “help” you examine their ears.
BREAST EXAM
• When performing a breast exam, try to convince yourself that there is a “BB” sized cancer hidden in that breast. This causes you to do the exam infinitely more carefully.
HAND WASHING
• Patients appreciate seeing you wash your hands prior to doing any part of the physical exam on them or their children.
HEARING LOSS
• Always have a hand held amplifier (can be purchased at a store like Radio Shack(TM) in the office.  Place the earphones on a patient with poor hearing and speak softly into the amplifier.
TREMOR
• Lay a sheet of paper on the hand to accentuate a patient’s tremor.
KNEE EXAM
• The lateral knee begins at the intersection of a line across the top of the patella with a line along the lateral edge of the patella.
HYPERVENTILLATION
• If there is a question of whether symptoms in an anxious patient are due to hyperventilation, have the patient hyperventilate while you are listening to the lungs to see if symptoms are reproduced.
RENAL COLIC
• If you are concerned the patient’s pain may be from renal colic, check for hyperaesthesia in the L1 dermatome.  If this is present, the patient has renal colic.
ANEMIA
• If the palmar creases are not red when the hand is opened and fingers spread (check with your own), think anemia. The lower conjuctiva may also be pale.  This usually means a hemoglobin of less than 10.
CONSOLIDATION OF LUNGS
• Percuss the clavicle while listening to the posterior lungs to check for consolidation and dullness in the lung fields.
FUNDOSCOPIC EXAM
• When performing a fundoscopic exam on a patient with a large refractive error, the examiner may have great difficulty focusing on the retina.  Have the patient wear their glasses and try again with the setting at zero.  If the glasses are the correct prescription, the retina should be focused for the examiner.  (The examiner may have to wear their prescription spectacles as well.)  Practice will help decrease the problem with glare from the glasses.

MUSCULOSKELETAL
QUADRICEPS STRENGTHENING EXERCISES / CHONDROMALACIA PATELLAE
• For conditions like Chondromalacia Patellae when the quads need strengthening but without stretching the quad’s tendon, have the patient lift the heel off the floor while keeping the knee locked, in the sitting position.  The lifting is from the hip, so the hamstrings must clear the surface of the chair while the leg is lifted.  The patient then holds the leg up for 1-2 minutes.  This needs to be done multiple times a day.  A good reminder for the patient is to do this during every commercial break when they are watching television or when talking on the telephone.  When the patient can do this exercise for the entire commercial break consistently, place a 5 pound sack of sugar or flour on the dorsal aspect of the ankle and continue with the exercises.  The weight of the sack can be increased as the patient tolerates.
• Another method is using an old strapped purse over the ankle and placing various weights in the purse.
HEEL SPUR
• One of the best ways to pad the heel when a patient has symptoms from a heel spur is to use the Styrofoam (TM) that surrounds stereo systems or television sets when they are packed.  Cut an inch thick layer the size and shape of the affected heel.  Place the Styrofoam pad into the shoe.  These are portable and can be moved to any other shoe and easily replaced when the weight of the patient and continuous use has flattened the pad.  The pad gives a good cushioning effect and slightly lifts the heel.  When the patient steps on this pad, it will compress to less than half an inch.
FROZEN SHOULDER / ADHESIVE CAPSULITIS
• When a patient has a shoulder injury and there is a concern that they will develop a frozen shoulder, range of motion exercises help prevent this complication.  The patient may not be able to do active exercises secondary to weakness of the muscles or pain.  Passive range of motion can be accomplished by having the patient grasp over the end of a mop or broom handle and using the unaffected arm to push the broom or mop handle through all the motions necessary.  The affected arm should remain fully extended at the elbow and the unaffected hand should grasp the broom handle far enough away from the affected hand to easily push the affected arm through full range of motion.
MUSCLE TENSION HEADACHE / POSITIONAL NECK PAIN
• If a secretary or computer operator is having symptoms of overuse of the trapezius muscles from bending over a keyboard all day (the same position the head is in when lying supine on a pillow at night), decrease the height of the chair or raise the workstation.  This way, the head is erect,the back is straight, and the traps are less utilized.  They may have to pad or support the elbows in this new position.
LOW BACK PAIN
• Teach these patients to “get set” before lifting (just short of a valsalva – tighten abdominals and gluteals).  Always lift with the powerful leg muscles instead of using the back as a crowbar.  Have the patient draw where the pain is located each visit.  Compare the drawing to see if the location is consistent.
• The lumbar curve is the culprit and the puny abdominal muscles are the potential saviors – strengthen the abdominals.  Use leg lifts (not high), shoulder lifts (not sit-ups), and knee to chest grabs.
• When examining a patient complaining of low back pain, do the straight leg-raising test while the patient is sitting.  Converse with the patient or appear to be examining the knee to differentiate a true positive from a false positive.
• Make sure that the patient does one exercise for regular stretching – knees to chest, hold 30 seconds keeping the curve of the back on the floor, 5 repetitions twice a day.
• Some patients with back pain have episacral lipomas as the cause.  These are fatty lumps caused by a herniation of the deep layer of fat through the fascia into the superficial layers.  These lumps (if they are causing the back pain) will be exquisitely painful to palpation.  Inject only the symptomatic lipomas with lidocaine and a steroid.  They should get immediate relief.
LATERAL EPICONDYLITIS
• If you suspect lateral epicondylitis, use the chair lift test for confirmation.  Have the patient stand behind the chair, reach over the back of the chair with the affected arm and grasp the lowest part of the back of the chair above the seat, and lift the chair straight up.  This should cause pain directly over the lateral epicondyle.
RETURN TO SPORT AFTER INJURY
• When the patient can walk without pain, they can begin to jog. When the patient can jog without pain, they can begin to run.  When they can run without pain, they can begin to do figure 8s.  When they can do figure 8s without pain, they may return to their sport.
LEG CRAMPS
• To help prevent leg cramps at night, have the patient lie supine in bed with their feet up against the footboard.  They can then do plantar flexes of the toes, working the calf muscles.
SPRAINED ANKLE
• For rehab range of motion for a sprained ankle, have the patient use that foot to write the alphabet in the air.
• A tilt board can be made by nailing a square piece on top of plywood of semi-circular pieces of plywood in an x pattern.
AUTO ACCIDENT
• Have the patient draw the accident or you draw it from their description and place this in the chart.
CARPAL TUNNEL SYNDROME
• A  neutral position wrist splint can be made using a bowling glove.
HAMSTRING TIGHTNESS
• Twice a day, have the patient lie in bed, pull the leg up until the thigh is at 90 degrees with the hip, straighten the leg at the knee10 times while holding behind the thigh.  Pull the toes back.
RAYNAUD’S
• When a patient is exhibiting Raynaud’s phenomenon in cold weather, they can attempt to force blood into the fingertips by “windmilling” their arms at the shoulder to use centrifugal force to force the blood past the vasospasm.
OSTEOARTHRITIS OF THE KNEE
• A lateral heel pad can help alleviate some of the pain associated with osteoarthritis of the knee (medial compartment).  Cut a heel pad in half and place inside the shoe.

RESPIRATORY
ASTHMA / INHALERS
• One of the best spacers for inhalers is the inside tube of a toilet paper roll. It is cheap, easily accessible, and can be fun for the patient to use. It is made of cardboard which will absorb the large droplets from the inhaler, allowing only the mist to penetrate the mouth and airways.  It also obviates the need to coordinate a deep breath at the same time the inhaler is triggered.
• If the patient has ever smoked marijuana, they can use that skill when using an MDI.  They inhale the same way and hold the medication in the lungs the same way.
• For children using an inhaler or mister, use a Dixie (TM) cup and cut a nick for the baby’s nose and insert the inhaler or mister through a cut on the bottom (for infants, use a plastic pill cup).
• Removing the bottom of a small Dixie (TM) cup or Styrofoam (TM) cup makes a good spacer for infants or small children.
INCENTIVE SPIROMETRY
• Have the patient blow up small balloons as cheap incentive spirometry.
SNORING
• Have the spouse of a snorer wear earplugs.
APPROXIMATING PEAK FLOW
• Hold your finger in front of the child and have them “blow it out”. This gives the examiner an idea of peak flow.
DIABETES
• Diabetics must check the inside of their shoes every time prior to wearing shoes.  There may be a foreign body that has accidentally gotten inside the shoe and the patient may not be able to feel the foreign body until damage has been done.
• Over a period of weeks or months, you can see the pattern of home blood sugars well if the patient checks blood glucose once a day, but at different times of the day each day.
• When a diabetic patient is not in good control, see them more frequently.

HEART AND BLOOD
REDUCING SODIUM / INCREASING POTASSIUM
• When a patient is on a diuretic or needs to decrease sodium in their diet and increase potassium, Morton’s Lite Salt(TM) can be used instead of regular table salt.  This product is half sodium chloride and half potassium chloride. The use and taste is similar to regular salt.
• Mrs. Dash(TM) also contains potassium.
NITROGLYCERIN
• Be sure to have the patients take the cotton out of the bottle as soon as they fill the prescription.  Many patients have been found dead trying to get the cotton out in an emergency.
HYPOKALEMIA
• A rare cause of hypokalemia is chewing tobacco hypokalemia.  Some brands of chewing tobacco contain licorice which contains an ingredient with mineralo-corticoid activity.
EXERCISE
• The calculations for target and maximum heart rate can be confusing. 170 – age is a simple and safe calculation.
• Don’t increase mileage or duration >15% per week.
• When writing an exercise prescription, use FITT – frequency, intensity, time, and type of exercise.

GI TRACT
CONSTIPATION
• Prune juice mixed with 7-UP(TM) tastes similar to Dr. Pepper(TM).  Persons who dislike the taste of prune juice may find this a more palatable solution.
• Increase fiber by using a concoction of oat bran, wheat bran, and Metamucil® BID.  This may help IBS as well.
DIARRHEA
• Diarrhea can sometimes persist after the infectious etiology has been treated.  This may mean that the normal lacto-bacilli have been eliminated and need to be replaced. Lactinex® granules or unpasteurized yogurt may be helpful.
OBESITY
• Ask the patient to bring in a usual shopping list tape to see what they normally buy at the grocery store.
• Obese patients may benefit from a medication like metformin even if they are not overtly diabetic.
• After a patient has lost 15-25 pounds, have them buy a turkey from the grocery store that weighs as much as they lost.  This is representative of the extra weight they have been carrying for years.
• The liquids the patient is consuming daily can contain a surprising amount of calories.  Switching milk, soft drinks, and juices to diet drinks can greatly reduce calories ingested.
ESOPHAGEAL REFLUX
• Use stacks of old newspapers to raise the head of the bed when treating GE reflux.  Caffeine (includes chocolate), tobacco, alcohol, and mint (gum, candies, and some mint flavored antacids) all reduce LES pressure.  Consider removing all of these from the patient’s daily regime when treating symptomatic GE reflux.
IRRITABLE BOWEL
• Patients can use Imodium® as a prophylaxis before doing activities that always cause diarrhea.
DEHYDRATION
• Half strength Gatoraid(TM) can be a good rehydrating fluid in adults.

PROCEDURES
BLOOD DRAWING
• At times, when trying to draw blood from a vein, it can be difficult to have the correct angle of the needle with the skin because the syringe or Vacutainer presses into the skin and doesn’t allow the needle the correct angle for best penetration.  Using a butterfly needle helps this situation.  Another method is to use the plastic guard on the needle to bend the tip (distal to the hub) 30 to 45 degrees with the bevel side up.  It is then easier to direct the needle into the skin without the syringe or Vacutainer interfering with the angle.
INTRAVENOUS LINE PLACEMENT
• Line up the bevel of the needle with the numbers on the syringe so that you’ll always know which direction the bevel is pointed after the needle has pierced the skin and is no longer visible.
• Turn the bevel upside down when in the vein. This helps the catheter slide into the vein.
• When drawing blood or placing an IV in a difficult to find vein, apply a blood pressure cuff upside down. Inflate it, then, let the pressure down until the pulse is barely palpated.  The upside down cuff gets the tubing out of the way.  The technique allows arterial supply but occludes venous return creating maximal venous dilation.
IMPACTED CERUMEN
• Removal of impacted cerumen that can’t be removed easily with an ear spoon can be accomplished using water pressure.  Attach a 50 cc syringe to an 18 gauge Angiocath (without the stylet).  Cut the Angiocath to 1 to 2 inches.  Fill the syringe with body temperature water.  Lay the tip of the Angiocath along a wall of the ear canal and flush out the cerumen.  More than one attempt may be necessary.  Do not do this procedure if there is a possibility of a ruptured tympanic membrane.
• Colace® can be used to soften earwax for easier removal.
• Hydrogen peroxide can be used to clean out cerumen.  Kids call it the rice crispy medicine.  It can also be used twice a week to prevent future impactions.
• Mineral oil or sweet oil can also be used to soften earwax.
• There is an inexpensive devise called the “Elephant Ear Washer”.  It is a spray squirt bottle with a flexible tube attached to the outflow.  You can spray directly into the ear canal varying the strength and direction of flow.
POSTERIOR NOSE BLEEDS
• A Foley catheter can be used as an emergency pack to treat posterior nose bleeds.  Cover the bladder of the Foley with a lubricating jelly, insert the deflated Foley through the nares into the back of the pharynx, inflate the bladder, then pull the Foley back into position to tamponade the bleed.  A padded umbilical clamp can be placed over the Foley at the nares to hold the packing in place.
ENDOMETRIAL BIOPSY
• When doing an endometrial biopsy using a plastic device, place the plastic in the freezer until it has stiffened.  The Pipelle® will more easily pass through the cervical os when stiffened.  The body temperature will thaw the frozen instrument after a very short period of time.
NASOGASTRIC TUBE PLACEMENT
• An NG tube can usually be passed more easily if it has been placed in the freezer prior to use.  It becomes stiffer and is easier for the patient to swallow and the examiner to manipulate.
HEMORRHOIDS
• NSAIDS can help speed resorption of a thrombosis and reduce the need for incision and removal.  Symptoms should be better within 24 hours.  These can be combined with aggressive sitz baths.
• Bag Balm® applied to hemorrhoids can be very soothing.  It can also be used for eczema.
LOCAL ANESTHETIC
• If a patient is allergic to the “caines”, Benadryl can be injected as a local anesthetic.
• Bacteriostatic saline can be used as a very brief (few minutes only) local aneshetic.  It contains a high concentration of benzyl alcohol, but being isotonic, does not cause pain during injection.  This can be used to numb the skin to aspirate a small cyst or superficial bursitis.  If you use an insulin syringe, the patient will rarely feel the injection or the subsequent aspirating needle.
NASAL DISCHARGE AFTER AN INJURY
• Check for glucose in the nasal discharge.  A positive Dextrostix® means a CSF leakage.
ESOPHAGEAL REFLUX
• If you suspect chronic esophageal reflux, check the secretions coughed up with litmus paper.  Acid positive suggests reflux.
• Use Kegel like exercises to increase the strength of the abdominal muscles and perhaps lessen the need for medications.
OBJECT IN EAR
• When an insect is trapped in a patient’s ear canal, kill the insect with mineral oil or lidocaine before attempting to remove it.
• Acetone (nail polish remover) will dissolve Styrofoam (TM) trapped in the ear canal.
PAINFUL PROCEDURE
• Warn the patient that vinegar applied to the cervix can sting.  When doing any painful procedure, be honest with the patient and let them know when it will hurt.
• Mix bupivicaine with lidocaine for longer pain relief.
• When giving injections such as flu shots, wrap your hand circumferentially around the upper arm and squeeze tightly just before and during the injection.  This fools the sensory pathways (gate theory) and the patient won’t feel the needle.
• When doing a painful procedure on a child, send the parents out of the room.
• When suturing a child’s wound and trying to determine if restraints will be needed, look at the child’s feet.  If the child is comfortable with their feet are apart and “flopped open”, restraints won’t be necessary.  If their feet are together and pointing straight up, the child is nervous and restraints will be necessary.
• With any painful but brief procedure such as phlebotomy, injections, or cervical biopsies, have the patient take deep breaths.
• Use a 30-gauge needle to inject lidocaine for local anesthesia (but draw it up with a larger needle).
• Use Hurricaine® gel topically on the cervix and os before biopsies.  Have the patient count to 20 out loud during endometrial curetting to make the procedure more tolerable.
• Have the patient take 600 mg of ibuprofen prior to the office visit for an endometrial biopsy to decrease cramping during the procedure.
PROCEDURE ETIQUETTE
• Be sure to have all the equipment and tools you might need for a procedure prior to beginning the procedure.  It appears unprofessional and sloppy to have to keep stopping the procedure to procure the correct instruments.
SUBUNGAL HEMATOMA
• Light an alcohol wipe (burns about 30 seconds) and use it to heat the end of a paper clip (unfolded).  Use the hot paper clip end to burn a hole through the nail to drain the hematoma.
SPLINTER REMOVAL
• Use the No-scalpel vasectomy dissector to grasp the splinter for easier removal.
FOREIGN BODIES
• To locate non-radioopaque foreign bodies in extremities, have the radiologist do a mammogram of the affected area.
• To remove a foreign body from the nose, place a drop of crazy/super glue on the wooden end of a cotton swab.  Quickly press the wooden end against the foreign body for 10-15 seconds until the glue sets.  Then simply remove the cotton swab with the foreign body attached.
• Any time you are using a bare needle (such as removing a foreign body from the eye) and need a longer handle, place the end of a cotton swab into the hub of the needle.
• Another way to remove a foreign body stuck in a child’s nose is to close the unaffected nares with a finger, then use an Ambubag or the mother’s mouth to puff air into the child’s mouth which pushes the foreign body out the nose.
CIRCUMCISION
• When utilizing the Gomco® technique, use a small sterile safety pin to capture both side of the foreskin after the dorsal slit is cut and the bell is on the glans.  The pin can fit up through the instrument aperture and gives good control of the foreskin.
INGROWN TOENAIL
• Continuous hot soaks and massaging the skin away from the nail can many times obviate the need for a partial nail removal.
• When doing a partial nail removal, use a straight hemostat to grasp the portion to be removed, then twist away from the edge.  This pops the edge right out and defines the section that needs to be removed.
• Use a male urethral swab to place phenol at the base of a partial removal.  It is small enough to prevent a large chemical burn of the nail bed.
• Placing an ear wick under the nail edge will help lift the nail edge as the wick slowly expands as it absorbs moisture.
• An “English nail splitter” to cut the nail and a periosteal elevator to dissect under the nail makes removing nails easier.
SEBACEOUS CYSTS
• When removing a non infected sebaceous cyst, use a punch biopsy to remove the core or plugged pore.  After removing the sebaceous material, tease the cyst wall out through the punch biopsy hole.  The scar will be minimal.
• Curved blunt Mayo scissors are great for tissue dissection to follow around the edges of the cyst to be removed.
RING REMOVAL
• To remove a ring on a swollen finger without cutting the ring, insert one end of a string or ribbon under the ring from the distal end of the finger to the proximal end.  Wrap the distal portion of the string circumferentially around the finger compressing the swelling from the distal edge of the ring to the distal tip of the finger.  Several repetitions may be necessary.  You may want to lubricate the surface of the string or ribbon after it is wrapped on the finger.  Pull the string at the proximal end of the finger (that was tucked under the ring) and unwrap toward the distal end of the finger.  The ring should advance forward as the unwrapping proceeds.
FISHHOOK REMOVAL
• If the hook is embedded such that it shouldn’t be pushed on through to clip off the barbed end, pull the hook back through the path it took to become embedded.  Attach a length of line to the curve of the hook, align the direction of pull parallel to the shank, stabilize the extremity in which the hook is embedded, and make a sudden jerk of the line assuring that the pull causes the hook to duck back through the same path it took going in.
WARTS
• If the patient has a wart the size of the end of an ear speculum, you can place the speculum over the wart and press down onto the skin for a nice seal.  Then you can apply the caustic agent to the wart without getting it on the surrounding skin.
CACTI THORNS
• To remove cacti thorns from the skin, place duct tape over the area and pull it off.  Repeat several times.  You can place meat tenderizer on the skin for 10 minutes prior to using the tape for easier removal.
FOLEY CATHETER PLACEMENT
• If you are having difficulty placing a foley catheter and need a stiffer catheter, place it in the freezer or in ice before trying to insert.
GASTRIC TUBE REPLACEMENT
• A coat hanger can be used as a stylet for replacing a gastric tube that has “popped out” of an established tract.
VASECTOMY
• After numbing the skin and area around the vas, spray the skin with some of the remaining lidocaine. This allows better sliding of the vas and skin under the examiner’s fingers for easier isolation of the vas.
• Prescribe the patient two ice-cold beers after a vasectomy – one to drink and one to use as an ice pack.
WOUND REPAIR
• Super glue can be used sometimes in place of stitches.
FINGER INJURY
• A good splint for a finger injury can be made by cutting a coat hanger to the proper sizes, placing these on the lateral and medial side of the affected digit and taping.
DECUBITI
• An antibiotic brew can be placed into bone cement and then placed in the decubitus for weeks to help promote healing and decrease infection.  This is described in the podiatric and orthopedic literature.
HEAD LICE
• Using Dippity Do (TM) or similar hair gel, cover the entire scalp and then cover this with a shower cap.  This smothers the lice.  For resistant cases, use mayonnaise in the same way.
SKIN TAGS
• Clamp across the base of the tag with a hemostat (like crushing the foreskin prior to a dorsal slit).  Remove the hemostat and then clip the tag.  This greatly decreases bleeding and may obviate the need for silver nitrate or other chemical coagulants or even a local anesthetic.
FLUORESCEIN
• When using a fluorescein strip for an eye exam, wet the tip of the strip with sterile saline or an anesthetic drop before placing it on the lower conjunctiva.  Remember that fluorescein will stain contact lenses.
TICKS
• To extract an embedded tick, use an Allis clamp.  Place the clamp just past the tick’s head and pull.  This will not squeeze the tick.
IUD
• When an IUD is placed, curl the string at the cervical os like curling the ribbons on wrapping packages.  This moves the sharp tip and is less noticeable to the patient and her partner.
CXR READING
• For congestive heart failure, turn the chest x-ray upside down.  You can see cephalization better this way.
• An UPPER lobe infiltrate on chest x-ray is cancer until proven otherwise.
EPISIOTOMY
• A modified midline episiotomy (just off center) may help avoid 3rd and 4th degree tears when an episiotomy is indicated.
SUTURE REMOVAL
• An 18 gauge needle works well to remove sutures.  The tip can be bent into a hook if desired.  An 18 gauge needle can also be used as a lance to incise abscesses.
• Another method for suture removal is to grasp one loose end with a small hemostat, then cut one end under the knot with an eleven blade.
• Place gauze soaked with hydrogen peroxide over the sutures for a few minutes to soften them and the skin for easier removal.
BROWN RECLUSE BITE
• Nitroglycerin ointment or patch over a brown recluse bite can reduce the amount of necrosis.
ASPIRATION AND INJECTION
• Use an 18 or 20 gauge catheter instead of a needle when draining a joint or bursa when you intend to inject lidocaine and/or steroids.  This way you don’t have a sharp needle to cause bleeding or pain as the bursa collapses or during the manipulation as you change syringes for the injection.  The 18 gauge catheter is less likely to kink.

CHILDREN
COLIC
• Maneuvers to help colicky babies include propping them upright to feed, ruling out or treating GE reflux, and ruling out or treating milk allergy.
BURPING BABIES
• With the baby upright and facing away from the seated examiner, grasp the baby around the chest with the examiner’s thumbs on the baby’s back and the fingers wrapped around the chest.  Place the baby’s left hip inside the examiner’s left knee.  Rotate the baby 30 to 45 degrees to his/her left.  This brings the fundal air bubble in contact with the esophagus and should result in a quick spontaneous burp.  Occasionally, you need to add a few degrees of forward or backwards to the left lean.
URINE SAMPLING OF SMALL CHILD
• To get a urine sample from a reluctant child, have the mother stoke the middle of the back just above the gluteal crease.  This will often induce a micturation reflex.
MENINGISMUS
• If a child does not follow the examiner around the room with their eyes, the child’s neck is probably stiff and painful which may be a sign of meningitis.
CRADLE CAP
• A mild soap like Dawn(TM) dishwashing soap can be used to daily scrub this area.
• Nizoral® shampoo (available OTC) works well to clear cradle cap, although it is not “no more tears”.
HEIGHT AND WEIGHT RECORDING
• To help assure accurate plotting of children’s heights and weight, develop a “plotter helper” using an overhead transparency with a hole in the middle of intersecting vertical and horizontal lines.
• Liquid medications with an adult dose of 2 teaspoons can be given to children at the dose calculated by the “decimal move rule”.  Take the child’s weight in pounds and move the decimal point one column to the left to figure out how many milliliters to administer (eg; 40 pounds =  4.0 ml,  85 pounds =8.5  ml).  This works for most OTC cough/cold remedies and some prescribed medications.
CHILDREN’S CONSTIPATION
• Half of a Metamucil (TM) cookie wafer per day may help remedy this problem.
BREAST FEEDING
• If the baby doesn’t seem to be getting enough milk, check the hydration status of the mother.
ATTENTION GETTING
• To get and keep the attention of an 8 to 12 month old, get in front of them and say “fa, la, la” over and over.  They will be entranced with the movement of your mouth.

WOMEN
KEGEL EXERCISE REMINDERS
• Kegel exercises for stress incontinence need to repeated frequently during the day for maximum effectiveness.  Reminders for patients to do these exercises include any time a commercial comes on TV, whenever the patient is talking on the telephone, or whenever the patient opens the refrigerator door.  This would insure that the patient has opportunities to do these exercises many times each day.
VAGINITIS WITH PRURITIS
• Fill 30 gelatin capsules with boric acid powder. Insert one capsule into vagina nightly for 30 days (even through menses).  This returns the vaginal environment to its normal acidity.
CYST OF CANAL OF NUCK
• A tender mass in the inguinal region or labia of young, athletic females may be a hydrocele.  It may even contain an ovary.
OSTEOPOROSIS
• Two cod liver oil capsules a day helps increase the intake of vitamin D, which can help prevent osteoporosis and perhaps some types of cancer.
VAGINITIS
• To prevent irritant vaginitis, don’t douche, don’t use bubble baths, and don’t scrub the perineum with soap.
• Patients with vaginitis may present like a UTI. If the urine is negative, try to determine if the patient’s discomfort is when the urine is coming through the urethra or when the urine hits the vagina.  This can be a difficult distinction for most patients.  If the discomfort is when the urine hits the vagina, a vaginitis is the problem, not a UTI.
• Women who persistently get candida vaginitis while on antibiotics can be treated with anti-yeast vaginal suppositories every other day during the course of their antibiotics.
VAGINAL DRYNESS
• White Crisco (TM) can be used as a lubricant for vaginal dryness and as a lubricant for intercourse (may weaken condoms).
VULVAR HERPES
• The first episode of vulvar herpes can be excruciatingly painful to the point of inability to urinate secondary to the pain of the urine touching the open sores.  Have the patient sit in a tub of warm water and urinate in the bathtub.
POST MENOPAUSAL BLEEDING
• PMB is cancer until proven otherwise.  Biopsy if any doubt exists.
MASTITIS
• Apply cold, purple cabbage leaves inside both sides of the bra and change when the leaves wilt.
UTI
• Doubling the first dose of antibiotics when treating a urinary tract infection may help decrease symptoms faster.
• Pyridium can “numb” the bladder to reduce symptoms.  Do not give more than 2-3 days worth since this only masks symptoms, it doesn’t cure the problem.  Remind patients that this turns the urine pink or orange and can stain clothing or contact lenses.
CLAMPING UMBILICAL CORD
• There is no hurry to clamp the cord.  Milk the blood away from the clamp site before clamping to reduce splatter when cutting.
RIPENING THE CERVIX
• One capsule of evening primrose oil by mouth three times a day and two capsules intravaginally each night after 37 weeks of gestation may help ripen the cervix for delivery.
BREAST DISCHARGE
• If a patient has a breast discharge and you are concerned it may be blood, do a test for blood using a fecal occult blood testing kit.  If you think the discharge is milk, look at the discharge under the microscope and look for fat globules.

PSYCHOSOCIAL
TOBACCO CESSATION
• Have the patient daily put the money they would have spent on cigarettes into a jar.  This will show them how much money they actually spend on cigarettes and they can reward themselves with a present at the end of a week/month/year.
• When advising a patient to set a quit smoking day, pick a day that trash is picked up in their neighborhood.  They can discard all their cigarettes, lighters, and ashtrays and will not be able to get them back.
• For a patient who has chosen a quit date, place a nicotine patch on the as they go to bed the night before.  This way they will not wake up in nicotine withdrawal on the morning of their first day as a nonsmoker.
DEPRESSION
• A pneumonic for taking a history for depression is SIGECAPS (SIG – prescription, E – energy, CAPS – capsule).  This stands for suicide, interests, guilt, energy, concentration, appetite, psychomotor retardation, and sleep.
• If there is a positive response on screening for depression, ask the patients if they are surprised by this.  This gives them a chance to open up.
• Ask what they do for fun. This will check affect, energy, activities, and interests.
• Ask if they cry easily. If they break down and cry, the answer is yes.
• Virtually everyone with depression feels tired and doesn’t sleep well.  Ask, “Do you feel tired all the time?”  They not only feel sleepy but physically weak and unmotivated.  For sleep, focus on the quality of sleep and whether they feel rested and refreshed rather than on a specific sleep pattern.
• When starting an antidepressant medication, start with half the dose you would normally start the patient on for the first 2-4 days.  This decreases side effects.  Capsules might be dissolved in apple juice with half the juice ingested the first day and the other half the second day.
RED FLAGS FOR ABUSE OF PAIN MEDS
• Calling for medication after hours.
• Unbelievable stories about what happened to their medications.
• Allergic to every medication except the one they want.
• The patient knows the names of major medications that they aren’t on, but purposely mispronounce them.
PSEUDO-SEIZURE
• Doing an ABG to look for respiratory acidosis can help differentiate pseudo-seizures from true grand mal seizures.
COMPLIANCE
• To help patients remember to take their medication, discover something they do everyday with the same frequency as they need to take their medication (like brushing their teeth).  Place the medication there.
INSOMNIA
• Treat using the side effects of amitriptyline.  Start with 10 mg at bedtime and allow the patient to titrate themselves to an effective dose.  Hydroxyzine can be used in the same fashion and dosage.  Trazodone is another medication that can be used for this purpose.
• Improvements in sleep hygiene can be accomplished using Feng Shui in the bedroom.  Aim the foot of the bed toward the door and remove anything having to do with work from the bedroom.
DENYING PAIN MEDICATIONS
Use an “I” statement instead of a “you” statement when denying narcotic requests – “I feel uncomfortable . . .”  “I don’t want to get you hooked.”  “I am not helping you by continuing this course.”
PERSEVERATING THOUGHTS
• After a traumatic event, patients may have recurring, perseverating thoughts.  To help them rid themselves of these thoughts, have them place a rubber band around their wrist and snap it each time they have one of these thoughts as they tell themselves to stop thinking about this.
DIFFUSELY POSITIVE REVIEW OF SYSTEMS
• If a patient has a diffusely positive review of systems, ask if their teeth itch or if their stools glow in the dark.  A positive response to either of these questions is highly correlated with a psychological cause.

NEURO
PARKINSONS
• Sometimes, the first sign of Parkinsons is micrographia.
NEURALGIA, NEURITIS
• When all else fails, try thiamine 25 mg TID for 6 weeks or longer.
POST CONCUSSION
• Diamox ® (carbonic anhydrase inhibitor) may help accident victims with “fuzzy thinking” on post accident day 2 or 3.
PERIACTIN®
• This is an old antihistamine that is an anti serotonin.  Its many uses can include stimulating appetites in children, migraine prophylaxis, pruritis of chicken pox, allergies, treatment of serotonin syndrome, and treating dumping syndrome.
COMA
• Patients who are in a coma can sometimes hear what we say.  Talk to your patients, but be careful what you say.
ALZHEIMER IN DOWNS
• Two signs in patients with Down Syndrome may be early indicators of Alzheirmer’s Disease – morning myoclonus, and in those with a functional gait, stopping confused when walking from one floor color or pattern to a different color or pattern (this may be a depth perception problem).
HEADACHES
• Help focus the patient by having them describe the worst headache they’ve ever had and the headache that brought them to the office today.
• Have the patient keep a headache diary.
• Two minute neuro exam – observe for normal behavior, movement of face, and speech; cranial nerve examination; and fundoscopic exam.
• Trigger point injections using lidocaine or just sterile saline can ease tension and migraine headaches.  A small needle like that on a TB syringe decreases pain of injection.
• Sucking on weeping willow leaves or making a tea of the leaves can help relieve pain when away from availability of medical care or medications. The leaves contain aspirin.

HEENT
APHTHOUS ULCERS
• Punch a hole in a Tessalon Perle® (benzonatate) and dab the fluid onto the mouth ulcer to numb the ulcer.  After the ulcer is numb, the fluid must be rinsed out since the fluid will anesthetize the gutters of the mouth and throat as saliva rinses the fluid across other areas of the oral cavity.
• Use a mixture of 1/3 hydrogen peroxide, 1/3 Decadron syrup, and 1/3 water to swish and spit every 2-3 hours.
• Combine Benadryl (numbing agent) with Kaopectate® (sticking agent) for a swish and spit.
• Chewing real licorice several times a day may relieve symptoms.
• Cover the ulcers with a sucralfate paste every 6 hours.
PAINFUL TEETH
Oil of cloves placed on the tooth using a cotton swab can help relieve the pain of a dental cavity.
OTITIS EXTERNA PREVENTION
• For a patient who gets repeated episodes of otitis externa, a prophylaxis may be used.  Take a half and half mixture of white vinegar and rubbing alcohol in a dropper container.  After swimming or bathing, place 2 or 3 drops of the solution in the ear canal.  The vinegar is acetic acid which changes the pH of the ear canal and kills pathogens.  The rubbing alcohol is a drying solution to help clear the ear canal of moisture.  This solution can be used as a treatment in some situations.
• Another prevention could be placing baby oil or olive oil in the ear canal before swimming.
OTITIS EXTERNA
• When using a wick for OE, put the wick in dry.  After putting in the medication drops, leave the wick in place for 48 hours.
• If there is pain on movement of the external ear and the external ear is red and swollen, add an oral anti-pseudomonas medication.
• A mixture of phenol 2% and acetic acid 1% can help numb the pain of otitis externa.
ALLERGY PHYSICAL SIGNS
• The presence of visible tonsils in an adult or later teen can be a marker for chronic airborne allergies.  Other signs of chronic airborne allergies include the “nasal salute” (pushing up the tip of the nose while wiping off rhinorrhea), a deviated septum (wiping the nose laterally for years), allergic shiners, multiple family members with allergies, and multiple episodes of otitis media.
ALLERGIES
• Hypertonic saline flushes for congested noses.  Mix 1/8 teaspoon of salt in a cup of warm water. Tell the patient that we clean our face and our hands, but never clean our noses.  This will do that.
• Have a child blow up a balloon or hold the nose of a baby while it swallows to “pop” the ears.
• Use nasal strips (like the athletes) at night to decrease nasal stuffiness.
• Afrin® nasal spray or another local decongestant can help open Eustachian tubes in otitis media.  Use less than 5 days duration to prevent a rebound phenomenon.
• Simply Saline (TM) is an OTC product that is a preservative-free nasal spray.  It can be used to moisturize the nose without irritation caused by preservatives.
• Before nasal steroid sprays became available, one could use a regular steroid asthma inhaler for nasal purposes.  Cover the mouthpiece of the inhaler with a rubber (not silicone) baby bottle nipple.  Cut a small hole in the tip of the nipple with scissors.  The nipple directs the flow up the nose.  This can still be used if you want a “powered” nasal sprayer.
ANTIHISTAMINE TOLERANCE
• Even with the newer non-sedating antihistamines, patients sometimes complain of a tolerance effect to the chronic medication. It might be beneficial to alternate with another antihistamine every 6 to 12 months.  With the older antihistamines, alternating monthly is preferable.  After a “vacation” from the medication, it seems to be effective again.
SINUS CONGESTION
• For chronic sinus congestion, try a mucolytic agent or a protein digesting enzyme to liquefy secretions and promote drainage (proteolytic, papaya juice, Humibid®).
PHARYNGITIS
• Have patients gargle with warm water instead of salt water.  Warm water can soothe, salt water can irritate.
• Smell strep throat in patients.  It has a distinctive, somewhat fetid odor that can aid in diagnosis.
THROAT EXAM
• Have the patient pant like a dog when taking a throat culture.  This will avoid the gag reflex.
• For children 8 months to 2 years of age, have the parent tip the child’s head back while seated on the parent’s lap with the back to the parent.  The child usually then opens the mouth wide.
• Instead of having the patient say “aah”, have them take a big deep breath through their mouth to open up the posterior pharynx.  Having them stick their tongues out brings the “gaggy” part of the tongue forward where you’re almost guaranteed to touch it with a tongue blade.
TEMPORALMANDIBULAR JOINT SYMPTOMS
• One cause of TMJ symptoms is malocclusion of the bite.  If one side of the set of teeth contact before the opposite side, the TMJ must be activated to allow the opposite side to completely close.  Over time, this can lead to inflammation of the joint or surrounding muscle from overuse.  To check for malocclusion, have the patient open their mouth.  Lay a tongue blade flat along the surface of the lower teeth on either side.  Have the patient bite down to lightly hold the tongue blades.  If one blade is held fast but the other tongue blade can easily be removed, malocclusion is probably present and the patient should see a dentist for correction.
PRURITIS OF THE EAR CANAL
• Use mineral oil drops. Volsol HC® contains acetic acid and hydrocortisone can treat eczema of the canal.
NOSE BLEEDS
• In adults, frequent nose bleeds can be prevented by applied estrogen cream to the nares and septum 2-3 times a day.  This can also be used for atrophic rhinitis.
• There can be pathology in most patients’ noses.  You can use an otoscope with a large ear speculum to examine the inside of the nose.  Cover the insufflation hole with the pad of the index finger to prevent fogging of the lens.
CONJUNCTIVITIS
• Place wet tea bags on closed eyes to take away the sting of conjunctivitis.
• For children with viral conjunctivitis, use baby shampoo, 1 teaspoon in a cup of water, as drops for treatment instead of antibiotic eye drops.
EYE DROPS
• Gently pinch the lower eyelid and pull it forward to form a “pocket” for easy instillation of eye
drops.
FOREIGN BODY IN THE EYE
• Using a cotton swab, always evert the upper lid to do a complete survey of the eye for a foreign
body.
CHALAZIONS AND STYES
• Use a hard boiled egg for moist heat. An egg is the perfect shape to fit under the orbital rim.

ELDERLY
WEIGHT LOSS IN THE ELDERLY
• Poor digestion, poor absorption, and a sluggish gut may occur in the elderly which leads to weight loss, anemia, weakness, etc.  Absorption may be aided using Entozyme®, Phazyme®, and extra bulk.  Don’t forget to check dentition.
NUTRITIONAL DEFICIENCIES
• In the elderly or alcoholics who are not eating well, watch for weight loss, changes in personality, depression, or loneliness which may indicate or lead to nutritional deficits.  Pellagra gives diarrhea, dementia, and dermatitis.  Scurvy may present with petechaie and dementia.
CHRONIC CONSTIPATION IN THE ELDERLY
• The elderly seem to like routines. Suggest they drink a tumbler full of warm water each morning upon rising from bed.  Then they should eat breakfast, then sit on the toilet for a full 20 minutes.  Stool softeners or fiber agents may also be added. By the third day, they usually have become regular.
THYROID DISEASE IN THE ELDERLY
• Atrial fibrillation can be the first sign of hyperthyroidism, especially in the elderly.
GERIATRICS
• When an older patient presents with new vague symptoms, it behooves the physician to consider side effects of the many medications the patient is taking.  Stop adding medications if you are unsure.  Use a trial of decreasing medications.
• Geriatric patients seem more compliant and don’t smoke as much as other populations.  Those people all died out.
• If a patient has Alzheimer’s and develops delerium, look for a UTI, even a low grade one.
• In patients with a poor appetite, find and use their comfort food.  Give up on nutrition and go for
calories.
• If a patient develops a poor appetite, check the digitalis level.
• Get a sitter or a family member to stay with an elderly patient in the hospital to avoid falls especially with “sundowner” syndrome.
• Approach every visit with an elderly patient as an opportunity to learn about integrity, honor, and pride.
NURSING HOME CARE
• Two major factors not usually considered can greatly influence the type of care patients receive in a nursing home – a change in the Nursing Home Administrator or a change in the director of nursing.
GET UP AND GO TEST
• Patients should be able to get up out of a chair and walk 10 feet in less than 10 seconds.  This correlates well with ability to do activities of daily living and indirect activities of daily living.  It assesses function and neuro status.
• A quick get up and go test is watching the patient get out of the chair and onto the exam table.
DEHYDRATION IN THE ELDERLY
• If no IV or gastric tube access is available, rehydration can be attempted in the Nursing Home by hypodermal clysis through the back, abdomen, or thighs at a rate of 70 to 90 ml/hour.

PHILOSOPHY OF PRACTICING FAMILY MEDICINE
• The essence of Family Medicine is follow up.
• Medicine is mostly pattern recognition. Listen to the patient and observe over time.
• The patient is giving their interpretation or belief of the facts.  They may misinterpret key clues.
• Give 100% of yourself to the patient in front of you, without thinking of the next few patients.
• On hospital rounds, sit down for good eye contact and be at the same level as the patient.
• On morning hospital rounds, see chronic and dying patients first, ending with patients who are improving and doing well.  This puts you in a better frame of mind to start the office day.
• Don’t look into the waiting room and be overwhelmed by the number waiting.  You can only see patients one at a time anyway.
• Don’t look ahead on the schedule and start dreading a certain patient before their time.
• Remember, it’s the patient’s problem.
• Learn how to appear unhurried.  Your body language gives it away.
• Leave the patient knowing you’ll be thinking of them until the next visit.
• Have the attitude of “there you are” instead of “here I am”.
• Don’t use your bedside manner all up in the hospital and office, save some for home.
• You can say no.
• Don’t be afraid to ask for help.
• The science of medicine deals with how people are alike, the art of medicine deals with how they are different.
• The doctor patient relationship is like a rowboat with each having an oar. If only one is rowing, the boat just goes in circles.  Be careful you don’t take both oars.
• You are not God.
• Doctors tend to remember the bad results and dismiss the good.
• Smile – be happy to see the patient, they’re worried.
• Don’t be afraid to apologize.
• Let the patient, not the relatives, do the talking.
• A good history is far superior to the best MRI.
• Be honest but not cruel.
• Explain in simple terms. Patients are not ignorant, but they don’t know the medical language.
• When in doubt, see and examine the patient.
• Call the patient yourself with significant test results.
• Don’t appear to rush, even if you are rushing.
• Patients are your friends who are putting their trust in you.
• Put personal notes about patients in the margins of the chart – anniversaries, names of pets, significant events in their children’s life, phonetically spelled name, etc.
• Each patient is a person, not just an illness.
• When a patient dies, it doesn’t mean you’ve failed.
• It’s acceptable to go to a funeral if convenient.
• Have patients on multiple medications bring in their medications for review and completeness.
• Write the plan for pediatric patients – a crying baby distracts a parent from hearing your instructions.
• Medicine and golf – the two most humbling experiences possible.
• A good doctor is worth their weight in gold – so is a good plumber.
• What you learn today may be proven wrong tomorrow.  Use it anyway – it may be proven again to be right the day after tomorrow.
• Medicine is a cruel mistress – balance your time and life.
• Get to know the person who has the disease before you become the adversary of the disease.
• Apologize when you’re late, this diffuses anger.
• When a patient presents for a work excuse or a return to work form but did not see you while they were ill, write the work slip using the facts only – “this patient states that they were ill and missed work on . . . My examination today reveals an individual who may return to work.”
• When you are called to the hospital to pronounce a patient you don’t know personally, take the head nurse and the chaplain in with you to talk to the family.  They can help comfort the patient and explain the events prior to death.
• Most pediatric visits are really parentriatics.
• Walk with your patient toward the waiting room.  This extends the visit, allows for social time,
and moves the patient towards the check out desk.
• Appropriate humor helps the patient to see the physician as human.
• Have the patient schedule a follow up appointment as they leave the office.  They can cancel if it isn’t needed, but this removes the worry of when a follow up is needed, protects the doctor’s time in the schedule, and gives a caring message to the patient.
• Always ask the patient, “what about this problem worries you the most?” and, “what do you think this could be?”.
• Construct a genogram on all patients and look for patterns.
• If a patient is succeeding, ask what helped them succeed and then use this with other patients.
• Don’t be afraid to say, “I don’t know what’s wrong”.  Honesty is the best policy.
• Make the patient feel that you have all the time in the world for them and that nothing else matters but them.
• Don’t go into a pelvic exam with the patient already lying down.  This puts them into even more of a powerless position.
• If you show kindness and concern, you’ll receive the same.
• Let the patient talk uninterrupted for at least the first minute to allow the patient to get their story out.
• Think of taking a history using a metaphor of a lens.  If it is focused too closely, things may be missed. You may need to use a wide-angle lens.  If the wide-angle lens is gaining too much scattered information, a close up lens may be necessary.
• If what you’re doing isn’t working, try the opposite (sometimes you need to determine what the opposite is) especially when questioning the patient or giving patient education.
• Use the phrase “I need your help” to empower the patient or family and enlist the patient as a partner.
• Don’t let a pill be the measure of your empathy.  Sometimes a prescription is not the answer.
• Have a location in the practice that is your “quiet place” – listen to music, rest, make peace.
• Remember (or write notes in the margins of the chart) about personal and family information and ask about this at each visit.
• Don’t believe any blood pressure reading but the one you took yourself.
• See every patient as an opportunity to learn new techniques or patterns or to improve yourself.
• Take the effort to get to know the patient as a person.
• Everyone deserves the basic respect of a human being.
• Talk to the patient, not at the patient.
• Always ask about exposure to violence.  You will be continually surprised by what you hear.
• Have patients repeat what they’ve heard you tell them.
• If you have a “feeling” something is wrong then it probably is.  Listen to your “gut”.
• When referring a patient to a consultant, define the expected outcome to both, describe for the consultant the unique personality characteristics and attitudes of the patient, describe for the patient the unique personality characteristics and attitudes of the consultant, and define your role in this whole process.  You are lending your Doctor-Patient relationship to the consultant.
• Do a quick review of systems at each visit.  This will pick up problems the patient may not think is important enough to mention.
• When examining any rash, look at the entire body’s skin surface.
• The best lab test is a follow up visit.
• With patients who react to “everything”, try herbal or “natural” remedies.
• Have the patient bring in to the office every medication, herbal remedy, or OTC they’re taking.
• Make sure all diabetics take their shoes off every visit (and examine their feet).
• When dealing with a “difficult” patient, especially a personality disorder, get to know their past and social lives in order to help understand them and their reactions.
• Never assume the patient is telling the entire story.  Watch the wording.
• Always be honest with your patient and yourself.
• Know yourself. Understand your assumptions, fears and biases before seeing patients, and understand how that colors your thinking.
• When dealing with mentally retarded/developmentally-delayed patients, lose all pretenses and don’t be afraid of them.
• The staff’s job is to help the patient, not shield the doctor.
• Service to the patient is the best business strategy.
• Make sure the doctors and the nurses are available to the patients.
• When you are with a patient, you must be there attentively and psychologically.
• Always be at the office before the first patient, if you start late, you will be behind.
• Try to do routine prescriptions and call backs between patient visits so you don’t “dump” a lot of work on your staff at the end of the day.
• Don’t sit down between patients. It is harder to get up than to move while standing.
• Individualize any patient education handout you give a patient.
• If you don’t know why the patient is here today, ask – and keep asking until you understand.  Try to find out their expectations in the first minute.
• Nonverbals are much more important than verbals.
• Find out the patient’s name, or more importantly, what they want to be called.  This is the patient’s identity.
• Any phone call that takes more than two minutes should be an office visit.
• Draw the patient explanation in the chart for reference at a later date or proof if ever necessary.
• When it is obvious that a relationship with a new patient is not going to work, realize it quickly, end the encounter, but don’t charge the patient.
• If a child is present at a delivery, the child needs a coach too.
• The most important information you’ll ever need is the knowledge of what you don’t know and what you can’t do.  Know yourself and your limits.
• Some patients are slow processors.  Never mistake slowness for lack of intelligence.
• When a patient transfers care to you, find out how often the former doctor saw them, what that doctor did “correctly” and what was done “incorrectly”.
• Remember social histories.  Patients will be amazed that you remember their job, children, etc. and be impressed that you care about them as a person.
• If you’re concerned about a patient, call them that night.  This demonstrates caring, shows patients that we worry about them, and allows for reinforcement of the treatment plan.
• It is enjoyable to work where you live.  Patients see you in non-threatening, non-clinical settings and can better accept you as a person.  You can see patients in non-clinical settings which may change your attitude and approach to that patient in the office.
• Never assume the patient is taking the medication.
• The patient is not always completely honestly answering your questions, especially about sex or abuse.
• Do a mini mental status on elderly patients, their appearance can fool you.
• You never learn anything by talking. Listen to the patient.
• If you listen to the patient long enough, they will tell their whole story.
• Be sure to give each patient enough time. At some point, increasing the number of patients per hour will decrease quality of care.
• For good time management, ask the patient to prioritize their most important issues at the
beginning of the visit.
• Let the patient determine the appropriateness of humor.  They might not think what you do or say is funny or can misinterpret your actions.
• Never laugh at your patients, only with them.
• Explore your patient’s explanation of their symptoms, what the symptoms mean to them personally, and what they think could get rid of their symptoms.
• When a child reaches 12 years of age, explain confidentiality to the patient and parents.  The parents will need to leave the room for at least part of every visit.  It helps when the child hears the parents agree to this.
• Talk directly to children.  Be calm, quiet, and treat them with respect.  Look them in the eye at their level.
• At some point during the visit, appropriately touch the patient.
• When all else has failed, stop all medications and start again, especially in elderly patients.
• A good carotid pulse means no significant aortic stenosis.
• Don’t tick off the nurses or staff.
• Keep your resident, consultant, partner informed.
• When on call, don’t stand when you could sit and don’t sit when you could lie down.
• Give patients permission to call you at home if they’re very sick.  They will rarely abuse this privilege, but will greatly appreciate it.
• Carry 3 x 5 cards with you to write down who needs to be called for close follow up.
• Asking “who lives in your household” will usually get you relationship information without having to ask embarrassing questions.
• On physical exam, start away from the area that hurts and work your way to it.
• Appropriate self-disclosure to patients (eg: own LBP or colonoscopy) can display empathy, experience, and connectedness.
• It’s ok to begin the visit with social chit-chat if you know the patient.
• Don’t make assumptions about older patients’ cognitive abilities – get specifics and dates.
• Treat your patients as you would want your family members treated.
• Don’t be the first or last doctor to use a specific medication.
• People feel better when they smile or laugh with you.
• Invest time in a relationship, especially when it is needed.
• It is easier with children to examine whatever part is pointed at you first.
• If the visit is going long, do parts of the physical as you’re taking the history.
• If you are having trouble “bonding” with a patient, try to find something you can like about them; something about which you can honestly and genuinely say something positive.
• Ask the patient, “what makes this worse or better?” and, “what is causing this/concerns you about this?”.  If they have no answers to these questions, then a simple physical diagnosis is unlikely.  Save time and move “sideways”.  Try to get to know who this person is by inquiring about context and social history.
• Persistence and tenaciousness are usually good qualities, but you have to know when to let go.
• In these days of relating to computers and speaking through interpreters, appropriate touching can break down barriers.
• Keep a pad of Post-It (TM) notes in your examining room to make notes and reminders to yourself
that can be placed in the chart.
• Keep a quarter sheet size note pad with the practice’s name on it in each exam room to write down your advice to patients so they’ll have something in hand when they leave.
• “Huddle up” with the nurses and staff at the beginning of the schedule to plan personnel and time needs of the session.
• Observe the body language of the person who is attending the patient, they may have an agenda of their own (cuts down on triangulation, “by the ways,” and calls before or after the visit).
• The caregivers are part of your care and may need you more than the patient.
• It’s just as important to help patients have a “good death” as it is to help patients have a “good delivery”.
• Document on the lab slip or report the date you read it and what action was taken (filed, patient called, letter sent, etc.).
• Take at least a few seconds prior to going into a patient’s room to refocus from the last patient and to update yourself on this patient’s life and issues.
• If you are concerned about a patient you have sent to a consultant, call the patient even before the results or consultant’s letter are back to see how things went and how the patient is doing.
• Spend time wisely on things that will make a difference in the patient’s life or illness and less time on the unproductive areas of the physical exam that won’t make a difference anyway.
• During a well baby check, always find something about which you can compliment the mother.
• Learn the value of silence – the patient is thinking, let them process.
• If you allow the patient to talk, they will tell you things you wouldn’t have thought to ask.
• The patient didn’t read the book, their symptoms may not be classic.
• If you schedule a return visit for a patient in 90 days or 12 weeks instead of 3 months, you can see the patient before they run out of their prescription medications since most insurance companies will allow 30 pills a month (for a once a day medication) but most months have 31 days.
• Even if you are in a hurry, move slowly when examining babies and small children.
• If a patient has a need to be seen frequently, just schedule them regularly instead of having them call for “emergency” appointment.  It will save time in the long run.
• If you do not have nearly instant hot water available in all exam rooms, invest in a hot water recirculation system.  This brings hot water past all faucets in the office for instant hot water for hand washing and warming pelvic exam specula.
• If you are feeling distracted during a patient interview, look at the patient’s eyes and note the color of their eyes. The patient interprets this as good eye contact.
• Don’t dwell on the 1% of bad things that happen in the office but on the 99% of enjoyable interactions.
• Virtually no patient comes to the office for a “complete checkup”.  They are worried about something, such as a symptom like chest pain or the discovery of a serious illness in a friend or family member.  Save time by finding out why they’re really there instead of finding out as a “by the way” after you’ve done a full physical.
• Virtually all patients who describe “not being able to get a full breath” have anxiety as the cause.