{"id":56,"date":"2018-03-17T22:19:29","date_gmt":"2018-03-18T02:19:29","guid":{"rendered":"http:\/\/wisdomoftheageds.info\/?page_id=56"},"modified":"2018-03-19T21:52:06","modified_gmt":"2018-03-20T01:52:06","slug":"clinical-pearls","status":"publish","type":"page","link":"https:\/\/wisdomoftheageds.info\/index.php\/clinical-pearls\/","title":{"rendered":"Clinical Pearls"},"content":{"rendered":"

FORWARD
\n<\/span><\/strong>This section is a collection of clinical pearls, \u201ctricks of the trade\u201d, and words of wisdom from experienced Family Physicians.\u00a0 Individual doctors interviewed for this book had up to 55 years of experience in medicine.\u00a0 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 \u201ctricks\u201d.\u00a0 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.<\/p>\n

Over 100 board certified Family Physicians from almost every area of the United States were identified using a targeted, convenience sampling technique.\u00a0 One person (the author of this book) interviewed every physician.\u00a0 Their clinical pearls are in this book in no particular order and do not link directly to the listing of contributing physicians.\u00a0 The majority of these \u201ctricks of the trade\u201d have not been tested using evidence-based methodologies.\u00a0 In fact, few have ever been the subjects of random controlled trials.\u00a0 Some of the medications suggested for certain treatments are \u201coff-label\u201d for that medication.\u00a0 These suggestions would have to be viewed as evidence class C or \u201cexpert opinion\u201d.\u00a0 They may not work well for practice populations that differ from the contributing physician\u2019s patients.\u00a0 The reader is advised to review these clinical pearls with skepticism and to use them at their (or their patients\u2019) own risk.<\/p>\n

-Rick Ricer, MD\u00a0 2003<\/p>\n

—————————————————————–<\/p>\n

SECTION LINKS<\/strong><\/span>
\nSkin<\/a>
\nPhysical Exam<\/a>
\nMusculoskeletal<\/a>
\nRespiratory<\/a>
\nHeart and Blood<\/a>
\nGI Tract<\/a>
\nProcedures<\/a>
\nChildren<\/a>
\nWomen<\/a>
\nPsychosocial<\/a>
\nNeuro<\/a>
\nHEENT<\/a>
\nElderly<\/a>
\nPhilosophy of Practicing Family Medicine<\/a>
\nAdd your own Clinical Pearl<\/strong><\/a><\/p>\n

——————————————————————-
\n<\/a>
\nSKIN<\/strong><\/span>
\nDIAPER RASH
\n\u2022 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).\u00a0 This gives an extremely good water resistant barrier over the skin and does not irritate the skin.\u00a0 It can be applied after each diaper change and cleaning.
\n\u2022 Wash the baby\u2019s bottom after each bowel movement and put oil on the bottom and in the creases to prevent diaper rash.
\n\u2022 A mixture of nystatin, hydrocortisone cream, and zinc oxide can be used to treat almost any diaper rash.
\n\u2022 Mix cod liver oil and flour into a paste and paint onto the skin with each diaper change.
\nDRYING A WEEPING LESION
\n\u2022 One of the best ways to dry a weeping skin lesion is to apply Domeboro\u2019s solution\u00ae (aluminum sulfate, calcium acetate) at every opportunity and allow to air dry.\u00a0 This is an OTC product. Mix one pouch or tablet in a pint of tap water (2 in a quart).\u00a0 Use a jar with a replaceable lid, such as an old mayonnaise jar with a screw on lid.\u00a0 Place the solution on the kitchen counter or other area of high traffic.\u00a0 Whenever the patient passes that area, have them shake up the solution, dab it on the lesions, and allow to air dry.\u00a0 This is good for poison ivy, chicken pox, and other weeping lesions.
\nCONTACT DERMATITIS \/ ALLERGIC DERMATITIS
\n\u2022 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.\u00a0 After this is dry, it creates a barrier between the jewelry and the skin, which prevents contact with the skin and the reaction.\u00a0 The nail polish needs to be reapplied whenever it begins to wear off.
\n\u2022 An easily overlooked cause of dermatitis is the formaldehyde in wash-and-wear clothing.\u00a0 It can cause a rash under new clothing.
\nPOISON IVY
\n\u2022 The pharmacist can concoct a mixture of Cetaphil\u00ae cleanser with 0.1% menthol and 2.5% hydrocortisone cream.\u00a0 This can be used TID.
\n\u2022 Use a spray if touching the skin is very uncomfortable.
\nDERMATITIS
\n\u2022 Gold Bond\u00ae powder absorbs moisture and soothes the skin.\u00a0 It can be used for dermatitis under breasts or in the skin folds and for a perianal rash.
\nPRURITIS
\n\u2022 Oatmeal baths are helpful in softening skin and reducing itching.\u00a0 A cup of oatmeal mixed into the bath water helps soothe the skin.\u00a0 Remind the patient to completely flush all the oatmeal down the drain and through the trap. Dried oatmeal in plumbing can act like concrete.\u00a0 A way to avoid the oatmeal going down the drain is to place it in a cloth bag and placing that in the tub.
\n\u2022 Adding baking soda to bath water can decrease itching.\u00a0 Make the water milky.
\nPRURITIS WITH NO RASH
\n\u2022 This may be scabies.\u00a0 Persons who shower daily are not likely to produce retrievable mites.\u00a0 Eurax\u00ae (crotamiton) is an anti-itch cream and scabicide.
\nBLISTERS
\n\u2022 Many times patients will develop blisters on their feet from running increased distances or in new shoes.\u00a0 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.\u00a0 Several coats may be needed.\u00a0 This creates a \u201csecond skin\u201d over the blister so the patient can resume activity.\u00a0 The procedure may need to be repeated prior to each activity.\u00a0 Placing benzoin on the base of the blister can be painful for the patient.
\n\u2022 Place Duoderm\u00ae over denuded blisters for protection and relief.
\nDECUBITI AND STASIS ULCERS
\n\u2022 Place Amino-Cerv\u00ae or similar product in the crater to promote epithelialization and nitroglycerin cream or ointment on the edges to increase circulation.\u00a0 Too much nitroglycerin can cause a headache.
\n\u2022 Mix Betadine\u00ae and table sugar into a paste, apply this into the wound, then wash it out and repack every 8 hours.\u00a0 Cover the wound with regular gauze.
\nHAIR LOSS
\n\u2022 Losing more hair than normal may be a sign of a masked depression.
\nALOPECIA AREATA
\n\u2022 Anthraderm ointment\u00ae can be applied twice daily to bald spots.\u00a0 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.\u00a0 Steroid injections might be tried after a 3-month trial fails.
\nFOOT ODOR
\n\u2022 For patients with sweaty, stinking feet, a combination of alum, isopropyl alcohol, and formalin can relieve the problem.\u00a0 Saturate the alcohol with powdered alum, then add 1-2 tablespoons of formalin. Pat the feet with cotton balls dipped into the solution nightly.\u00a0 The alum is an antiperspirant, the alcohol is a drying agent, and the formalin \u201cpickles\u201d dead skin.
\nBRITTLE NAILS
\n\u2022 Even if the patient is not anemic, supplemental iron may help. Treat for at least a month.\u00a0 Oral gelatin may also be beneficial.
\nPRURITIS ANI
\n\u2022 One of the most common causes is the phenolphthalein dye in pink toilet paper.\u00a0 Discontinue all colored paper.
\nATHLETE\u2019S FOOT
\n\u2022 Use vinegar soaks (1\/2 cup vinegar in a bucket of warm water for 15 minutes BID), then apply antifungals.
\nECZEMA
\n\u2022 Ask your local pharmacist to fabricate a mixture of liquor carbonis detergens 2% solution in a steroid cream and apply BID.
\n\u2022 In a dry climate, frequent showering can still be done if the amount of soap used is greatly decreased.
\n\u2022 After bathing, take at least 2 minutes to pad dry and then apply oil or moisturizer.
\n\u2022 Crisco(TM) placed on the skin and wrapped with Saran Wrap(TM) can be a good treatment for eczema.\u00a0 A low potency steroid cream can even be applied under the Crisco(TM).
\nSKIN FISSURES
\n\u2022 Cracked skin is usually worse in the winter.\u00a0 Covering the fissure with Vasoline(TM) and then covering that with a bandage can soften the skin and correct the problem.\u00a0 This can also work for localized contact dermatitis or hand dermatitis.
\nALLERGY TO WOOL
\n\u2022 Patients with eczema who react to wool shouldn\u2019t use baby oil or mineral oil since this is derived from lanolin and they can react to that as well.
\nSKIN ANTIBIOTICS
\n\u2022 Use Polysporin\u00ae or Bactroban\u00ae instead of Neosporin\u00ae to decrease sensitivity reactions.
\nMELANOMA
\n\u2022 Smooth and well circumscribed skin lesions are almost never melanoma.\u00a0 Melanoma has irregular borders.
\n\u2022 Any non-healing skin lesion needs biopsied.
\nATOPIC DERMATITIS
\n\u2022 The most important treatment is to moisturize the skin.\u00a0 Apply lotion immediately after taking a bath or shower.
\nSKIN LESIONS
\n\u2022 Put paper tape or scotch tape over a lesion you want to follow, trace the lesion, and then place the tape in the chart.
\nSPLIT NAILS
\n\u2022 Super glue can help hold split nails together while they are healing.
\n\u2022 Some patients with onychomycosis do well with twice a day application of Vick\u2019s VapoRub (TM) on the involved nails for several months.
\nVENOUS STASIS ULCERS
\n\u2022 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.
\n\u2022 Silvadene\u00ae cream can help keep the wound moist and will prevent the dressing from adhering to the wound.
\nLOCAL SKIN REACTION
\n\u2022 Applying a baking soda paste can help soothe a local reaction such as a bee sting.\u00a0 An antiperspirant deodorant (aluminum) sprayed on the sting can also reduce symptoms.
\n\u2022 Put clear nail polish over chiggers or bug bites to decrease the itching.
\nCALLOUSES
\n\u2022 Covering callouses with Crisco(TM) and then saran wrap overnight will help soften them for pain relief and easier paring.
\nFUNGAL RASH
\n\u2022 If a rash itches only when the patient is hot or sweaty, think fungal cause.
\nWARTS
\n\u2022 When all else fails or prior to using a painful procedure, attempt to help the patient \u201cvisualize the warts away\u201d.\u00a0 Have them trace or draw the affected area complete with every wart, then have them perform a ceremony where they burn the paper and \u201cburn the warts away\u201d.\u00a0 They can also do relaxation techniques, then imagine their white blood cells are Pac-Man(TM) like cells that \u201ceat up\u201d the warts leaving only a beautiful and wart free area.\u00a0 This can be done nightly.
\n\u2022 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.\u00a0 This is delivered to the farmer in liquid nitrogen.\u00a0 You can get on their route inexpensively by renting a 20-liter flask from them.
\n\u2022 There is a gas vent available for cryo guns that screws in just behind the pinhole orifice.\u00a0 This has a very small capillary tube that will vent out gas.\u00a0 This allows a steady stream of liquid to be delivered to the orifice and will greatly decrease the \u201csputtering\u201d effect of most cryo guns.
\n<\/a>
\nPHYSICAL EXAM<\/strong><\/span>
\nABDOMINAL EXAMINATION \/ ABDOMINAL PAIN
\n\u2022 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.\u00a0 This contracts the rectus muscle.\u00a0 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.
\n\u2022 Carry on a conversation with the patient while you\u2019re examining the abdomen to distract them.
\n\u2022 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.\u00a0 If this doesn\u2019t elucidate pain, but there is pain when palpating without the stethoscope, the pain is probably not present.
\n\u2022 The size of the liver is the best 2 of 3 when using palpation, percussion, and the scratch test.
\n\u2022 Many times, mothers are concerned about appendicitis whenever their children have vomiting or any abdominal pain.\u00a0 Have the child jump up and down on one foot. If they can do this without pain, they don\u2019t have appendicitis.
\nRED REFLEX EXAM
\n\u2022 Sometimes it is difficult to examine the red reflexes of a newborn if they will not open their eyes.\u00a0 The examiner can use the non-dominant hand to support the baby\u2019s chest and central body.\u00a0 Lifting the baby directly above the examiner\u2019s head usually causes the baby to open their eyes and look down at the examiner.\u00a0 The eyes can then easily be examined using the ophthalmoscope held in the dominant hand.
\n\u2022 You can use the otoscope to look for a red reflex in an infant or child.\u00a0 Simple slide the magnifying lens off to the side.\u00a0 You will be looking down the beam of light at zero diopters and can see a beautiful red reflex.
\nEAR EXAMINATION
\n\u2022 The otoscope is a light source and magnifier only.\u00a0 The tip of the otoscope does not need to be buried into the ear canal.\u00a0 This is painful for the patient.\u00a0 Because the tips are tapered, a false impression is perceived that the tip should be pushed far into the canal.\u00a0 This is not necessary and is uncomfortable.\u00a0 The tympanic membrane can be visualized using only a penlight as long as the canal is straightened properly.\u00a0 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.\u00a0 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.\u00a0 This gives a good seal without having to ram the tip deep into the ear canal.\u00a0 Use the largest caliber tip that can easily be placed just inside the ear canal.\u00a0 It can be very difficult to visualize anything through a tiny opening of a pediatric tip.\u00a0 These are somewhat of a misnomer.
\n\u2022 Practice insufflating the tympanic membrane in order to be able to differentiate normal from abnormal.
\nHYPERTENSION
\n\u2022 A more accurate BP reading in massively obese individuals can be found at the wrist.\u00a0 Put the cuff on the forearm where there isn\u2019t as much adipose tissue to distort cuff efficiency.\u00a0 Of course, the proper size cuff is still necessary.
\n\u2022 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.
\nPELVIC EXAM
\n\u2022 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).
\n\u2022 To be most comfortable, the patient needs to keep her bottom on the table and her knees as far apart as she can.
\n\u2022 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.
\n\u2022 When preparing for a bimanual exam, spend 30 seconds spreading the lubricant around the fingers.\u00a0 This provides less friction during the exam and allows the examiners fingers to warm up the lubricant.
\n\u2022 When doing a pelvic exam, use a separate sheet to drape the patient from the abdomen down and always keep the legs covered.
\n\u2022 When a patient has very loose vaginal walls, cut a finger off a rubber glove, then cut the tip off that finger.\u00a0 Place over a speculum.\u00a0 This will keep the walls from intruding into the speculum when opened.
\n\u2022 For the first pelvic exam, explain it to the patient prior to undressing and show all the instruments.\u00a0 Explain how to relax and make sure the knees are wide apart.
\n\u2022 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.\u00a0 It should pop into view.\u00a0 If this fails, find the cervix with you finger first and aim the speculum there.
\n\u2022 Use the intravaginal finger(s) to push the organs up to the lightly pressing lower abdominal hand.
\nEXAMINING CHILDREN\u2019S EARS
\n\u2022 To keep a child still during an otoscopic exam, tell them there\u2019s a bird in their ear and to listen for the bird to whistle.\u00a0 You whistle when you can see the TM.
\n\u2022 Another way to distract them is to let them play with your retractable tape measure while you examine their ears.
\n\u2022 Yet another way to distract kids for the otoscopic exam is to massage the tragus while talking to them, which desensitizes and reduces reactions.
\n\u2022 The examiner can whisper to the child and have the child concentrate on hearing the whisper while the examiner searches for the TM.
\n\u2022 Have the child hold the otoscope and \u201chelp\u201d you examine their ears.
\nBREAST EXAM
\n\u2022 When performing a breast exam, try to convince yourself that there is a \u201cBB\u201d sized cancer hidden in that breast. This causes you to do the exam infinitely more carefully.
\nHAND WASHING
\n\u2022 Patients appreciate seeing you wash your hands prior to doing any part of the physical exam on them or their children.
\nHEARING LOSS
\n\u2022 Always have a hand held amplifier (can be purchased at a store like Radio Shack(TM) in the office.\u00a0 Place the earphones on a patient with poor hearing and speak softly into the amplifier.
\nTREMOR
\n\u2022 Lay a sheet of paper on the hand to accentuate a patient\u2019s tremor.
\nKNEE EXAM
\n\u2022 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.
\nHYPERVENTILLATION
\n\u2022 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.
\nRENAL COLIC
\n\u2022 If you are concerned the patient\u2019s pain may be from renal colic, check for hyperaesthesia in the L1 dermatome.\u00a0 If this is present, the patient has renal colic.
\nANEMIA
\n\u2022 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.\u00a0 This usually means a hemoglobin of less than 10.
\nCONSOLIDATION OF LUNGS
\n\u2022 Percuss the clavicle while listening to the posterior lungs to check for consolidation and dullness in the lung fields.
\nFUNDOSCOPIC EXAM
\n\u2022 When performing a fundoscopic exam on a patient with a large refractive error, the examiner may have great difficulty focusing on the retina.\u00a0 Have the patient wear their glasses and try again with the setting at zero.\u00a0 If the glasses are the correct prescription, the retina should be focused for the examiner.\u00a0 (The examiner may have to wear their prescription spectacles as well.)\u00a0 Practice will help decrease the problem with glare from the glasses.
\n<\/a>
\nMUSCULOSKELETAL<\/strong><\/span>
\nQUADRICEPS STRENGTHENING EXERCISES \/ CHONDROMALACIA PATELLAE
\n\u2022 For conditions like Chondromalacia Patellae when the quads need strengthening but without stretching the quad\u2019s tendon, have the patient lift the heel off the floor while keeping the knee locked, in the sitting position.\u00a0 The lifting is from the hip, so the hamstrings must clear the surface of the chair while the leg is lifted.\u00a0 The patient then holds the leg up for 1-2 minutes.\u00a0 This needs to be done multiple times a day.\u00a0 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.\u00a0 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.\u00a0 The weight of the sack can be increased as the patient tolerates.
\n\u2022 Another method is using an old strapped purse over the ankle and placing various weights in the purse.
\nHEEL SPUR
\n\u2022 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.\u00a0 Cut an inch thick layer the size and shape of the affected heel.\u00a0 Place the Styrofoam pad into the shoe.\u00a0 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.\u00a0 The pad gives a good cushioning effect and slightly lifts the heel.\u00a0 When the patient steps on this pad, it will compress to less than half an inch.
\nFROZEN SHOULDER \/ ADHESIVE CAPSULITIS
\n\u2022 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.\u00a0 The patient may not be able to do active exercises secondary to weakness of the muscles or pain.\u00a0 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.\u00a0 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.
\nMUSCLE TENSION HEADACHE \/ POSITIONAL NECK PAIN
\n\u2022 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.\u00a0 This way, the head is erect,the back is straight, and the traps are less utilized.\u00a0 They may have to pad or support the elbows in this new position.
\nLOW BACK PAIN
\n\u2022 Teach these patients to \u201cget set\u201d before lifting (just short of a valsalva \u2013 tighten abdominals and gluteals).\u00a0 Always lift with the powerful leg muscles instead of using the back as a crowbar.\u00a0 Have the patient draw where the pain is located each visit.\u00a0 Compare the drawing to see if the location is consistent.
\n\u2022 The lumbar curve is the culprit and the puny abdominal muscles are the potential saviors \u2013 strengthen the abdominals.\u00a0 Use leg lifts (not high), shoulder lifts (not sit-ups), and knee to chest grabs.
\n\u2022 When examining a patient complaining of low back pain, do the straight leg-raising test while the patient is sitting.\u00a0 Converse with the patient or appear to be examining the knee to differentiate a true positive from a false positive.
\n\u2022 Make sure that the patient does one exercise for regular stretching \u2013 knees to chest, hold 30 seconds keeping the curve of the back on the floor, 5 repetitions twice a day.
\n\u2022 Some patients with back pain have episacral lipomas as the cause.\u00a0 These are fatty lumps caused by a herniation of the deep layer of fat through the fascia into the superficial layers.\u00a0 These lumps (if they are causing the back pain) will be exquisitely painful to palpation.\u00a0 Inject only the symptomatic lipomas with lidocaine and a steroid.\u00a0 They should get immediate relief.
\nLATERAL EPICONDYLITIS
\n\u2022 If you suspect lateral epicondylitis, use the chair lift test for confirmation.\u00a0 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.\u00a0 This should cause pain directly over the lateral epicondyle.
\nRETURN TO SPORT AFTER INJURY
\n\u2022 When the patient can walk without pain, they can begin to jog. When the patient can jog without pain, they can begin to run.\u00a0 When they can run without pain, they can begin to do figure 8s.\u00a0 When they can do figure 8s without pain, they may return to their sport.
\nLEG CRAMPS
\n\u2022 To help prevent leg cramps at night, have the patient lie supine in bed with their feet up against the footboard.\u00a0 They can then do plantar flexes of the toes, working the calf muscles.
\nSPRAINED ANKLE
\n\u2022 For rehab range of motion for a sprained ankle, have the patient use that foot to write the alphabet in the air.
\n\u2022 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.
\nAUTO ACCIDENT
\n\u2022 Have the patient draw the accident or you draw it from their description and place this in the chart.
\nCARPAL TUNNEL SYNDROME
\n\u2022 A\u00a0 neutral position wrist splint can be made using a bowling glove.
\nHAMSTRING TIGHTNESS
\n\u2022 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.\u00a0 Pull the toes back.
\nRAYNAUD\u2019S
\n\u2022 When a patient is exhibiting Raynaud\u2019s phenomenon in cold weather, they can attempt to force blood into the fingertips by \u201cwindmilling\u201d their arms at the shoulder to use centrifugal force to force the blood past the vasospasm.
\nOSTEOARTHRITIS OF THE KNEE
\n\u2022 A lateral heel pad can help alleviate some of the pain associated with osteoarthritis of the knee (medial compartment).\u00a0 Cut a heel pad in half and place inside the shoe.
\n<\/a>
\nRESPIRATORY<\/strong><\/span>
\nASTHMA \/ INHALERS
\n\u2022 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.\u00a0 It also obviates the need to coordinate a deep breath at the same time the inhaler is triggered.
\n\u2022 If the patient has ever smoked marijuana, they can use that skill when using an MDI.\u00a0 They inhale the same way and hold the medication in the lungs the same way.
\n\u2022 For children using an inhaler or mister, use a Dixie (TM) cup and cut a nick for the baby\u2019s nose and insert the inhaler or mister through a cut on the bottom (for infants, use a plastic pill cup).
\n\u2022 Removing the bottom of a small Dixie (TM) cup or Styrofoam (TM) cup makes a good spacer for infants or small children.
\nINCENTIVE SPIROMETRY
\n\u2022 Have the patient blow up small balloons as cheap incentive spirometry.
\nSNORING
\n\u2022 Have the spouse of a snorer wear earplugs.
\nAPPROXIMATING PEAK FLOW
\n\u2022 Hold your finger in front of the child and have them \u201cblow it out\u201d. This gives the examiner an idea of peak flow.
\nDIABETES
\n\u2022 Diabetics must check the inside of their shoes every time prior to wearing shoes.\u00a0 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.
\n\u2022 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.
\n\u2022 When a diabetic patient is not in good control, see them more frequently.
\n<\/a>
\nHEART AND BLOOD<\/strong><\/span>
\nREDUCING SODIUM \/ INCREASING POTASSIUM
\n\u2022 When a patient is on a diuretic or needs to decrease sodium in their diet and increase potassium, Morton\u2019s Lite Salt(TM) can be used instead of regular table salt.\u00a0 This product is half sodium chloride and half potassium chloride. The use and taste is similar to regular salt.
\n\u2022 Mrs. Dash(TM) also contains potassium.
\nNITROGLYCERIN
\n\u2022 Be sure to have the patients take the cotton out of the bottle as soon as they fill the prescription.\u00a0 Many patients have been found dead trying to get the cotton out in an emergency.
\nHYPOKALEMIA
\n\u2022 A rare cause of hypokalemia is chewing tobacco hypokalemia.\u00a0 Some brands of chewing tobacco contain licorice which contains an ingredient with mineralo-corticoid activity.
\nEXERCISE
\n\u2022 The calculations for target and maximum heart rate can be confusing. 170 \u2013 age is a simple and safe calculation.
\n\u2022 Don\u2019t increase mileage or duration >15% per week.
\n\u2022 When writing an exercise prescription, use FITT \u2013 frequency, intensity, time, and type of exercise.
\n<\/a>
\nGI TRACT<\/strong><\/span>
\nCONSTIPATION
\n\u2022 Prune juice mixed with 7-UP(TM) tastes similar to Dr. Pepper(TM).\u00a0 Persons who dislike the taste of prune juice may find this a more palatable solution.
\n\u2022 Increase fiber by using a concoction of oat bran, wheat bran, and Metamucil\u00ae BID.\u00a0 This may help IBS as well.
\nDIARRHEA
\n\u2022 Diarrhea can sometimes persist after the infectious etiology has been treated.\u00a0 This may mean that the normal lacto-bacilli have been eliminated and need to be replaced. Lactinex\u00ae granules or unpasteurized yogurt may be helpful.
\nOBESITY
\n\u2022 Ask the patient to bring in a usual shopping list tape to see what they normally buy at the grocery store.
\n\u2022 Obese patients may benefit from a medication like metformin even if they are not overtly diabetic.
\n\u2022 After a patient has lost 15-25 pounds, have them buy a turkey from the grocery store that weighs as much as they lost.\u00a0 This is representative of the extra weight they have been carrying for years.
\n\u2022 The liquids the patient is consuming daily can contain a surprising amount of calories.\u00a0 Switching milk, soft drinks, and juices to diet drinks can greatly reduce calories ingested.
\nESOPHAGEAL REFLUX
\n\u2022 Use stacks of old newspapers to raise the head of the bed when treating GE reflux.\u00a0 Caffeine (includes chocolate), tobacco, alcohol, and mint (gum, candies, and some mint flavored antacids) all reduce LES pressure.\u00a0 Consider removing all of these from the patient\u2019s daily regime when treating symptomatic GE reflux.
\nIRRITABLE BOWEL
\n\u2022 Patients can use Imodium\u00ae as a prophylaxis before doing activities that always cause diarrhea.
\nDEHYDRATION
\n\u2022 Half strength Gatoraid(TM) can be a good rehydrating fluid in adults.
\n<\/a>
\nPROCEDURES<\/strong><\/span>
\nBLOOD DRAWING
\n\u2022 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\u2019t allow the needle the correct angle for best penetration.\u00a0 Using a butterfly needle helps this situation.\u00a0 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.\u00a0 It is then easier to direct the needle into the skin without the syringe or Vacutainer interfering with the angle.
\nINTRAVENOUS LINE PLACEMENT
\n\u2022 Line up the bevel of the needle with the numbers on the syringe so that you\u2019ll always know which direction the bevel is pointed after the needle has pierced the skin and is no longer visible.
\n\u2022 Turn the bevel upside down when in the vein. This helps the catheter slide into the vein.
\n\u2022 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.\u00a0 The upside down cuff gets the tubing out of the way.\u00a0 The technique allows arterial supply but occludes venous return creating maximal venous dilation.
\nIMPACTED CERUMEN
\n\u2022 Removal of impacted cerumen that can\u2019t be removed easily with an ear spoon can be accomplished using water pressure.\u00a0 Attach a 50 cc syringe to an 18 gauge Angiocath (without the stylet).\u00a0 Cut the Angiocath to 1 to 2 inches.\u00a0 Fill the syringe with body temperature water.\u00a0 Lay the tip of the Angiocath along a wall of the ear canal and flush out the cerumen.\u00a0 More than one attempt may be necessary.\u00a0 Do not do this procedure if there is a possibility of a ruptured tympanic membrane.
\n\u2022 Colace\u00ae can be used to soften earwax for easier removal.
\n\u2022 Hydrogen peroxide can be used to clean out cerumen.\u00a0 Kids call it the rice crispy medicine.\u00a0 It can also be used twice a week to prevent future impactions.
\n\u2022 Mineral oil or sweet oil can also be used to soften earwax.
\n\u2022 There is an inexpensive devise called the \u201cElephant Ear Washer\u201d.\u00a0 It is a spray squirt bottle with a flexible tube attached to the outflow.\u00a0 You can spray directly into the ear canal varying the strength and direction of flow.
\nPOSTERIOR NOSE BLEEDS
\n\u2022 A Foley catheter can be used as an emergency pack to treat posterior nose bleeds.\u00a0 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.\u00a0 A padded umbilical clamp can be placed over the Foley at the nares to hold the packing in place.
\nENDOMETRIAL BIOPSY
\n\u2022 When doing an endometrial biopsy using a plastic device, place the plastic in the freezer until it has stiffened.\u00a0 The Pipelle\u00ae will more easily pass through the cervical os when stiffened.\u00a0 The body temperature will thaw the frozen instrument after a very short period of time.
\nNASOGASTRIC TUBE PLACEMENT
\n\u2022 An NG tube can usually be passed more easily if it has been placed in the freezer prior to use.\u00a0 It becomes stiffer and is easier for the patient to swallow and the examiner to manipulate.
\nHEMORRHOIDS
\n\u2022 NSAIDS can help speed resorption of a thrombosis and reduce the need for incision and removal.\u00a0 Symptoms should be better within 24 hours.\u00a0 These can be combined with aggressive sitz baths.
\n\u2022 Bag Balm\u00ae applied to hemorrhoids can be very soothing.\u00a0 It can also be used for eczema.
\nLOCAL ANESTHETIC
\n\u2022 If a patient is allergic to the \u201ccaines\u201d, Benadryl can be injected as a local anesthetic.
\n\u2022 Bacteriostatic saline can be used as a very brief (few minutes only) local aneshetic.\u00a0 It contains a high concentration of benzyl alcohol, but being isotonic, does not cause pain during injection.\u00a0 This can be used to numb the skin to aspirate a small cyst or superficial bursitis.\u00a0 If you use an insulin syringe, the patient will rarely feel the injection or the subsequent aspirating needle.
\nNASAL DISCHARGE AFTER AN INJURY
\n\u2022 Check for glucose in the nasal discharge.\u00a0 A positive Dextrostix\u00ae means a CSF leakage.
\nESOPHAGEAL REFLUX
\n\u2022 If you suspect chronic esophageal reflux, check the secretions coughed up with litmus paper.\u00a0 Acid positive suggests reflux.
\n\u2022 Use Kegel like exercises to increase the strength of the abdominal muscles and perhaps lessen the need for medications.
\nOBJECT IN EAR
\n\u2022 When an insect is trapped in a patient\u2019s ear canal, kill the insect with mineral oil or lidocaine before attempting to remove it.
\n\u2022 Acetone (nail polish remover) will dissolve Styrofoam (TM) trapped in the ear canal.
\nPAINFUL PROCEDURE
\n\u2022 Warn the patient that vinegar applied to the cervix can sting.\u00a0 When doing any painful procedure, be honest with the patient and let them know when it will hurt.
\n\u2022 Mix bupivicaine with lidocaine for longer pain relief.
\n\u2022 When giving injections such as flu shots, wrap your hand circumferentially around the upper arm and squeeze tightly just before and during the injection.\u00a0 This fools the sensory pathways (gate theory) and the patient won\u2019t feel the needle.
\n\u2022 When doing a painful procedure on a child, send the parents out of the room.
\n\u2022 When suturing a child\u2019s wound and trying to determine if restraints will be needed, look at the child\u2019s feet.\u00a0 If the child is comfortable with their feet are apart and \u201cflopped open\u201d, restraints won\u2019t be necessary.\u00a0 If their feet are together and pointing straight up, the child is nervous and restraints will be necessary.
\n\u2022 With any painful but brief procedure such as phlebotomy, injections, or cervical biopsies, have the patient take deep breaths.
\n\u2022 Use a 30-gauge needle to inject lidocaine for local anesthesia (but draw it up with a larger needle).
\n\u2022 Use Hurricaine\u00ae gel topically on the cervix and os before biopsies.\u00a0 Have the patient count to 20 out loud during endometrial curetting to make the procedure more tolerable.
\n\u2022 Have the patient take 600 mg of ibuprofen prior to the office visit for an endometrial biopsy to decrease cramping during the procedure.
\nPROCEDURE ETIQUETTE
\n\u2022 Be sure to have all the equipment and tools you might need for a procedure prior to beginning the procedure.\u00a0 It appears unprofessional and sloppy to have to keep stopping the procedure to procure the correct instruments.
\nSUBUNGAL HEMATOMA
\n\u2022 Light an alcohol wipe (burns about 30 seconds) and use it to heat the end of a paper clip (unfolded).\u00a0 Use the hot paper clip end to burn a hole through the nail to drain the hematoma.
\nSPLINTER REMOVAL
\n\u2022 Use the No-scalpel vasectomy dissector to grasp the splinter for easier removal.
\nFOREIGN BODIES
\n\u2022 To locate non-radioopaque foreign bodies in extremities, have the radiologist do a mammogram of the affected area.
\n\u2022 To remove a foreign body from the nose, place a drop of crazy\/super glue on the wooden end of a cotton swab.\u00a0 Quickly press the wooden end against the foreign body for 10-15 seconds until the glue sets.\u00a0 Then simply remove the cotton swab with the foreign body attached.
\n\u2022 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.
\n\u2022 Another way to remove a foreign body stuck in a child\u2019s nose is to close the unaffected nares with a finger, then use an Ambubag or the mother\u2019s mouth to puff air into the child\u2019s mouth which pushes the foreign body out the nose.
\nCIRCUMCISION
\n\u2022 When utilizing the Gomco\u00ae 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.\u00a0 The pin can fit up through the instrument aperture and gives good control of the foreskin.
\nINGROWN TOENAIL
\n\u2022 Continuous hot soaks and massaging the skin away from the nail can many times obviate the need for a partial nail removal.
\n\u2022 When doing a partial nail removal, use a straight hemostat to grasp the portion to be removed, then twist away from the edge.\u00a0 This pops the edge right out and defines the section that needs to be removed.
\n\u2022 Use a male urethral swab to place phenol at the base of a partial removal.\u00a0 It is small enough to prevent a large chemical burn of the nail bed.
\n\u2022 Placing an ear wick under the nail edge will help lift the nail edge as the wick slowly expands as it absorbs moisture.
\n\u2022 An \u201cEnglish nail splitter\u201d to cut the nail and a periosteal elevator to dissect under the nail makes removing nails easier.
\nSEBACEOUS CYSTS
\n\u2022 When removing a non infected sebaceous cyst, use a punch biopsy to remove the core or plugged pore.\u00a0 After removing the sebaceous material, tease the cyst wall out through the punch biopsy hole.\u00a0 The scar will be minimal.
\n\u2022 Curved blunt Mayo scissors are great for tissue dissection to follow around the edges of the cyst to be removed.
\nRING REMOVAL
\n\u2022 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.\u00a0 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.\u00a0 Several repetitions may be necessary.\u00a0 You may want to lubricate the surface of the string or ribbon after it is wrapped on the finger.\u00a0 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.\u00a0 The ring should advance forward as the unwrapping proceeds.
\nFISHHOOK REMOVAL
\n\u2022 If the hook is embedded such that it shouldn\u2019t be pushed on through to clip off the barbed end, pull the hook back through the path it took to become embedded.\u00a0 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.
\nWARTS
\n\u2022 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.\u00a0 Then you can apply the caustic agent to the wart without getting it on the surrounding skin.
\nCACTI THORNS
\n\u2022 To remove cacti thorns from the skin, place duct tape over the area and pull it off.\u00a0 Repeat several times.\u00a0 You can place meat tenderizer on the skin for 10 minutes prior to using the tape for easier removal.
\nFOLEY CATHETER PLACEMENT
\n\u2022 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.
\nGASTRIC TUBE REPLACEMENT
\n\u2022 A coat hanger can be used as a stylet for replacing a gastric tube that has \u201cpopped out\u201d of an established tract.
\nVASECTOMY
\n\u2022 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\u2019s fingers for easier isolation of the vas.
\n\u2022 Prescribe the patient two ice-cold beers after a vasectomy \u2013 one to drink and one to use as an ice pack.
\nWOUND REPAIR
\n\u2022 Super glue can be used sometimes in place of stitches.
\nFINGER INJURY
\n\u2022 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.
\nDECUBITI
\n\u2022 An antibiotic brew can be placed into bone cement and then placed in the decubitus for weeks to help promote healing and decrease infection.\u00a0 This is described in the podiatric and orthopedic literature.
\nHEAD LICE
\n\u2022 Using Dippity Do (TM) or similar hair gel, cover the entire scalp and then cover this with a shower cap.\u00a0 This smothers the lice.\u00a0 For resistant cases, use mayonnaise in the same way.
\nSKIN TAGS
\n\u2022 Clamp across the base of the tag with a hemostat (like crushing the foreskin prior to a dorsal slit).\u00a0 Remove the hemostat and then clip the tag.\u00a0 This greatly decreases bleeding and may obviate the need for silver nitrate or other chemical coagulants or even a local anesthetic.
\nFLUORESCEIN
\n\u2022 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.\u00a0 Remember that fluorescein will stain contact lenses.
\nTICKS
\n\u2022 To extract an embedded tick, use an Allis clamp.\u00a0 Place the clamp just past the tick\u2019s head and pull.\u00a0 This will not squeeze the tick.
\nIUD
\n\u2022 When an IUD is placed, curl the string at the cervical os like curling the ribbons on wrapping packages.\u00a0 This moves the sharp tip and is less noticeable to the patient and her partner.
\nCXR READING
\n\u2022 For congestive heart failure, turn the chest x-ray upside down.\u00a0 You can see cephalization better this way.
\n\u2022 An UPPER lobe infiltrate on chest x-ray is cancer until proven otherwise.
\nEPISIOTOMY
\n\u2022 A modified midline episiotomy (just off center) may help avoid 3rd and 4th degree tears when an episiotomy is indicated.
\nSUTURE REMOVAL
\n\u2022 An 18 gauge needle works well to remove sutures.\u00a0 The tip can be bent into a hook if desired.\u00a0 An 18 gauge needle can also be used as a lance to incise abscesses.
\n\u2022 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.
\n\u2022 Place gauze soaked with hydrogen peroxide over the sutures for a few minutes to soften them and the skin for easier removal.
\nBROWN RECLUSE BITE
\n\u2022 Nitroglycerin ointment or patch over a brown recluse bite can reduce the amount of necrosis.
\nASPIRATION AND INJECTION
\n\u2022 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.\u00a0 This way you don\u2019t have a sharp needle to cause bleeding or pain as the bursa collapses or during the manipulation as you change syringes for the injection.\u00a0 The 18 gauge catheter is less likely to kink.
\n<\/a>
\nCHILDREN<\/strong><\/span>
\nCOLIC
\n\u2022 Maneuvers to help colicky babies include propping them upright to feed, ruling out or treating GE reflux, and ruling out or treating milk allergy.
\nBURPING BABIES
\n\u2022 With the baby upright and facing away from the seated examiner, grasp the baby around the chest with the examiner\u2019s thumbs on the baby\u2019s back and the fingers wrapped around the chest.\u00a0 Place the baby\u2019s left hip inside the examiner\u2019s left knee.\u00a0 Rotate the baby 30 to 45 degrees to his\/her left.\u00a0 This brings the fundal air bubble in contact with the esophagus and should result in a quick spontaneous burp.\u00a0 Occasionally, you need to add a few degrees of forward or backwards to the left lean.
\nURINE SAMPLING OF SMALL CHILD
\n\u2022 To get a urine sample from a reluctant child, have the mother stoke the middle of the back just above the gluteal crease.\u00a0 This will often induce a micturation reflex.
\nMENINGISMUS
\n\u2022 If a child does not follow the examiner around the room with their eyes, the child\u2019s neck is probably stiff and painful which may be a sign of meningitis.
\nCRADLE CAP
\n\u2022 A mild soap like Dawn(TM) dishwashing soap can be used to daily scrub this area.
\n\u2022 Nizoral\u00ae shampoo (available OTC) works well to clear cradle cap, although it is not \u201cno more tears\u201d.
\nHEIGHT AND WEIGHT RECORDING
\n\u2022 To help assure accurate plotting of children\u2019s heights and weight, develop a \u201cplotter helper\u201d using an overhead transparency with a hole in the middle of intersecting vertical and horizontal lines.
\n\u2022 Liquid medications with an adult dose of 2 teaspoons can be given to children at the dose calculated by the \u201cdecimal move rule\u201d.\u00a0 Take the child\u2019s weight in pounds and move the decimal point one column to the left to figure out how many milliliters to administer (eg; 40 pounds =\u00a0 4.0 ml,\u00a0 85 pounds =8.5\u00a0 ml).\u00a0 This works for most OTC cough\/cold remedies and some prescribed medications.
\nCHILDREN\u2019S CONSTIPATION
\n\u2022 Half of a Metamucil (TM) cookie wafer per day may help remedy this problem.
\nBREAST FEEDING
\n\u2022 If the baby doesn\u2019t seem to be getting enough milk, check the hydration status of the mother.
\nATTENTION GETTING
\n\u2022 To get and keep the attention of an 8 to 12 month old, get in front of them and say \u201cfa, la, la\u201d over and over.\u00a0 They will be entranced with the movement of your mouth.
\n<\/a>
\nWOMEN<\/strong><\/span>
\nKEGEL EXERCISE REMINDERS
\n\u2022 Kegel exercises for stress incontinence need to repeated frequently during the day for maximum effectiveness.\u00a0 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.\u00a0 This would insure that the patient has opportunities to do these exercises many times each day.
\nVAGINITIS WITH PRURITIS
\n\u2022 Fill 30 gelatin capsules with boric acid powder. Insert one capsule into vagina nightly for 30 days (even through menses).\u00a0 This returns the vaginal environment to its normal acidity.
\nCYST OF CANAL OF NUCK
\n\u2022 A tender mass in the inguinal region or labia of young, athletic females may be a hydrocele.\u00a0 It may even contain an ovary.
\nOSTEOPOROSIS
\n\u2022 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.
\nVAGINITIS
\n\u2022 To prevent irritant vaginitis, don\u2019t douche, don\u2019t use bubble baths, and don\u2019t scrub the perineum with soap.
\n\u2022 Patients with vaginitis may present like a UTI. If the urine is negative, try to determine if the patient\u2019s discomfort is when the urine is coming through the urethra or when the urine hits the vagina.\u00a0 This can be a difficult distinction for most patients.\u00a0 If the discomfort is when the urine hits the vagina, a vaginitis is the problem, not a UTI.
\n\u2022 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.
\nVAGINAL DRYNESS
\n\u2022 White Crisco (TM) can be used as a lubricant for vaginal dryness and as a lubricant for intercourse (may weaken condoms).
\nVULVAR HERPES
\n\u2022 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.\u00a0 Have the patient sit in a tub of warm water and urinate in the bathtub.
\nPOST MENOPAUSAL BLEEDING
\n\u2022 PMB is cancer until proven otherwise.\u00a0 Biopsy if any doubt exists.
\nMASTITIS
\n\u2022 Apply cold, purple cabbage leaves inside both sides of the bra and change when the leaves wilt.
\nUTI
\n\u2022 Doubling the first dose of antibiotics when treating a urinary tract infection may help decrease symptoms faster.
\n\u2022 Pyridium can \u201cnumb\u201d the bladder to reduce symptoms.\u00a0 Do not give more than 2-3 days worth since this only masks symptoms, it doesn\u2019t cure the problem.\u00a0 Remind patients that this turns the urine pink or orange and can stain clothing or contact lenses.
\nCLAMPING UMBILICAL CORD
\n\u2022 There is no hurry to clamp the cord.\u00a0 Milk the blood away from the clamp site before clamping to reduce splatter when cutting.
\nRIPENING THE CERVIX
\n\u2022 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.
\nBREAST DISCHARGE
\n\u2022 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.\u00a0 If you think the discharge is milk, look at the discharge under the microscope and look for fat globules.
\n<\/a>
\nPSYCHOSOCIAL<\/strong><\/span>
\nTOBACCO CESSATION
\n\u2022 Have the patient daily put the money they would have spent on cigarettes into a jar.\u00a0 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.
\n\u2022 When advising a patient to set a quit smoking day, pick a day that trash is picked up in their neighborhood.\u00a0 They can discard all their cigarettes, lighters, and ashtrays and will not be able to get them back.
\n\u2022 For a patient who has chosen a quit date, place a nicotine patch on the as they go to bed the night before.\u00a0 This way they will not wake up in nicotine withdrawal on the morning of their first day as a nonsmoker.
\nDEPRESSION
\n\u2022 A pneumonic for taking a history for depression is SIGECAPS (SIG \u2013 prescription, E \u2013 energy, CAPS \u2013 capsule).\u00a0 This stands for suicide, interests, guilt, energy, concentration, appetite, psychomotor retardation, and sleep.
\n\u2022 If there is a positive response on screening for depression, ask the patients if they are surprised by this.\u00a0 This gives them a chance to open up.
\n\u2022 Ask what they do for fun. This will check affect, energy, activities, and interests.
\n\u2022 Ask if they cry easily. If they break down and cry, the answer is yes.
\n\u2022 Virtually everyone with depression feels tired and doesn\u2019t sleep well.\u00a0 Ask, \u201cDo you feel tired all the time?\u201d\u00a0 They not only feel sleepy but physically weak and unmotivated.\u00a0 For sleep, focus on the quality of sleep and whether they feel rested and refreshed rather than on a specific sleep pattern.
\n\u2022 When starting an antidepressant medication, start with half the dose you would normally start the patient on for the first 2-4 days.\u00a0 This decreases side effects.\u00a0 Capsules might be dissolved in apple juice with half the juice ingested the first day and the other half the second day.
\nRED FLAGS FOR ABUSE OF PAIN MEDS
\n\u2022 Calling for medication after hours.
\n\u2022 Unbelievable stories about what happened to their medications.
\n\u2022 Allergic to every medication except the one they want.
\n\u2022 The patient knows the names of major medications that they aren\u2019t on, but purposely mispronounce them.
\nPSEUDO-SEIZURE
\n\u2022 Doing an ABG to look for respiratory acidosis can help differentiate pseudo-seizures from true grand mal seizures.
\nCOMPLIANCE
\n\u2022 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).\u00a0 Place the medication there.
\nINSOMNIA
\n\u2022 Treat using the side effects of amitriptyline.\u00a0 Start with 10 mg at bedtime and allow the patient to titrate themselves to an effective dose.\u00a0 Hydroxyzine can be used in the same fashion and dosage.\u00a0 Trazodone is another medication that can be used for this purpose.
\n\u2022 Improvements in sleep hygiene can be accomplished using Feng Shui in the bedroom.\u00a0 Aim the foot of the bed toward the door and remove anything having to do with work from the bedroom.
\nDENYING PAIN MEDICATIONS
\nUse an \u201cI\u201d statement instead of a \u201cyou\u201d statement when denying narcotic requests \u2013 \u201cI feel uncomfortable . . .\u201d\u00a0 \u201cI don\u2019t want to get you hooked.\u201d\u00a0 \u201cI am not helping you by continuing this course.\u201d
\nPERSEVERATING THOUGHTS
\n\u2022 After a traumatic event, patients may have recurring, perseverating thoughts.\u00a0 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.
\nDIFFUSELY POSITIVE REVIEW OF SYSTEMS
\n\u2022 If a patient has a diffusely positive review of systems, ask if their teeth itch or if their stools glow in the dark.\u00a0 A positive response to either of these questions is highly correlated with a psychological cause.
\n<\/a>
\nNEURO<\/strong><\/span>
\nPARKINSONS
\n\u2022 Sometimes, the first sign of Parkinsons is micrographia.
\nNEURALGIA, NEURITIS
\n\u2022 When all else fails, try thiamine 25 mg TID for 6 weeks or longer.
\nPOST CONCUSSION
\n\u2022 Diamox \u00ae (carbonic anhydrase inhibitor) may help accident victims with \u201cfuzzy thinking\u201d on post accident day 2 or 3.
\nPERIACTIN\u00ae
\n\u2022 This is an old antihistamine that is an anti serotonin.\u00a0 Its many uses can include stimulating appetites in children, migraine prophylaxis, pruritis of chicken pox, allergies, treatment of serotonin syndrome, and treating dumping syndrome.
\nCOMA
\n\u2022 Patients who are in a coma can sometimes hear what we say.\u00a0 Talk to your patients, but be careful what you say.
\nALZHEIMER IN DOWNS
\n\u2022 Two signs in patients with Down Syndrome may be early indicators of Alzheirmer\u2019s Disease \u2013 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).
\nHEADACHES
\n\u2022 Help focus the patient by having them describe the worst headache they\u2019ve ever had and the headache that brought them to the office today.
\n\u2022 Have the patient keep a headache diary.
\n\u2022 Two minute neuro exam \u2013 observe for normal behavior, movement of face, and speech; cranial nerve examination; and fundoscopic exam.
\n\u2022 Trigger point injections using lidocaine or just sterile saline can ease tension and migraine headaches.\u00a0 A small needle like that on a TB syringe decreases pain of injection.
\n\u2022 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.
\n<\/a>
\nHEENT<\/strong><\/span>
\nAPHTHOUS ULCERS
\n\u2022 Punch a hole in a Tessalon Perle\u00ae (benzonatate) and dab the fluid onto the mouth ulcer to numb the ulcer.\u00a0 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.
\n\u2022 Use a mixture of 1\/3 hydrogen peroxide, 1\/3 Decadron syrup, and 1\/3 water to swish and spit every 2-3 hours.
\n\u2022 Combine Benadryl (numbing agent) with Kaopectate\u00ae (sticking agent) for a swish and spit.
\n\u2022 Chewing real licorice several times a day may relieve symptoms.
\n\u2022 Cover the ulcers with a sucralfate paste every 6 hours.
\nPAINFUL TEETH
\nOil of cloves placed on the tooth using a cotton swab can help relieve the pain of a dental cavity.
\nOTITIS EXTERNA PREVENTION
\n\u2022 For a patient who gets repeated episodes of otitis externa, a prophylaxis may be used.\u00a0 Take a half and half mixture of white vinegar and rubbing alcohol in a dropper container.\u00a0 After swimming or bathing, place 2 or 3 drops of the solution in the ear canal.\u00a0 The vinegar is acetic acid which changes the pH of the ear canal and kills pathogens.\u00a0 The rubbing alcohol is a drying solution to help clear the ear canal of moisture.\u00a0 This solution can be used as a treatment in some situations.
\n\u2022 Another prevention could be placing baby oil or olive oil in the ear canal before swimming.
\nOTITIS EXTERNA
\n\u2022 When using a wick for OE, put the wick in dry.\u00a0 After putting in the medication drops, leave the wick in place for 48 hours.
\n\u2022 If there is pain on movement of the external ear and the external ear is red and swollen, add an oral anti-pseudomonas medication.
\n\u2022 A mixture of phenol 2% and acetic acid 1% can help numb the pain of otitis externa.
\nALLERGY PHYSICAL SIGNS
\n\u2022 The presence of visible tonsils in an adult or later teen can be a marker for chronic airborne allergies.\u00a0 Other signs of chronic airborne allergies include the \u201cnasal salute\u201d (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.
\nALLERGIES
\n\u2022 Hypertonic saline flushes for congested noses.\u00a0 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.\u00a0 This will do that.
\n\u2022 Have a child blow up a balloon or hold the nose of a baby while it swallows to \u201cpop\u201d the ears.
\n\u2022 Use nasal strips (like the athletes) at night to decrease nasal stuffiness.
\n\u2022 Afrin\u00ae nasal spray or another local decongestant can help open Eustachian tubes in otitis media.\u00a0 Use less than 5 days duration to prevent a rebound phenomenon.
\n\u2022 Simply Saline (TM) is an OTC product that is a preservative-free nasal spray.\u00a0 It can be used to moisturize the nose without irritation caused by preservatives.
\n\u2022 Before nasal steroid sprays became available, one could use a regular steroid asthma inhaler for nasal purposes.\u00a0 Cover the mouthpiece of the inhaler with a rubber (not silicone) baby bottle nipple.\u00a0 Cut a small hole in the tip of the nipple with scissors.\u00a0 The nipple directs the flow up the nose.\u00a0 This can still be used if you want a \u201cpowered\u201d nasal sprayer.
\nANTIHISTAMINE TOLERANCE
\n\u2022 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.\u00a0 With the older antihistamines, alternating monthly is preferable.\u00a0 After a \u201cvacation\u201d from the medication, it seems to be effective again.
\nSINUS CONGESTION
\n\u2022 For chronic sinus congestion, try a mucolytic agent or a protein digesting enzyme to liquefy secretions and promote drainage (proteolytic, papaya juice, Humibid\u00ae).
\nPHARYNGITIS
\n\u2022 Have patients gargle with warm water instead of salt water.\u00a0 Warm water can soothe, salt water can irritate.
\n\u2022 Smell strep throat in patients.\u00a0 It has a distinctive, somewhat fetid odor that can aid in diagnosis.
\nTHROAT EXAM
\n\u2022 Have the patient pant like a dog when taking a throat culture.\u00a0 This will avoid the gag reflex.
\n\u2022 For children 8 months to 2 years of age, have the parent tip the child\u2019s head back while seated on the parent\u2019s lap with the back to the parent.\u00a0 The child usually then opens the mouth wide.
\n\u2022 Instead of having the patient say \u201caah\u201d, have them take a big deep breath through their mouth to open up the posterior pharynx.\u00a0 Having them stick their tongues out brings the \u201cgaggy\u201d part of the tongue forward where you\u2019re almost guaranteed to touch it with a tongue blade.
\nTEMPORALMANDIBULAR JOINT SYMPTOMS
\n\u2022 One cause of TMJ symptoms is malocclusion of the bite.\u00a0 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.\u00a0 Over time, this can lead to inflammation of the joint or surrounding muscle from overuse.\u00a0 To check for malocclusion, have the patient open their mouth.\u00a0 Lay a tongue blade flat along the surface of the lower teeth on either side.\u00a0 Have the patient bite down to lightly hold the tongue blades.\u00a0 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.
\nPRURITIS OF THE EAR CANAL
\n\u2022 Use mineral oil drops. Volsol HC\u00ae contains acetic acid and hydrocortisone can treat eczema of the canal.
\nNOSE BLEEDS
\n\u2022 In adults, frequent nose bleeds can be prevented by applied estrogen cream to the nares and septum 2-3 times a day.\u00a0 This can also be used for atrophic rhinitis.
\n\u2022 There can be pathology in most patients\u2019 noses.\u00a0 You can use an otoscope with a large ear speculum to examine the inside of the nose.\u00a0 Cover the insufflation hole with the pad of the index finger to prevent fogging of the lens.
\nCONJUNCTIVITIS
\n\u2022 Place wet tea bags on closed eyes to take away the sting of conjunctivitis.
\n\u2022 For children with viral conjunctivitis, use baby shampoo, 1 teaspoon in a cup of water, as drops for treatment instead of antibiotic eye drops.
\nEYE DROPS
\n\u2022 Gently pinch the lower eyelid and pull it forward to form a \u201cpocket\u201d for easy instillation of eye
\ndrops.
\nFOREIGN BODY IN THE EYE
\n\u2022 Using a cotton swab, always evert the upper lid to do a complete survey of the eye for a foreign
\nbody.
\nCHALAZIONS AND STYES
\n\u2022 Use a hard boiled egg for moist heat. An egg is the perfect shape to fit under the orbital rim.
\n<\/a>
\nELDERLY<\/strong><\/span>
\nWEIGHT LOSS IN THE ELDERLY
\n\u2022 Poor digestion, poor absorption, and a sluggish gut may occur in the elderly which leads to weight loss, anemia, weakness, etc.\u00a0 Absorption may be aided using Entozyme\u00ae, Phazyme\u00ae, and extra bulk.\u00a0 Don\u2019t forget to check dentition.
\nNUTRITIONAL DEFICIENCIES
\n\u2022 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.\u00a0 Pellagra gives diarrhea, dementia, and dermatitis.\u00a0 Scurvy may present with petechaie and dementia.
\nCHRONIC CONSTIPATION IN THE ELDERLY
\n\u2022 The elderly seem to like routines. Suggest they drink a tumbler full of warm water each morning upon rising from bed.\u00a0 Then they should eat breakfast, then sit on the toilet for a full 20 minutes.\u00a0 Stool softeners or fiber agents may also be added. By the third day, they usually have become regular.
\nTHYROID DISEASE IN THE ELDERLY
\n\u2022 Atrial fibrillation can be the first sign of hyperthyroidism, especially in the elderly.
\nGERIATRICS
\n\u2022 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.\u00a0 Stop adding medications if you are unsure.\u00a0 Use a trial of decreasing medications.
\n\u2022 Geriatric patients seem more compliant and don\u2019t smoke as much as other populations.\u00a0 Those people all died out.
\n\u2022 If a patient has Alzheimer\u2019s and develops delerium, look for a UTI, even a low grade one.
\n\u2022 In patients with a poor appetite, find and use their comfort food.\u00a0 Give up on nutrition and go for
\ncalories.
\n\u2022 If a patient develops a poor appetite, check the digitalis level.
\n\u2022 Get a sitter or a family member to stay with an elderly patient in the hospital to avoid falls especially with \u201csundowner\u201d syndrome.
\n\u2022 Approach every visit with an elderly patient as an opportunity to learn about integrity, honor, and pride.
\nNURSING HOME CARE
\n\u2022 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.
\nGET UP AND GO TEST
\n\u2022 Patients should be able to get up out of a chair and walk 10 feet in less than 10 seconds.\u00a0 This correlates well with ability to do activities of daily living and indirect activities of daily living.\u00a0 It assesses function and neuro status.
\n\u2022 A quick get up and go test is watching the patient get out of the chair and onto the exam table.
\nDEHYDRATION IN THE ELDERLY
\n\u2022 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.
\n<\/a>
\nPHILOSOPHY OF PRACTICING FAMILY MEDICINE<\/strong><\/span>
\n\u2022 The essence of Family Medicine is follow up.
\n\u2022 Medicine is mostly pattern recognition. Listen to the patient and observe over time.
\n\u2022 The patient is giving their interpretation or belief of the facts.\u00a0 They may misinterpret key clues.
\n\u2022 Give 100% of yourself to the patient in front of you, without thinking of the next few patients.
\n\u2022 On hospital rounds, sit down for good eye contact and be at the same level as the patient.
\n\u2022 On morning hospital rounds, see chronic and dying patients first, ending with patients who are improving and doing well.\u00a0 This puts you in a better frame of mind to start the office day.
\n\u2022 Don\u2019t look into the waiting room and be overwhelmed by the number waiting.\u00a0 You can only see patients one at a time anyway.
\n\u2022 Don\u2019t look ahead on the schedule and start dreading a certain patient before their time.
\n\u2022 Remember, it\u2019s the patient\u2019s problem.
\n\u2022 Learn how to appear unhurried.\u00a0 Your body language gives it away.
\n\u2022 Leave the patient knowing you\u2019ll be thinking of them until the next visit.
\n\u2022 Have the attitude of \u201cthere you are\u201d instead of \u201chere I am\u201d.
\n\u2022 Don\u2019t use your bedside manner all up in the hospital and office, save some for home.
\n\u2022 You can say no.
\n\u2022 Don\u2019t be afraid to ask for help.
\n\u2022 The science of medicine deals with how people are alike, the art of medicine deals with how they are different.
\n\u2022 The doctor patient relationship is like a rowboat with each having an oar. If only one is rowing, the boat just goes in circles.\u00a0 Be careful you don\u2019t take both oars.
\n\u2022 You are not God.
\n\u2022 Doctors tend to remember the bad results and dismiss the good.
\n\u2022 Smile – be happy to see the patient, they\u2019re worried.
\n\u2022 Don\u2019t be afraid to apologize.
\n\u2022 Let the patient, not the relatives, do the talking.
\n\u2022 A good history is far superior to the best MRI.
\n\u2022 Be honest but not cruel.
\n\u2022 Explain in simple terms. Patients are not ignorant, but they don\u2019t know the medical language.
\n\u2022 When in doubt, see and examine the patient.
\n\u2022 Call the patient yourself with significant test results.
\n\u2022 Don\u2019t appear to rush, even if you are rushing.
\n\u2022 Patients are your friends who are putting their trust in you.
\n\u2022 Put personal notes about patients in the margins of the chart \u2013 anniversaries, names of pets, significant events in their children\u2019s life, phonetically spelled name, etc.
\n\u2022 Each patient is a person, not just an illness.
\n\u2022 When a patient dies, it doesn\u2019t mean you\u2019ve failed.
\n\u2022 It\u2019s acceptable to go to a funeral if convenient.
\n\u2022 Have patients on multiple medications bring in their medications for review and completeness.
\n\u2022 Write the plan for pediatric patients – a crying baby distracts a parent from hearing your instructions.
\n\u2022 Medicine and golf \u2013 the two most humbling experiences possible.
\n\u2022 A good doctor is worth their weight in gold \u2013 so is a good plumber.
\n\u2022 What you learn today may be proven wrong tomorrow.\u00a0 Use it anyway \u2013 it may be proven again to be right the day after tomorrow.
\n\u2022 Medicine is a cruel mistress \u2013 balance your time and life.
\n\u2022 Get to know the person who has the disease before you become the adversary of the disease.
\n\u2022 Apologize when you\u2019re late, this diffuses anger.
\n\u2022 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 \u2013 \u201cthis patient states that they were ill and missed work on . . . My examination today reveals an individual who may return to work.\u201d
\n\u2022 When you are called to the hospital to pronounce a patient you don\u2019t know personally, take the head nurse and the chaplain in with you to talk to the family.\u00a0 They can help comfort the patient and explain the events prior to death.
\n\u2022 Most pediatric visits are really parentriatics.
\n\u2022 Walk with your patient toward the waiting room.\u00a0 This extends the visit, allows for social time,
\nand moves the patient towards the check out desk.
\n\u2022 Appropriate humor helps the patient to see the physician as human.
\n\u2022 Have the patient schedule a follow up appointment as they leave the office.\u00a0 They can cancel if it isn\u2019t needed, but this removes the worry of when a follow up is needed, protects the doctor\u2019s time in the schedule, and gives a caring message to the patient.
\n\u2022 Always ask the patient, \u201cwhat about this problem worries you the most?\u201d and, \u201cwhat do you think this could be?\u201d.
\n\u2022 Construct a genogram on all patients and look for patterns.
\n\u2022 If a patient is succeeding, ask what helped them succeed and then use this with other patients.
\n\u2022 Don\u2019t be afraid to say, \u201cI don\u2019t know what\u2019s wrong\u201d.\u00a0 Honesty is the best policy.
\n\u2022 Make the patient feel that you have all the time in the world for them and that nothing else matters but them.
\n\u2022 Don\u2019t go into a pelvic exam with the patient already lying down.\u00a0 This puts them into even more of a powerless position.
\n\u2022 If you show kindness and concern, you\u2019ll receive the same.
\n\u2022 Let the patient talk uninterrupted for at least the first minute to allow the patient to get their story out.
\n\u2022 Think of taking a history using a metaphor of a lens.\u00a0 If it is focused too closely, things may be missed. You may need to use a wide-angle lens.\u00a0 If the wide-angle lens is gaining too much scattered information, a close up lens may be necessary.
\n\u2022 If what you\u2019re doing isn\u2019t working, try the opposite (sometimes you need to determine what the opposite is) especially when questioning the patient or giving patient education.
\n\u2022 Use the phrase \u201cI need your help\u201d to empower the patient or family and enlist the patient as a partner.
\n\u2022 Don\u2019t let a pill be the measure of your empathy.\u00a0 Sometimes a prescription is not the answer.
\n\u2022 Have a location in the practice that is your \u201cquiet place\u201d \u2013 listen to music, rest, make peace.
\n\u2022 Remember (or write notes in the margins of the chart) about personal and family information and ask about this at each visit.
\n\u2022 Don\u2019t believe any blood pressure reading but the one you took yourself.
\n\u2022 See every patient as an opportunity to learn new techniques or patterns or to improve yourself.
\n\u2022 Take the effort to get to know the patient as a person.
\n\u2022 Everyone deserves the basic respect of a human being.
\n\u2022 Talk to the patient, not at the patient.
\n\u2022 Always ask about exposure to violence.\u00a0 You will be continually surprised by what you hear.
\n\u2022 Have patients repeat what they\u2019ve heard you tell them.
\n\u2022 If you have a \u201cfeeling\u201d something is wrong then it probably is.\u00a0 Listen to your \u201cgut\u201d.
\n\u2022 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.\u00a0 You are lending your Doctor-Patient relationship to the consultant.
\n\u2022 Do a quick review of systems at each visit.\u00a0 This will pick up problems the patient may not think is important enough to mention.
\n\u2022 When examining any rash, look at the entire body\u2019s skin surface.
\n\u2022 The best lab test is a follow up visit.
\n\u2022 With patients who react to \u201ceverything\u201d, try herbal or \u201cnatural\u201d remedies.
\n\u2022 Have the patient bring in to the office every medication, herbal remedy, or OTC they\u2019re taking.
\n\u2022 Make sure all diabetics take their shoes off every visit (and examine their feet).
\n\u2022 When dealing with a \u201cdifficult\u201d patient, especially a personality disorder, get to know their past and social lives in order to help understand them and their reactions.
\n\u2022 Never assume the patient is telling the entire story.\u00a0 Watch the wording.
\n\u2022 Always be honest with your patient and yourself.
\n\u2022 Know yourself. Understand your assumptions, fears and biases before seeing patients, and understand how that colors your thinking.
\n\u2022 When dealing with mentally retarded\/developmentally-delayed patients, lose all pretenses and don\u2019t be afraid of them.
\n\u2022 The staff\u2019s job is to help the patient, not shield the doctor.
\n\u2022 Service to the patient is the best business strategy.
\n\u2022 Make sure the doctors and the nurses are available to the patients.
\n\u2022 When you are with a patient, you must be there attentively and psychologically.
\n\u2022 Always be at the office before the first patient, if you start late, you will be behind.
\n\u2022 Try to do routine prescriptions and call backs between patient visits so you don\u2019t \u201cdump\u201d a lot of work on your staff at the end of the day.
\n\u2022 Don\u2019t sit down between patients. It is harder to get up than to move while standing.
\n\u2022 Individualize any patient education handout you give a patient.
\n\u2022 If you don\u2019t know why the patient is here today, ask \u2013 and keep asking until you understand.\u00a0 Try to find out their expectations in the first minute.
\n\u2022 Nonverbals are much more important than verbals.
\n\u2022 Find out the patient\u2019s name, or more importantly, what they want to be called.\u00a0 This is the patient\u2019s identity.
\n\u2022 Any phone call that takes more than two minutes should be an office visit.
\n\u2022 Draw the patient explanation in the chart for reference at a later date or proof if ever necessary.
\n\u2022 When it is obvious that a relationship with a new patient is not going to work, realize it quickly, end the encounter, but don\u2019t charge the patient.
\n\u2022 If a child is present at a delivery, the child needs a coach too.
\n\u2022 The most important information you\u2019ll ever need is the knowledge of what you don\u2019t know and what you can\u2019t do.\u00a0 Know yourself and your limits.
\n\u2022 Some patients are slow processors.\u00a0 Never mistake slowness for lack of intelligence.
\n\u2022 When a patient transfers care to you, find out how often the former doctor saw them, what that doctor did \u201ccorrectly\u201d and what was done \u201cincorrectly\u201d.
\n\u2022 Remember social histories.\u00a0 Patients will be amazed that you remember their job, children, etc. and be impressed that you care about them as a person.
\n\u2022 If you\u2019re concerned about a patient, call them that night.\u00a0 This demonstrates caring, shows patients that we worry about them, and allows for reinforcement of the treatment plan.
\n\u2022 It is enjoyable to work where you live.\u00a0 Patients see you in non-threatening, non-clinical settings and can better accept you as a person.\u00a0 You can see patients in non-clinical settings which may change your attitude and approach to that patient in the office.
\n\u2022 Never assume the patient is taking the medication.
\n\u2022 The patient is not always completely honestly answering your questions, especially about sex or abuse.
\n\u2022 Do a mini mental status on elderly patients, their appearance can fool you.
\n\u2022 You never learn anything by talking. Listen to the patient.
\n\u2022 If you listen to the patient long enough, they will tell their whole story.
\n\u2022 Be sure to give each patient enough time. At some point, increasing the number of patients per hour will decrease quality of care.
\n\u2022 For good time management, ask the patient to prioritize their most important issues at the
\nbeginning of the visit.
\n\u2022 Let the patient determine the appropriateness of humor.\u00a0 They might not think what you do or say is funny or can misinterpret your actions.
\n\u2022 Never laugh at your patients, only with them.
\n\u2022 Explore your patient\u2019s explanation of their symptoms, what the symptoms mean to them personally, and what they think could get rid of their symptoms.
\n\u2022 When a child reaches 12 years of age, explain confidentiality to the patient and parents.\u00a0 The parents will need to leave the room for at least part of every visit.\u00a0 It helps when the child hears the parents agree to this.
\n\u2022 Talk directly to children.\u00a0 Be calm, quiet, and treat them with respect.\u00a0 Look them in the eye at their level.
\n\u2022 At some point during the visit, appropriately touch the patient.
\n\u2022 When all else has failed, stop all medications and start again, especially in elderly patients.
\n\u2022 A good carotid pulse means no significant aortic stenosis.
\n\u2022 Don\u2019t tick off the nurses or staff.
\n\u2022 Keep your resident, consultant, partner informed.
\n\u2022 When on call, don\u2019t stand when you could sit and don\u2019t sit when you could lie down.
\n\u2022 Give patients permission to call you at home if they\u2019re very sick.\u00a0 They will rarely abuse this privilege, but will greatly appreciate it.
\n\u2022 Carry 3 x 5 cards with you to write down who needs to be called for close follow up.
\n\u2022 Asking \u201cwho lives in your household\u201d will usually get you relationship information without having to ask embarrassing questions.
\n\u2022 On physical exam, start away from the area that hurts and work your way to it.
\n\u2022 Appropriate self-disclosure to patients (eg: own LBP or colonoscopy) can display empathy, experience, and connectedness.
\n\u2022 It\u2019s ok to begin the visit with social chit-chat if you know the patient.
\n\u2022 Don\u2019t make assumptions about older patients\u2019 cognitive abilities – get specifics and dates.
\n\u2022 Treat your patients as you would want your family members treated.
\n\u2022 Don\u2019t be the first or last doctor to use a specific medication.
\n\u2022 People feel better when they smile or laugh with you.
\n\u2022 Invest time in a relationship, especially when it is needed.
\n\u2022 It is easier with children to examine whatever part is pointed at you first.
\n\u2022 If the visit is going long, do parts of the physical as you\u2019re taking the history.
\n\u2022 If you are having trouble \u201cbonding\u201d with a patient, try to find something you can like about them; something about which you can honestly and genuinely say something positive.
\n\u2022 Ask the patient, \u201cwhat makes this worse or better?\u201d and, \u201cwhat is causing this\/concerns you about this?\u201d.\u00a0 If they have no answers to these questions, then a simple physical diagnosis is unlikely.\u00a0 Save time and move \u201csideways\u201d.\u00a0 Try to get to know who this person is by inquiring about context and social history.
\n\u2022 Persistence and tenaciousness are usually good qualities, but you have to know when to let go.
\n\u2022 In these days of relating to computers and speaking through interpreters, appropriate touching can break down barriers.
\n\u2022 Keep a pad of Post-It (TM) notes in your examining room to make notes and reminders to yourself
\nthat can be placed in the chart.
\n\u2022 Keep a quarter sheet size note pad with the practice\u2019s name on it in each exam room to write down your advice to patients so they\u2019ll have something in hand when they leave.
\n\u2022 \u201cHuddle up\u201d with the nurses and staff at the beginning of the schedule to plan personnel and time needs of the session.
\n\u2022 Observe the body language of the person who is attending the patient, they may have an agenda of their own (cuts down on triangulation, \u201cby the ways,\u201d and calls before or after the visit).
\n\u2022 The caregivers are part of your care and may need you more than the patient.
\n\u2022 It\u2019s just as important to help patients have a \u201cgood death\u201d as it is to help patients have a \u201cgood delivery\u201d.
\n\u2022 Document on the lab slip or report the date you read it and what action was taken (filed, patient called, letter sent, etc.).
\n\u2022 Take at least a few seconds prior to going into a patient\u2019s room to refocus from the last patient and to update yourself on this patient\u2019s life and issues.
\n\u2022 If you are concerned about a patient you have sent to a consultant, call the patient even before the results or consultant\u2019s letter are back to see how things went and how the patient is doing.
\n\u2022 Spend time wisely on things that will make a difference in the patient\u2019s life or illness and less time on the unproductive areas of the physical exam that won\u2019t make a difference anyway.
\n\u2022 During a well baby check, always find something about which you can compliment the mother.
\n\u2022 Learn the value of silence – the patient is thinking, let them process.
\n\u2022 If you allow the patient to talk, they will tell you things you wouldn\u2019t have thought to ask.
\n\u2022 The patient didn\u2019t read the book, their symptoms may not be classic.
\n\u2022 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.
\n\u2022 Even if you are in a hurry, move slowly when examining babies and small children.
\n\u2022 If a patient has a need to be seen frequently, just schedule them regularly instead of having them call for \u201cemergency\u201d appointment.\u00a0 It will save time in the long run.
\n\u2022 If you do not have nearly instant hot water available in all exam rooms, invest in a hot water recirculation system.\u00a0 This brings hot water past all faucets in the office for instant hot water for hand washing and warming pelvic exam specula.
\n\u2022 If you are feeling distracted during a patient interview, look at the patient\u2019s eyes and note the color of their eyes. The patient interprets this as good eye contact.
\n\u2022 Don\u2019t dwell on the 1% of bad things that happen in the office but on the 99% of enjoyable interactions.
\n\u2022 Virtually no patient comes to the office for a \u201ccomplete checkup\u201d.\u00a0 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.\u00a0 Save time by finding out why they\u2019re really there instead of finding out as a \u201cby the way\u201d after you\u2019ve done a full physical.
\n\u2022 Virtually all patients who describe \u201cnot being able to get a full breath\u201d have anxiety as the cause.
\n<\/a><\/p>\n","protected":false},"excerpt":{"rendered":"

FORWARD This section is a collection of clinical pearls, \u201ctricks of the trade\u201d, and words of wisdom from experienced Family Physicians.\u00a0 Individual doctors interviewed for…<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"open","ping_status":"closed","template":"","meta":{"_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"footnotes":""},"class_list":["post-56","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/wisdomoftheageds.info\/index.php\/wp-json\/wp\/v2\/pages\/56","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/wisdomoftheageds.info\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/wisdomoftheageds.info\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/wisdomoftheageds.info\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/wisdomoftheageds.info\/index.php\/wp-json\/wp\/v2\/comments?post=56"}],"version-history":[{"count":28,"href":"https:\/\/wisdomoftheageds.info\/index.php\/wp-json\/wp\/v2\/pages\/56\/revisions"}],"predecessor-version":[{"id":156,"href":"https:\/\/wisdomoftheageds.info\/index.php\/wp-json\/wp\/v2\/pages\/56\/revisions\/156"}],"wp:attachment":[{"href":"https:\/\/wisdomoftheageds.info\/index.php\/wp-json\/wp\/v2\/media?parent=56"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}