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Showing posts from 2018

When to Use Urgent Care

We all know that Emergency Departments are over-crowded with long waits and exorbitant fees.  Free standing Urgent Care is a great solution for getting immediate care that won't break the bank.
Most are open after hours and on weekends and they provide a good and needed service for urgent small problems.

The key word here is "Small".  Or said another way; "Minor".   Most Urgent Care facilities are staffed by one or two nurses.  They can provide minimal immediate testing and sometimes a quick Xray.  They work with protocols to treat simple problems.  They can give immunizations and do rapid strept tests.  They can check urine for pregnancy or infection.  They can treat a new cough. They can remove splinters, tape a broken toe and treat a rash.  These are minor problems for most people and do not need to be seen in an Emergency Department.  The best place is your doctor's office but Urgent Care is a good alternative.

It's hard to know what is "minor…

Nutty Thanksgiving ICD-10 Codes

Ahhh, the things doctors have to go through to get paid by insurance companies and Medicare. Every patient encounter has to have a diagnosis code for each problem or procedure.  The book of codes is larger than a huge phonebook. ( Note:  I do understand that readers under age 30 may not have ever seen a phonebook but use your imagination - it's thick and big)

Here are a few of the wacky codes we are required to use for these conditions. Please don't ask me who thought these up:

W61.43 - Pecked by a turkey.  (Who knew they were so dangerous?  Another reason to go Vegan?) W60.0   - Contact with sharp leaves. (That leaf pile will decompose naturally so be safe. No need to rake) Y92.72  - Place of occurrence-chicken coop. (Yes we also have to show where the injury occurred) Y91.71  - Place of occurrence- barn.  (Please make it stop...) Z63.1    - Problems in relationships with in-laws (This will be a common one this season) Y93.E2 - Injury due to activity-laundry (Women, protect yourse…

Ruptured Plantar Fascia

Many people have experienced plantar fasciitis.  It is a painful bottom (plantar surface) of the foot that often comes on after athletic exercise, prolonged hiking or running or just for no reason at all.
The plantar fascia is a band of tissue that connects the heel bone to the toes.  This wide ligament covers the entire bottom of the foot and acts like a elastic band under the arch and helps absorb shock when you walk.  Inflammation and tiny micro tears are the culprit in plantar fasciitis.  Most patients can diagnose it themselves and it rarely needs imaging or any special tests.

Ruptured plantar fascia is relatively rare and the snap occurs suddenly, usually with exercise.  The force of jumping or stepping can cause a tear that causes sudden pain and inability to bear weight on that foot.  The injured athlete often feels a "pop" when the fascia snaps.  Within 24 hours the blood from the tear forms a bruise on the bottom of the foot.

So what should be done for a torn plan…

Tick Paralysis

We spotted a Coyote in our backyard, laying near some outdoor lawn chairs.  When we approached she did not jump up and run, as would be expected, but attempted to crawl up the side of the yard.  She was clearly unable to walk and did not respond like a wild animal would.

We called our local wildlife rescue (www.discoverwildcare.org) and they immediately responded, threw a sheet over the animal to keep her calm and took her to the rescue facility.  A vet examined her and found she was a young female and was covered in ticks.  Tests were done and the diagnosis was Tick Paralysis.

Tick Paralysis rarely affects humans but it is well known in dogs, sheep, horses, pigs and other animals when a feeding tick produces a neurotoxin. It is most common in the Spring from April to June. The toxin travels through the lymph system and can affect respiration, vocal cords, limbs and results in inability to walk.  It is fatal, usually due to respiratory failure.

The incidence in humans is unknown and…

Preventing Skin Cancer

Spring is here and that means sun.  Who doesn't like the feeling of sun shining down on a warm day, especially after a gloomy, cold winter.  But skin cancer incidence is rising worldwide and we must protect from too much sun exposure.

Skin cancer is the most common type of cancer.  We break skin cancer into two major types; melanoma and non-melanoma.  Melanoma is the least common (2%) but is responsible for the most skin cancer deaths (80%).  The non-melanoma cancers are squamous cell and basal cell and it is rare for them to cause death.  All of these types are linked to sun exposure.  Here is what the evidence shows for skin cancers:

1. Sun Exposure: All skin cancers are linked to increased total and recreational sun exposure.  The more sun exposure, the more risk.  Avoiding midday exposure when the sun is strongest, especially in children, is advised but there are no studies that look at this exposure by itself.

2. Indoor Tanning: Evidence shows indoor tanning is associated wi…

Rural Nurse Diagnoses and Treats His Own Heart Attack

Here is a remarkable feel good story as reported in the letters section of The New England Journal of Medicine. 

A 44 year old male nurse was working alone in a rural part of Western Australia when he developed severe chest pain and dizziness.  He knew these were symptoms of a heart attack and he was over 90 miles from the nearest medical facility and 600 miles from Perth, where advanced care could be obtained.  He got an EKG on himself and sent it electronically through the Western Australian Department of Health which was started in 2012 for rural community practitioners.

Sure enough, the electronic read came back and showed he was in the middle of a massive myocardial infarction (MI).  Did he panic?  Hell no!
This remarkable nurse proceeded to chew an aspirin, take sublingual nitroglycerine and start an IV on himself.  He administered the right drugs; intravenous heparin, opiates and another blood thinner called clopidogrel. He got him self ready for thrombolysis and received this…

Rectal Exam-Is it Needed?

Medical practice is constantly changing and this is a good thing.  As evidence comes forth, we change how we care for patients to ensure "evidence-based" quality. We no longer bleed patients or deliver caustic enemas.  We understand that ulcers are the result of H pylori bacteria and that autism is not caused by bad mothering.  It took 20 years for hand washing to be accepted for infection control after Ignaz Semmelweis made the connection of why 1/3 of hospitalized women died after childbirth in 1850.

Our newest evidence is that digital rectal exams (DRE) looking for prostate cancer in men is probably not effective for diagnosis.  In fact is might even be harmful if it leads to biopsies and further studies.

As an Internist, I was trained that a digital rectal exam (DRE) was needed and essential for every male physical exam after the age of 40.  And my male patients have come to expect it.  The March-April issue of Annals of Family Medicine reports that in 7 studies with 92…

Internal Medicine Needed for Future

It's almost Spring and that means the "Match" has occurred for medical school doctors-to-be.  As American med students go through their four years of post-graduate training, they try to decide what type of doctor they want to be for the rest of their career.  Many things factor into this decision.
How were they treated on specialty rotation? Did they have a mentor? What do they know about the life-style and future earnings of that specialty? How much debt do they carry? And finally, what is intriguing and interesting about that line of work.  Once that decision is made, they apply for residency positions around the country.

I am a comprehensive Internal Medicine doctor, (now known as PCP), so I've always been interested in the fact that we need more physicians to work in primary care to care for the aging baby boomers and complexity of population growth and changes in medicine. Unfortunately, we are far from keeping up with the need.

In the 2018 Match, only 374 prim…

Brain Food

Isn't it interesting how much cauliflower looks like a brain?

Want to Lose Weight? Understand Calories

The United States is facing an obesity "epidemic" and the interest in the perfect diet for weight loss has never been higher.  Low-carb, low-carb-high-fat, HCG, Mediterranean, Paleo, anti-inflammatory diets each have their own champions and doctors who swear this is the final answer to losing weight.  Each week there is a new medical analysis on mainstream news that touts the effectiveness of a certain weight loss diet. This week it is the low-carb-high-fat ketogenic diet.  Maybe it suppresses hunger.  Maybe it's the diuretic effect and rapid weight loss in the first week.  Maybe it reduces insulin secretion. But maybe it is really because people have reduced their caloric intake.

Here's a fact: all diets work when people reduce their caloric intake.  
The various well-known diets all result in similar weight loss if the individual sticks to the diet.  Each diet reduces calories.  And when the diet is over, if the calorie count goes back up...weight is regained.

An …