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Patient Handout: Common Wintertime Illnesses

The following was posted in my exam rooms today.  Feel free to copy/distribute it.

Upper Respiratory Infection

  • Symptoms:  Stuffy/runny nose, cough, sneezing, sore/scratchy throat, fever
  • Cause:  Viruses - Can happen any time of the year
  • Course: Lasts for 3-7 days
  • Treatment (Over 2 years of age)
    • Decongestants (Pseudoephedrine, phenylephrine)
    • Cough suppressants
    • Tylenol/Ibuprofen
    • Mucinex to loosen phlegm
    • Antibiotics do not help an upper respiratory infection.
  • Contagiousness: Viruses are transmitted through direct contact with someone who is carrying the virus.  Washing hands is the best way to prevent spread.

Sinus Infection

  • Symptoms:  Pressure/pain on the cheeks below the eyes and/or on the forehead immediately above the eyes upper teeth hurting, nasal congestion, fever and sore throat.
  • Cause:  Bacteria or Viruses - The sinuses are filled with mucous when a person gets an upper respiratory infection or has bad allergies, and the symptoms of sinusitis are not uncommon in this case.  If the fluid becomes infected with a bacteria, the fluid becomes thicker, and the pain can become more intense.
  • Course: If viral, will go away within a week.  If bacterial, will take longer.
  • Treatment
    • Decongestants (Pseudoephedrine, phenylephrine)
    • Antihistamines can thicken the phlegm, so can make things worse.
    • Over the counter nasal sprays (Afrin, etc) can help, but should never be used for more than 5 consecutive days.
    • Mucinex to loosen phlegm
    • Saline rinses of the nasal passages can loosen phlegm
    • Prescription nasal sprays like Flonase can help; they can also prevent sinus infections in people who are prone to it.
    • Antibiotic use is debatable (although it is standard practice).  Many studies show that the addition of antibiotics to the above treatments does not speed up improvement.  If an antibiotic is prescribed, we strongly prefer to wait until symptoms have been there for 1 week and the other treatments have been tried.  We do not give antibiotics “just to be on the safe side,” or “because it always turns into a sinus infection.”  This is the type of prescribing that has caused antibiotic resistance to occur.
  • Contagiousness:  The viruses that cause sinus infections have similar contagiousness to the upper respiratory infection.  The bacteria infection is not contagious.

Bronchitis

  • Symptoms:  Persistent loose cough
  • Cause:  Viruses are the most likely cause of bronchitis, not bacteria (as is widely thought).
  • Course: Viral bronchitis lasts for 3-7 days
  • Treatment
    • Humidifier
    • Cough suppressants
    • Mucinex to loosen phlegm
    • Antibiotics do not help viral bronchitis.  We strongly prefer to not treat bronchitis with an antibiotic until the symptoms have been there over a week.  We will use them sooner to people who have chronic lung problems or are particularly frail.  If it lasts over a week, the likelihood it is bacterial is much higher, so an antibiotic may help.
  • Contagiousness: The viruses and bacteria that cause bronchitis have similar contagiousness to upper respiratory infections, although some are more prone to become airborne (because of the coughing).

Influenza

  • Symptoms:  High fever, body aches, and headaches are the hallmark symptoms of flu.  The patient also can have cough, upper respiratory symptoms and mild intestinal tract symptoms.  The fever tends to run higher than with other infections (102-105 range).   People who have influenza look like they’ve been hit by a truck.
  • Cause:  Influenza virus - there are two types, A and B - A being more serious.  This occurs between December and April - usually in January through March, and it occurs in epidemics.
  • Course: Lasts for 5-7 days
  • Treatment
    • Ibuprofen/Tylenol for body aches and fever.
    • Symptomatic treatment of other symptoms (Medications like Thera-Flu can help).
    • Rest and lots of fluids.
    • There are anti-viral medications for influenza, but these are reserved for people with Influenza A who are at increased risk of complications (the very old or very young, and people with lung or heart problems).
  • Complications - Influenza is a very dangerous infection for people who are at risk (infants and elderly).  The major complication is pneumonia caused by the Staph bacteria.  If someone is diagnosed with influenza and develops the symptoms of pneumonia (productive cough and shortness of breath), they need to see the doctor immediately and are generally hospitalized.
  • Contagiousness - Flu is very contagious during epidemics.  Hand washing can help, but the best preventive measure is to get an influenza vaccine in the fall.  Even if the strain of influenza is not the one in the vaccine, people who get a flu shot are less likely to have a serious case.

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Patient Handout: Immunizations

I suppose this will get me into hot water with the anti-vaccine crowd, but discussing the pros/cons of vaccines is a daily task for me.  I spend a lot of time convincing people that vaccines are safe.  So, to save myself time, I made a handout for this purpose. Let me just say that I would rather not jump headlong into the debate.  This topic has been covered ad nauseum on various places on the Internet.  The points I make in this post are what I see as being the best scientific information.  Be that as it may, I suspect this post will attract the usual opposition.

Sigh.  I guess I am diving into the mix.  Oh well.

Here goes nothing:

**********************************************

Immunization Questions and Answers

A lot of our patients have heard a lot of things about immunizations, some of them very frightening. Here are some answers to some common questions.

Are Immunizations Safe?

There is no way that we would ever recommend giving something unsafe to children we care for. All immunizations have been studied extensively by many researchers and even small questions about their safety are passed on to us. We feel that there is no compelling evidence at this time that any of the immunizations we give are unsafe.

How sure are you about this safety?

All of the doctors and staff in our office who have children have given them the appropriate immunizations. Do you think we would take unnecessary risks with our children?

What about the risk of autism?

Despite evidence to the contrary, there continues to be people who insist that immunizations increase the risk of autism. The rate of autism has been rising over the past number of years, but the criteria for making the diagnosis have been changed significantly. What we would not have called autism in the past is being labeled as mild autism. Unfortunately, some people are very vocal about opinions that are not informed by the evidence.

What about the stories about children that make it sound like immunizations cause autism?

This type of evidence is called anecdotal evidence. While this type of evidence is not useless, it takes much better evidence to prove something. Here is how anecdotal evidence can lead to wrong conclusions: if a person gets an antibiotic for a virus infection and then gets better, it does not mean the antibiotic made the infection go away. The person simply got better on their own, and would have done so with or without the antibiotic. In the same way, development of autism after immunizations are given does not prove anything. The fact is, children develop autism right around the age that immunizations are given. It would be equally valid to say that baby food causes autism.

Does Mercury play a role?

Thimerosal is a mercury-containing preservative that used to be added to immunizations. Since the symptoms of autism are similar to that of mercury poisoning, some have suggested that this is what caused some cases of autism. But since thimerosal was removed from vaccines (due to public worry), there has been absolutely no change in the incidence of autism in the US. None of our childhood vaccines contain thimerosal.

What about “herd immunity?”

Herd immunity is the protection that un-immunized children get from the fact that the rest of the population is immunized. While this does confer some protection, with the public fears causing an increasing number of people to decline immunizations, there has been an increase in diseases protected by immunizations (such as measles). Even if protection holds during childhood, the un-immunized person is subsequently at risk of developing the disease as an adult – and many of these diseases are far worse to get as an adult than as a child.

Can I just wait until my child gets older to immunize them?

Since we don’t think there is any danger with the vaccines, we don’t recommend putting them off. At a minimum, however, we strongly urge parents to give their children vaccines for diseases that could cause harm in infancy, including:

  • Prevnar – protects against meningitis and other infections in childhood. Even gives some protection against ear infections.
  • HIB – also protects against meningitis and other infections of childhood.
  • Rotavirus vaccine – this is a vaccine against a common form of diarrhea in young infants. Rotavirus causes many hospitalizations and some deaths.

What about the new Meningitis Vaccine?

The new vaccine against meninigococcus protects against one of the deadliest diseases around. This form of meningitis has a 50% fatality rate, kills within hours, and generally hits healthy young people. Thankfully, it is a rare disease. Obviously, we strongly recommend this vaccine.

What about the HPV Vaccine (the “Cervical Cancer” vaccine)?

Cervical cancer is very strongly associated with the Human Papilloma Virus, which is a sexually-transmitted virus that causes genital warts. The rate of infection is very high in young people in our country. Some parents argue that since this is a sexually-transmitted disease, abstinence will prevent this infection. However, even if a person is abstinent until marriage it is still possible to get HPV if their new spouse was not abstinent earlier in their life. While we do strongly urge abstinence, we strongly urge all young girls to get this vaccine.

Where can I find more information?

The American Academy of Pediatrics Web Site: www.cispimmunize.org

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Getting There

Those who read me much know I have a very large geek streak, especially related to Electronic Medical Records.  We have recently taken a big step toward communication with our patients via e-mail, and it is really a huge success.

Email Screenshot_edited

So now we have to advertise our patients.  Here is a handout being posted in the exam rooms:

Why we want your E-mail Address

You may have noticed that we are now asking for your e-mail address. While you may feel reluctant to give it to us, please do. We have begun to implement a plan to make your care better and easier. We realize communication is difficult at times (we really do!) and want to take steps to make this better for everyone. Here is our vision:

  • We are already e-mailing results of labs and tests to our patients who have given us these addresses.
    • When this happens, you will get an e-mail saying you have results to view. We are not sending the results directly to your e-mail (for obvious confidentiality reasons).
    • You will be directed to click a link that will bring you to our secure server.
    • The first time you do this, you will be required to supply a password.
    • Your results will then be available to look at or download.
    • You cannot e-mail us questions about these results (yet). If you have questions, please call.
  • Our next step will be to allow people to log on to our web site and request refills on their medications or appointments. Our hope is that this will reduce the traffic on our phones so that we can actually begin answering the phone before the automated attendant.
  • We are presently also working on some advice and directions regarding common questions and medical problems to be available on our web site. We get many phone calls about certain questions (common rashes, what to do for a cold, when to come in), and so we are working on some answers that you can easily find. Please be sure to visit our web site often to see how we are progressing on this.
  • Eventually we would like to have a two-way communication with our patients via e-mail or some other online communication tool. We don’t want to rush to this, however, as we want to do it well when we start and not miss important things. If this is something you would like, please let your insurance company know your desire, as most companies don’t yet pay for “e-visits.”
  • We are planning on starting with the use of “e-prescriptions” soon. As opposed to faxing, these would allow you to use any pharmacy and would also check ahead of time to see if your drug is covered by your insurance. That would be nice for everyone!
  • We also would eventually like to have an e-mail newsletter to our patients regarding things happening in our office or even in response to news headlines related to your care.

There are many more neat things we could add in the future, but all of these take time. Even though we are technologically ahead of most offices, we do not rush into changes of this sort (we have learned that the hard way).

If you do not use e-mail or the internet, you do benefit from much of this as it makes our phone traffic much less, meaning that you can talk to humans for a change!

Everyone is excited.

Oh yes, and I am notified when the patient reads their e-mail and even if they don't within 30 days.

Cool.

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How to be a good patient

This handout was posted in our exam rooms. We want you to get the best care possible in this office and hope to care for you for many years to come. If there is anything we can do to give you better care, please let us know. Yet there are some expectations we have for our patients. We ask that you read the list below and do your best to abide by these suggestions:

  1. Do not apologize for your symptoms – It is a very self-conscious thing to be sitting on the exam table. You can fill kind of stupid at times when your symptoms don’t seem to make sense. But if you had these symptoms, then please tell us what they are. It is not your fault that they don’t make sense.
  2. Wear many layers of clothing – We generally have no idea if our office will be hot or cold. Some mysterious person controls that and we have yet to locate them. Hence, you should come prepared for a freezing cold room or a furnace.
  3. Kids are sometimes not perfect – Since we take care of many children, we have come upon the great truth: kids are not always sedate and obedient. This may be a shock for some parents (who the rest of us resent), but we do realize that your children may misbehave sometimes. We don’t think you are a horrible parent because your child is not “seen but not heard.”
  4. Earwax is not embarrassing – It is a mystery why people always apologize about earwax. It is not a moral defect that brought the wax to your ears, and we won’t go home and tell our families about the wax we see in your ear. It’s OK to have wax. Honest!
  5. We believe you – When your child has had a fever for 5 days and then that fever disappears the moment you step into the office, we don’t think you made the fever up. And please, if your body fluids are a different color that normal; do not bring in a sample for us to see. Just tell us what it looked like. Please!
  6. “No news is good news” is a lie – If a reasonable amount of time has passed and you have not heard the results of a test, please contact us. We have a better system than most offices at keeping track of things, but things can be lost, ignored, or forgotten.
  7. The most precious thing you can give us is trust - You should never put your life into someone’s hands that you don’t trust. That does not mean you can’t question us (please do!), but it does mean that if you don’t trust our judgment, then it is probably time to find another doctor. We are happy to say that this does not happen very often.
  8. Stinky diapers smell bad – Please don’t stick them in the trash can. There is nothing subtle about that smell. We have special bags for that kind of thing.
  9. There is no such thing as a dumb question – except for one you should have asked, but did not. If you are confused about something you have been told, please ask someone to clarify it.
  10. Don’t save the most important thing for the “oh by the way” question at the end of your visit – It may be an uncomfortable thing you want to ask, or you may be scared you have a horrible disease, but if something is really worrying you, please ask it early in your visit.

Hopefully these guidelines will help you as you strive to be the “perfect patient.” If you stick to these guidelines, perhaps we will name a wing after you or take your birthday as a holiday. Who knows?

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Survival

Sometimes all you want to do is to survive. This is especially true when it is 2 AM and your child has a temperature of 104 degrees and won't stop crying. Such experiences have made me much more compassionate in my approach to parents when they bring their sick children in to the office. Still, I don't really want to spend my day taking care of the "worried well," and so we have created a "survival sheet" for parents in our practice. The idea is for parents to first go to this sheet and see if it answers their questions. Hopefully this will cut down on unnecessary visits and phone calls.

Here are some of the sections:

10 Things to know about fever

clip_image002[4]1. If your child is under 3 months of age, bring them immediately to be seen.

2. Fever does not contribute to global warming.

3. The only good reason to treat a fever is for the child’s comfort. This is a good reason

4. Fever does not cause seizures or brain damage in normal children.

5. Fever goes away immediately upon entering your doctor’s office. This is caused by the fever gnomes who like to make parents feel silly.

6. If you do treat the fever, use the above doses of Tylenol and Motrin. Generally, Motrin works longer and is somewhat stronger, but Tylenol doesn’t upset the stomach. They can be given at the same time.

7. 90% of fevers happen at 2 AM.

8. The official definition of a fever is a temperature over 100.5 degrees.

9. Milk does not “curdle” in the stomach of a child because of a fever. It curdles because the stomach has acid in it. It always curdles in the stomach.

10. When you come in and your child’s fever has gone away, we believe you that they actually had one. Honest.

Vomiting

When your child vomits...

1. Clear liquids (Pedialyte, Gatorade, etc.), and bland food (see Diarrhea section for BRAT diet) are best.

2. Many small portions of water are better tolerated than a few large portions (even a sip every 5 minutes is better than no fluids).

3. Call for any sign of dehydration (greatly decreased urine output, very dry mouth, listlessness), or if lasts more than 3 days.

4. Stay out of the line of fire.

Diarrhea

clip_image002[6]There are 4 circumstances to be concerned about diarrhea:

· There are signs of dehydration (greatly decreased urine output, very dry mouth, listlessness).

· There is blood in the stool.

· It lasts more than 5 days.

· You are in a public place and can’t hold it in.

1 If these are not the case, these tips may help you survive this wonderful illness:

  1. Avoid milk products and strong juices (such as apple juice).
  2. Children under 12 months will do better on “Isomil DF” which contains fiber to add bulk to the stool
  3. For older children, the BRAT diet (nice name) can be used: Bananas, Rice, Applesauce, and Toast (some people add Yogurt, to make it the “BRATY”)
  4. Plenty of liquids. Dehydration is the enemy!
  5. Kayopectate or Imodium AD may be used as directed
  6. Don’t go on any long car trips unless your ventilation is good or your sense of smell is bad.

I like that last line. I couldn't help myself...

When antibiotics may be useful

Antibiotics are one of the great advances of medical science history. Yet, there are times when they are not helpful, and may in fact be harmful. Although there has been suggestion by some parents to put Amoxicillin in the water supply, we generally do not call in antibiotics without first seeing your child. This is because of the possibility of creating antibiotic resistance in the bacteria if we unnecessarily prescribe antibiotics.

The following is a list of circumstances when antibiotics may be useful:

1. Ear infections. Call the office if your child is not improving in 3-4 days.

2. Strep throat with positive strep test, or if family member has positive strep test.

3. Cough lasting over a week may require antibiotics.

4. Urinary infections.

If your child appears very ill, or if you are very concerned, call to have them seen.

Antibiotics will not make a cold (or virus) get better any faster.

Click on the image of the sheet below to see the whole sheet.

Survival Sheet

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Patient Handout: Antibiotics

Common myths about infections and antibiotics

Much attention has been given to the fact that antibiotics are given too often. The reason for this concern is that the overuse of antibiotics can create resistance in the bacteria a person carries, making it much harder to treat serious infections in the future.

For that reason, the physicians in our practice are trying to avoid using antibiotics unless they are necessary. The problem is that many patients come to the office already convinced that their infection requires an antibiotic and so will not be satisfied unless they get one. This puts our staff in a difficult position, as we want to practice good medicine, but also strive keep our patients happy.

To help with this problem, here is a list of common misconceptions about when antibiotics are appropriate.

  • If mucous is green, it is time for antibiotics. Almost all respiratory infections go through a stage where the mucous turns green (or darker). This is due to a large number of white blood cells, and may actually mean that your body is winning the battle against the infection.
  • When a fever starts, it is time for antibiotics. Fever is part of the body’s defense against infection. Even fevers as high as 104 can be caused by viruses (which are not killed by antibiotics).
  • Sinus pain means you need antibiotics. Sinus pain is caused by a difference in pressure between the inside of the sinuses and the outside world. This is usually caused by thick mucous, and not necessarily infection. Decongestants can help with this (although they may not be appropriate with certain heart conditions and hypertension), as can salt water spray in the nose. The pain is best treated with acetaminophen (Tylenol, etc), or ibuprofen (Advil, etc.).
  • “The last time I had this I needed antibiotics, so I wanted to catch it early this time.” Most infections that do require antibiotics start with a virus infection and then turn into bacterial infection for which antibiotics are appropriate. To treat an infection “early” means that you would treat it when it does not yet need antibiotics. This is exactly what can cause resistant bacteria. If your symptoms are that of a virus, then antibiotics are a bad choice.
  • Bronchitis requires antibiotics. While there are some cases of bacterial bronchitis, the majority of cases of bronchitis are caused by viruses. Bronchitis happens when a person has a coarse cough (loose phlegm), and does not have pneumonia (as heard by the physician on exam). Overall, bronchitis probably accounts for the biggest number of inappropriate antibiotic prescriptions.
  • “I am immune to amoxicillin.” Amoxicillin is not the strongest antibiotic. This is exactly the reason we like to use it first. The goal of antibiotic therapy is to knock the bacterial infection down to the point that a patient’s body can do the rest. Most of the time, the “weaker” antibiotics do the job just fine. Stronger antibiotics are used when:
    • A person is has just finished a course of “weaker” antibiotics. In this instance, the bacteria are more likely to be resistant. This resistance only lasts for a few months.
    • A person who is physically frail.
    • An infection that appears especially serious.
  • “Can I have antibiotics to be on the safe side?” Antibiotic resistance is much less safe than waiting to see if an antibiotic will be needed.
  • “Can you call in an antibiotic?” We usually don’t call in antibiotics. The one sure exception for this is if a family member has a documented case of strep throat. The contagiousness of this is enough that it is reasonable to call it in. Sinus infections, bronchitis, and ear infections are not something we will call in antibiotics for. Please don’t ask.
  • “When I got an antibiotic last time, I got better. That means the antibiotic made me better.” Thankfully, most illnesses get better over time. It is very possible that it would have gotten better just as fast without the antibiotic. Just because the rooster crows every morning, doesn’t mean it causes the sun to rise.

In the past, physicians were quick to offer antibiotics in many situations we now know they are not needed. This changed, not only with the emergence of resistance, but also with studies that show that they may not really help. Here are some examples:

  • In one study, parents of children with obvious ear infections and fever were given ear drops to treat the pain and a prescription of an antibiotic to use if the child did not get better. 90% of the parents did not fill the antibiotic prescription.
  • A recent study of patients with sinusitis and fever showed that antibiotics and prednisone were no better than placebo at treating the infection.

Much of the problem is our mindset. Even many doctors and nurses find it hard to un-learn the long-held beliefs in antibiotics (so past and even recent experiences with physicians may not reflect this new mindset). Still, the need to change is clear.

We really want to practice the best medicine on our patients. I hope that reading this will help you realize that when we are reluctant to offer antibiotics, it is really in your best interest. If we use them unnecessarily, then when you really need them, they might not work. Please help us accomplish the goal of doing what is best for you and for all of our patients.

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Patient Education

old-classroom

We spend a lot of time educating our patients.  It is necessary to do so because there are so many misunderstandings that are widely held and our advice often contradicts these misunderstandings.  Also, it is part of the transaction of a medical encounter for us to give information to the patient.  This is what they are essentially paying us for: our medical opinion, which is in the form of information as well as a plan of action.  Both of these need to be communicated accurately.  If they are not, then we either get calls back, or we get noncompliant patients.

dunce In an effort to make our office more efficient, I have taken on the task of writing patient education material.  I am planning on posting this in exam rooms as well as on our web site.  My hope is that it will make the patient more receptive to our decisions as they have a clear idea about where we are coming from.  I find myself saying the same thing over and over again, I hear the nurses saying the same thing over and over again, and I hear the patients asking the same questions over and over again.  Wouldn't it be easier to just give better resources?

Now people may ask, why not use resources already out there for patients.  There are certainly good places for information, so why not use them?  There are several reasons for writing my own education material:

  1. I want them to hear my opinion.  I cannot read all of the resources out there on all subjects.  This is probably partly due to the innate distrust I have of others, which is ingrained in us during medical school and residency.  But the truth is, I want to ease the process, and so it will be much easier if it is my own words.
  2. I like to write.  Enough said.  I can add my own style (perhaps...some humor - but no llamas)
  3. I can link to numerous outside resources and can hand-pick the ones I think are good on specific subjects.

So I am starting this as a series on the blog.  I will post various educational pieces for patients.  For medical people out there, I want your opinions on the material and offer you the right to use it yourself.  For non-medical people, I ask you to also give your opinion and perhaps learn something.

For a good example of this, see my MRSA post.

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