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Thread: Medical Pearls

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    Lightbulb Medical Pearls

    Crossover test can detect temperature differences

    The crossover test is a bedside test that can help reveal subtle differences in temperature between two body parts. Place one hand on the body part to be tested for warmth and the other hand on the contralateral body part. After 30 to 60 seconds, cross each hand over to the opposite side. Even subtle temperature differences can be discerned in this manner. This test is especially useful for examining patients with suspected inflammatory arthritis. Of course, if there is an equal amount of warmth bilaterally, there will be no discernible difference in temperature.

    Timothy J. Drehmer, MD
    Dayton, Ohio
    ---------------------------------------------------------

    Lubricant for sutures


    When suturing in a hairy area such as the scalp, use of a lubricant such as Surgilube to smooth down the hair around the wound can keep the hair out of the way. Vaseline can also be used, but it can't be cleaned up as easily.

    Mark Cohen, MD
    Penfield, New York

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    Lightbulb "Birthday candles" help auscultation

    When trying to auscultate lung sounds on an uncooperative child, ask him or her to pretend to blow out candles on a birthday cake. Use your fingers as the candles, folding them down as the child blows and repeating as many times as needed for adequate auscultation.

    Joan Grother, RN
    Asheboro, North Carolina

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    Mnemonic aids diabetes care


    Time constraints in today's busy outpatient practice create challenges in maintaining the standard of care. I find the following mnemonic useful in addressing diabetes during patient examinations.

    S ight (annual eye examination)
    U rine albumin
    G lycosylated hemoglobin
    A therosclerosis (aspirin and lipids; palpate arteries)
    R educe weight (diet and exercise) and Remove footwear (monofilament testing; foot examination)


    Kumara Sidhartha, MD
    South Dennis, Massachusetts

    --------------------------------------------------------------------------

    How to lessen the pain of venipuncture


    I have observed that you can reduce the pain your patients experience from venipuncture by asking them which arm they prefer you use. By allowing patients this simple choice, you are helping them regain some control over their healthcare. The more control they have, the more compliant they are and the better the outcome.

    Neil Baum, MD
    New Orleans

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    Determining the severity of abdominal pain in children

    Differentiating the severity of abdominal pain in children can be difficult. Two techniques can help determine whether a serious underlying disorder is present. During history taking, ask the child what his or her favorite food is, and then ask if he or she would want to eat the food if you had some. Chances are, seriously ill children would not want to eat even their favorite food. On physical examination, ask the child to stand and hop up and down a few times. The ability to do this significantly reduces the probability of true peritonitis.

    Atma Persad, MD
    Stefan Grzbowski, MD
    Vancouver, British Columbia

    ---------------------------------------------------------------------------------------------------

    Waiting room tools can calm kids


    While doing a rotation at a pediatric center, I learned that placing old stethoscopes, patella hammers, and other "discarded" tools of the trade in the waiting room helps to calm kids. As young patients get acquainted with these instruments, they are less fearful when the doctor uses such tools on them during physical examinations.

    This idea, coupled with an occasional shedding of the white coat during pediatric consultations, is tremendously helpful to children who are prone to the "white coat" or "doctor's office" syndrome.


    Ayodele Erinle, MD
    Blue Bell, Pennsylvania

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    Outstretched arms equal height

    When I need to obtain the height of a patient who cannot stand by himself or herself because of orthopedic problems, I measure the distance between the end of the third finger of one hand and the end of the third finger of the other hand. The spread is practically equal to the patient's height.

    Josť Lamparelli, MD
    Buenos Aires

    -----------------------------------------------------------------------------------------------------

    Alleviate pruritus with ice

    I tell patients who can't help scratching itchy skin lesions that it's okay to scratch only if they use an ice cube instead of their fingers. The ice is nearly frictionless, and the cold helps relieve the itch.

    Gloria Adams, DO
    Phoenix

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    Identifying cardiac sounds

    There are occasions when it is clinically difficult to distinguish a systolic cardiac outflow murmur, a proximal carotid bruit, and a proximal left subclavian bruit from one another. Placing a blood pressure cuff on a patient's left arm and inflating it past his or her systolic pressure provides physicians with an additional tool in their clinical armamentarium. I have found that this maneuver attenuates an ipsilateral subclavian bruit (by reducing blood flow, and thus turbulence, through that vessel); augments an ipsilateral carotid bruit (by shunting more blood to that vessel); and does not appreciably affect a cardiac outflow murmur.

    Michael W. Rich, MD
    Akron, Ohio

    -----------------------------------------------------------------------------------------

    Help for unsteady hands


    Freezing a small lesion with liquid nitrogen can prove challenging for physicians without steady hands. However, with use of the plastic earpiece normally reserved for the otoscope, liquid nitrogen spray can be funneled directly onto the lesion without fear of damaging the surrounding tissue.


    Carol Healy, MD
    Oceanside, California

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    Clues to acute mesenteric embolism

    Acute mesenteric embolism is an elusive diagnosis associated with high morbidity and mortality. Consider this diagnosis in patients who present with the three A's:

    A trial fibrillation
    A bdominal pain
    A cidosis


    The only clue in elderly patients with abdominal pain and a history of atrial fibrillation may be unexplained metabolic acidosis. Other red flags include severe abdominal pain disproportionate to physical examination findings, leukocytosis, and thumbprinting on the abdominal radiographic film. If acute mesenteric embolism is suspected, immediate arteriography is indicated to confirm the diagnosis.

    Francis Q. Almeda, MD
    Chicago

    ------------------------------------------------------------------------------------------------

    Laughter's therapeutic effect


    While examining apprehensive patients with elevated blood pressure, I have found I can help them relax by telling a joke (in good taste, of course!). This directs their attention away from themselves and can result in normalization of their blood pressure. It also allows me to build rapport with my patients while reinforcing the old adage that laughter is the best medicine.

    Stanley T. Bohinski, DO
    Wilkes-Barre, Pennsylvania

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    "Socks first" deters spread of infection




    Patients with tinea pedis should be reminded to put on their socks before their underwear when getting dressed. Failing to do so can lead to contamination of the groin with dermatophytes.

    Christy Flory, RN, MS, NP
    Waltham, Massachusetts

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    Augmented Valsalva's maneuver terminates tachycardia




    In patients with hemodynamically stable supraventricular tachycardia, vagotonic techniques can be tried before drugs as the initial therapeutic option. Valsalva's maneuver has been shown to be the most effective vagotonic technique; its efficacy can be increased by applying firm pressure to the right side of the hypochondrium during the expiration phase at the end of the maneuver. This increases the venous return to the right side of the heart and augments the effect on cardiac stretch receptors, thereby increasing the chance of successful arrhythmia termination.

    Andrew R. J. Mitchell, BM, MRCP
    Eastbourne, England

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    Remember your ABCs when reading chest films




    When reading chest films, I have found the following alphabetical guide helpful to ensure that I don't rush and forget something.

    A >> Airway (midline, patent)
    B >> Bones (eg, fractures, lytic lesions)
    C >> Cardiac silhouette size
    D >> Diaphragm (eg, flat or elevated hemidiaphragm)
    E >> Edges (borders) of the heart (to rule out lingular and left middle lobe pneumonia or infiltrates)
    F >> Fields (lung fields well inflated; no effusions, infiltrates, or nodules noted)
    G >> Gastric bubble (present, obscured, absent)
    H >> Hilum (nodes, masses)
    I >> Instrumentation (eg, lines, tubes)


    Jeffrey M. Edmondson, MD
    Harker Heights, Texas

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