CLINICAL PEARLS of a problem FACULTY AND AUDIENCE May be - - PowerPoint PPT Presentation

2/23/2017 1

CLINICAL PEARLS

FACULTY AND AUDIENCE

A CLINICAL PEARL IS

• A distillation of clinical knowledge that is useful for solving

every day medical problems

• It may be a tip, a way to remember something, a framing
• f a problem
• May be evidence-based or experience-based

APPROACH SOCIAL ISSUES WITH MEDICAL FRAMEWORK

SO: Think differential, risk, prevention….

• What is the differential diagnosis of homelessness?
• What does homelessness put you at risk for?

OR

• Being imprisoned is bad for your health. How can it be

prevented?

• What puts a person at risk for incarceration?
• What does incarceration put a person at risk for?
• Try it on the issue of your choice!!!

CLINICAL PEARL: WHY IS THE DNR DISCUSSION HARD?

• BECAUSE ( it’s just hard) BUT ALSO…

The DNR discussion is really 3 discussions—

• 1: THE PROBLEM
• 2. THE GOALS
• 3. THE METHODS– resuscitation is one method

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END OF LIFE DISCUSSION PEARLS: USEFUL WORDS

• The Problem

“ There are three kinds of diseases: disease we can cure; diseases that we can’t

cure but we can help people live longer; and diseases where we can’t cure or prolong life but where we can help people feel better. You have …..”

• Goals

“Let’s hope for the best and plan for the worst. What would are your hopes?

What would be important for you to plan for?

DEPRESCRIBE: IMPROVE OUTCOMES!

THE AMPUTATION IN DIABETICS YOU FORGOT TO PREVENT?

• THE TEETH:
• Diabetics 2x more likely than non-diabetics to lose their teeth
• Refer to Denti-Cal while you can
• Emphasize brushing, flossing, nutrition
• Glycemic control improves dental outcomes
• Good dental hygiene may improve glycemic control!

GO TOGETHER LIKE PEANUT BUTTER AND JELLY: OPIATE SCRIPTS AND NARCAN

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AUDIENCE: SHARE YOUR CLINICAL PEARLS

• Email to Margaret.Wheeler@ucsf.edu
• We will collate them on to slides for presentation Thursday and

Friday

• TOP TEN will win a copy of Medical Care of Vulnerable and

Underserved Populations

TEACH-BACK FOR EVERYONE

• Patients remember less than

50% of what their doctors tell them

• Literacy depends on content

and context

• Assessing for understanding

improves recall

• Teach-Back

IMMIGRANTS ARE OUR HIGHEST RISK TRAVELERS

• If you have immigrant patients you

should be practicing travel medicine

• Vaccinate
• Prophylax
• Anticipatory Guidance
• Remember people go home for

medical care

• CDC Travel section for recs

INSULIN AND HOMELESSNESS: KNOW YOUR OPTIONS

• Common misconception: Insulin must be kept

in refrigerator

• Truth! Insulin can be kept at room

temperature for up to one month. Can be carried with belongings, taken to shelters, etc.

• Common misconception: Pens require a PA

and are hard to obtain

• Truth! Pens are increasingly covered as first-

line treatment, are more portable and less likely to be stolen than bottles and syringes, and have auditory clues for the visually impaired

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DIABETES AND HOMELESSNESS

• Remember food insecurity and discussing

strategies for taking meds, especially insulin

• Point of care HgA1c
• Tolerate higher A1cs
• Foot care: Try to put feet up; change socks

and inspect feet; foot care supplies in clinic

• Brush teeth or at least rinse after eating
• Hand out tooth brushes/toiletries
• Same day eye exams
• Needle exchange for needles and

disposal

• Med-Alert bracelets
• Give rx sugar tablets and discuss

hypoglycemia

• Get way to contact!

NOACS OR DOACS AND ATRIAL FIBRILLATION

• Switching appropriate patients off

Warfarin and onto NOAC can benefit patients who are low literacy and/or have inconsistent Vitamin K intake due to food insecurity

PICK PATIENT-CENTERED GLUCOSE TARGETS

• Annals September 2016: Yet more

evidence that intensive glucose lowering can be risky in high-risk individuals!

• Especially with older patients, CKD,

comorbid conditions….

IT’S FLU SEASON: REMEMBER

• Healthy folk, no treatment if >48 hr sx
• High risk treatment even if more than 48

hrs sx: PG, young, old, DM, lung disease, immunosuppressed, pregnant, sickle cell, ESRD, ESLD, Native ethnicity, nursing home and

• CAD :Getting the flu risk for MI
• Obesity predisposes severe disease
• VACCINATE
• Remember to ask about

work, who is in the family

• etc. for all patients with

flu–HR need post- exposure prophylaxis and vaccination

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COMPASSION SATISFACTION & “THE GOOD LIFE”

• Pleasure that comes from

helping others

• Increases connection
• Protects against burn-out
• The “ Good Life” full of

meaning, aimed at greater good rather than ease.

• What is meaningful in what

you do?

• What are you grateful for in

your work?

• What core values are

expressed through your work?

YOUTUBE IN YOUR OFFICE

• Great for teaching yourself new techniques but also for patients
• Use of inhalers, discus
• Exercises
• Epley maneuver
• SVT reverse maneuver at home

MOST POWERFUL THING WE DO TO DECREASE MORTALITY & MORBIDITY? SMOKING CESSATION

• One evidence-based step toward cessation?
• Smoke-free homes –voluntary no smoking at home
• Associated with:

Reduced secondhand smoke exposure Decreased consumption Increased cessation Reduced relapse to smoking

AUDIENCE: SHARE YOUR CLINICAL PEARLS

• Email to Margaret.Wheeler@ucsf.edu
• We will collate them on to slides for presentation Thursday and

Friday

• TOP TEN will win a copy of Medical Care of Vulnerable and

Underserved Populations

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CELLULITIS: IS OVER DIAGNOSED. WHAT ELSE COULD IT BE?

• Venous stasis and resulting dermatitis (lipodermatosclerosis)
• contact dermatitis;
• acute inflammatory edema
• In people who inject drugs, stasis may appear more complex because of venous

changes (asymmetrical, with depressed skin scars, etc.)

• Cellulitis is not bilateral. If bilateral, go back to the differential.
• If it is cellulitis: look at the feet for a portal of entry (often tinea pedis) and then

treat the primary problem

MUSCULAR-SKELETAL INJURIES: MAXIMIZE FUNCTION

• Generate a differential based on mechanism of injury (e.g. acute traumatic, chronic, overuse

type) and anatomy

• Use PE maneuvers as you would use tests (e.g. an MRI) to confirm /refute a
• differential. Only do tests you execute well: avoid generating extra diagnostic noise
• Avoid imaging unless changes management (see Choosing Wisely campaign)
• Maximizing function
• Ergonomics, training, behavioral approaches
• Low cost complementary rx– tennis ball massage; ice in the bottle; taping
• Massage/acupuncture at low cost/teaching clinics
• Home exercise programs with handouts from familydoctor.org or AAOS.org,

THANKS TO

• Era Kryzhanovskaya
• Dean Schillinger
• Claire Horton
• Jack Chase
• Diana Coffa
• Claudia Diaz Mooney