Re: Reference websites

[Guest guest]

up to date.comGooglePractice Improvement 1.for derm I have  two books The Washngotn MAnual is still occasional useful.JAMA and  on a longitudinal basis. one or two  good conferences  a year.

And I never talk to my husbdan becasue he is an interneis ta nd always  suggestd awful horrible rare problems.waddid ya do that CRP   for??Why a  tsh? Who cares if she  has PACS?  or are they PVCs?And they who really cares??

 

Hi!

I am unoffically open for the past 10 days or so...have seen about 7 patients. I am feeling very rusty and a bit unconfident as I have been out of clinical practice for 2 years and have never practiced alone before. Also I am in practice in a town I have never practiced medicine in before so I do not know any of the specialist etc. That said, one of my first patients is a 60 y/o transgender woman with increasingly frequent PAC's. Overwirght, on estrogen, very physically fit...rides a road bike 35+ miles 3+ times/week. TSH is wnl as is chol but her CRP is 4..2

I am feeling challenged!

 What websites are you all using for resources??

Thank You!

Danniell Harwood, MD

 

-- PATIENTS,please remember email may not be entirely secure and that Email is part of the medical  record and is placed into the chart ( be careful what you say!)Email is best used for appointment making and  brief  questions

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[Guest guest]

I second up to date. The CRP just shows she has inflammation somewhere. Does she have some pain somewhere? Teeth? Sinuses? Fat itself is inflammatory, but I don't know how much it will raise a CRP. Consider an EKG, maybe more (Holter or other as clinically indicated). If the PCs are bothering her, maybe put her on a beta blocker. Is she ANXIOUS ???Lonna

Hi!

I am unoffically open for the past 10 days or so...have seen about 7 patients. I am feeling very rusty and a bit unconfident as I have been out of clinical practice for 2 years and have never practiced alone before. Also I am in practice in a town I have never practiced medicine in before so I do not know any of the specialist etc. That said, one of my first patients is a 60 y/o transgender woman with increasingly frequent PAC's. Overwirght, on estrogen, very physically fit...rides a road bike 35+ miles 3+ times/week. TSH is wnl as is chol but her CRP is 4..2

I am feeling challenged!

What websites are you all using for resources??

Thank You!

Danniell Harwood, MD

-- PATIENTS,please remember email may not be entirely secure and that Email is part of the medical record and is placed into the chart ( be careful what you say!)Email is best used for appointment making and brief questions

Email replies can be expected within 24 hours-Please CALL if the matter is more urgent . MD ph fax

impcenter.org

[Guest guest]

When I get pts w palpitations- I ask about caffeine, drugs, lack of sleep, stress, drinking, smoking as possible triggers.

I order cbc for anemia, tsh, ekg and holter monitor if ekg is not helpful. Does PAC's bother her? SOB, CP, lightheaded, etc? Does a valsalva manuever help stop it? Could try a beta blocker or calan (constipating) if bothersome PAC. We once presented a case of a 28 yo woman who had palpitations that lead to syncope in shower. She was having a fib.

Is she on too much estrogen? Would it be better to switch to E2 patch? Woman at age of 60 usually go off their estrogen, did this pt have all her male parts removed? ie no testosterone source? Some of these pts are high risk for STD. Elevated CRP- could be from many things- I have a lab book that I look up DDx. Here is a link to recent crp study http://www.medscape.com/viewarticle/712266?src=mp & spon=34 & uac=123726DT  Chol and sugar ok? What is her BMI? Google is a good source. Anyway never feel alone. This group always comes to the rescue. it has helped me alot. We love the clinical questions. I met many specialists by having lunch at the hospital and going to there meetings

Yes Uptodate is excellent, but expensive. I use it thru our hospital web site. Epocrates is nice too. I have it on my iphone

 

Hi!

I am unoffically open for the past 10 days or so...have seen about 7 patients. I am feeling very rusty and a bit unconfident as I have been out of clinical practice for 2 years and have never practiced alone before. Also I am in practice in a town I have never practiced medicine in before so I do not know any of the specialist etc. That said, one of my first patients is a 60 y/o transgender woman with increasingly frequent PAC's. Overwirght, on estrogen, very physically fit...rides a road bike 35+ miles 3+ times/week. TSH is wnl as is chol but her CRP is 4..2

I am feeling challenged!

 What websites are you all using for resources??

Thank You!

Danniell Harwood, MD

 

-- M.D.www.elainemd.comOffice:

Go in the directions of your dreams and live the life you've imagined.This email transmission may contain protected and privileged, highly confidential medical, Personal and Health Information (PHI) and/or legal information. The information is intended only for the use of the individual or entity named above.

If you are not the intended recipient of this material, you may not use, publish, discuss, disseminate or otherwise distribute it. If you are not the intended recipient, or if you have received this transmission in error, please notify the sender immediately and confidentially destroy the information that email in error.

[Guest guest]

What units are you using for CRP?Here we use mg/L, and any value less than 5 or 7 ( different labs ) are considered normal.http://www.modernmedicine.com/modernmedicine/Primary+Care+Medicine/CRP-Levels-Linked-to-Heart-Disease-but-Causality-U/ArticleNewsFeed/Article/detail/649660?contextCategoryId=40137 & srcemalert=40137

Hi!

I am unoffically open for the past 10 days or so...have seen about 7 patients. I am feeling very rusty and a bit unconfident as I have been out of clinical practice for 2 years and have never practiced alone before. Also I am in practice in a town I have never practiced medicine in before so I do not know any of the specialist etc. That said, one of my first patients is a 60 y/o transgender woman with increasingly frequent PAC's. Overwirght, on estrogen, very physically fit...rides a road bike 35+ miles 3+ times/week. TSH is wnl as is chol but her CRP is 4..2

I am feeling challenged!

 What websites are you all using for resources??

Thank You!

Danniell Harwood, MD

 

-- Graham Chiuhttp://www.synapsedirect.comSynapse - the use from anywhere EMR.

[Guest guest]

When I get pts w palpitations- I ask about caffeine, drugs, lack of sleep, stress, drinking, smoking as possible triggers.

I order cbc for anemia, tsh, ekg and holter monitor if ekg is not helpful. Does PAC's bother her? SOB, CP, lightheaded, etc? Does a valsalva manuever help stop it? Could try a beta blocker or calan if bothersome PAC. We once presented a case of a 28 yo woman who had palpitations that lead to syncope in shower. She was having a fib.

Is she on too much estrogen? Would it be better to switch to E2 patch? Woman at age of 60 usually go off their estrogen, Elevated CRP- could be from many things- I have a lab book that I look up DDx. Here is a link to recent crp study http://www.medscape.com/viewarticle/712266?src=mp & spon=34 & uac=123726DT  Chol and sugar ok? What is her BMI? Google is a good source. Anyway never feel alone. This group always comes to the rescue. it has helped me alot. We love the clinical questions. I met many specialists by having lunch at the hospital and going to there meetings

 

Hi!

I am unoffically open for the past 10 days or so...have seen about 7 patients. I am feeling very rusty and a bit unconfident as I have been out of clinical practice for 2 years and have never practiced alone before. Also I am in practice in a town I have never practiced medicine in before so I do not know any of the specialist etc. That said, one of my first patients is a 60 y/o transgender woman with increasingly frequent PAC's. Overwirght, on estrogen, very physically fit...rides a road bike 35+ miles 3+ times/week. TSH is wnl as is chol but her CRP is 4..2

I am feeling challenged!

 What websites are you all using for resources??

Thank You!

Danniell Harwood, MD

 

-- M.D.www.elainemd.comOffice: Go in the directions of your dreams and live the life you've imagined.

This email transmission may contain protected and privileged, highly confidential medical, Personal and Health Information (PHI) and/or legal information. The information is intended only for the use of the individual or entity named above.

If you are not the intended recipient of this material, you may not use, publish, discuss, disseminate or otherwise distribute it. If you are not the intended recipient, or if you have received this transmission in error, please notify the sender immediately and confidentially destroy the information that email in error.

[Guest guest]

I use uptodate.com, American family physician magazine and it's web site.also got current diag tx book. Igot 5minute consult from skyscape.Sent from my iPod

When I get pts w palpitations- I ask about caffeine, drugs, lack of sleep, stress, drinking, smoking as possible triggers.

I order cbc for anemia, tsh, ekg and holter monitor if ekg is not helpful. Does PAC's bother her? SOB, CP, lightheaded, etc? Does a valsalva manuever help stop it? Could try a beta blocker or calan (constipating) if bothersome PAC. We once presented a case of a 28 yo woman who had palpitations that lead to syncope in shower. She was having a fib.

Is she on too much estrogen? Would it be better to switch to E2 patch? Woman at age of 60 usually go off their estrogen, did this pt have all her male parts removed? ie no testosterone source? Some of these pts are high risk for STD. Elevated CRP- could be from many things- I have a lab book that I look up DDx. Here is a link to recent crp study http://www.medscape.com/viewarticle/712266?src=mp & spon=34 & uac=123726DT Chol and sugar ok? What is her BMI? Google is a good source. Anyway never feel alone. This group always comes to the rescue. it has helped me alot. We love the clinical questions. I met many specialists by having lunch at the hospital and going to there meetings

Yes Uptodate is excellent, but expensive. I use it thru our hospital web site. Epocrates is nice too. I have it on my iphone

On Wed, Dec 30, 2009 at 1:08 PM, Dannielle Harwood <dharwood100sbcglobal (DOT) net> wrote:

Hi!

I am unoffically open for the past 10 days or so...have seen about 7 patients. I am feeling very rusty and a bit unconfident as I have been out of clinical practice for 2 years and have never practiced alone before. Also I am in practice in a town I have never practiced medicine in before so I do not know any of the specialist etc. That said, one of my first patients is a 60 y/o transgender woman with increasingly frequent PAC's. Overwirght, on estrogen, very physically fit...rides a road bike 35+ miles 3+ times/week. TSH is wnl as is chol but her CRP is 4..2

I am feeling challenged!

What websites are you all using for resources??

Thank You!

Danniell Harwood, MD

-- M.D.www.elainemd.comOffice:

Go in the directions of your dreams and live the life you've imagined.This email transmission may contain protected and privileged, highly confidential medical, Personal and Health Information (PHI) and/or legal information. The information is intended only for the use of the individual or entity named above.

If you are not the intended recipient of this material, you may not use, publish, discuss, disseminate or otherwise distribute it. If you are not the intended recipient, or if you have received this transmission in error, please notify the sender immediately and confidentially destroy the information that email in error.

[Guest guest]

Thank you all for your replies...very helpful.

I have her on a caffiene washout to see if that helps.....asked about all the other stuff and it was negative except of course for stress.......which makes a lot of sense since she is living transgender with NONE of her friends and colleagues knowing. Labs are all ok with exception of the hsCRP. I am not sure how our lab measure the hsCRP but they are who read 4.2 as in the high risk category.

Her estrogen level is actually rather low....level is consistent with a postmenopausal level or even a male despite the fact that sge takes estrogen. Being as how she is transgender I doubt she would be open to stopping the estrogen plus it might be offering a some cardiac protection since she has been on it continously for 20+ years.

As for parts...she only has her prostate.

I think part of my issue is that she works near the office and has started "stopping by" almost every day to report on her symptoms and how they are bothering her. They are quite frequent and now she associating them with some decreased exercise tolerance and SOB.

I did have my husband, an anesthesiologist look at her EKG and rhythm strip with me...so I am confident they are PAC's.

Plan right now is for a Holter and then a possible trip to cardiology .....

Another resource question.....does anyone have a list of lab codes they would like to share with me????

I cannot get the 2010 code books yet and so have no code books....am using the AAFP short and long list mostly.

There used to be a "medication management" code that I remember using for when I order liver enzymes on people taking statins etc. Also there was a "h/o anemia" code I used for ordering CBC etc, "fatigue" for TSH...blah, blah, blah.

Again....thank you!

Dannielle

To: Sent: Wed, December 30, 2009 8:51:07 PMSubject: Re: Reference websites

When I get pts w palpitations- I ask about caffeine, drugs, lack of sleep, stress, drinking, smoking as possible triggers.

I order cbc for anemia, tsh, ekg and holter monitor if ekg is not helpful. Does PAC's bother her? SOB, CP, lightheaded, etc? Does a valsalva manuever help stop it? Could try a beta blocker or calan (constipating) if bothersome PAC. We once presented a case of a 28 yo woman who had palpitations that lead to syncope in shower. She was having a fib.

Is she on too much estrogen? Would it be better to switch to E2 patch? Woman at age of 60 usually go off their estrogen, did this pt have all her male parts removed? ie no testosterone source? Some of these pts are high risk for STD. Elevated CRP- could be from many things- I have a lab book that I look up DDx. Here is a link to recent crp study http://www.medscape.com/viewarticle/712266?src=mp & spon=34 & uac=123726DT Chol and sugar ok? What is her BMI? Google is a good source. Anyway never feel alone. This group always comes to the rescue. it has helped me alot. We love the clinical questions. I met many specialists by having lunch at the hospital and going to there meetings

Yes Uptodate is excellent, but expensive. I use it thru our hospital web site. Epocrates is nice too. I have it on my iphone

On Wed, Dec 30, 2009 at 1:08 PM, Dannielle Harwood <dharwood100@ sbcglobal. net> wrote:

Hi!

I am unoffically open for the past 10 days or so...have seen about 7 patients. I am feeling very rusty and a bit unconfident as I have been out of clinical practice for 2 years and have never practiced alone before. Also I am in practice in a town I have never practiced medicine in before so I do not know any of the specialist etc. That said, one of my first patients is a 60 y/o transgender woman with increasingly frequent PAC's. Overwirght, on estrogen, very physically fit...rides a road bike 35+ miles 3+ times/week. TSH is wnl as is chol but her CRP is 4..2

I am feeling challenged!

What websites are you all using for resources??

Thank You!

Danniell Harwood, MD

-- M.D.www.elainemd. comOffice: Go in the directions of your dreams and live the life you've imagined.This email transmission may contain protected and privileged, highly confidential medical, Personal and Health Information (PHI) and/or legal information. The information is intended only for the use of the individual or entity named above. If you are not the intended recipient of this material, you may not use, publish, discuss, disseminate or otherwise distribute it. If you are not the intended recipient, or if you have received this transmission in error, please notify the sender immediately and confidentially destroy the information that email in error.

[Guest guest]

so  she has no support  a unique-isolating- situationand  PACs  with no syncope nopresyncope and is stopping by sdailt IT seems like you have done a good job with the eval Now she needs confidence and support not  more testing

I am not  there  obviously  but the medica-o-lizing   of a non illness something that is more condition  than  illness  may be not useful she needs maybe structured visits that are long and regular andmaybe she needs to be told to stop stopping by.

Good luckLet us know w hen you start having  fun:)

 

Thank you all for your replies...very helpful.

I have her on a caffiene washout to see if that helps.....asked about all the other stuff and it was negative except of course for stress.......which makes a lot of sense since she is living transgender with NONE of her friends and colleagues knowing. Labs are all ok with exception of the hsCRP. I am not sure how our lab measure the hsCRP but they are who read 4.2 as in the high risk category.

Her estrogen level is actually rather low....level is consistent with a postmenopausal level or even a male despite the fact that sge takes estrogen. Being as how she is transgender I doubt she would be open to stopping the estrogen plus it might be offering a some cardiac protection since she has been on it continously for 20+ years.

As for parts...she only has her prostate. 

I think part of my issue is that she works near the office and has started " stopping by " almost every day to report on her symptoms and how they are bothering her. They are quite frequent and now she associating them with some decreased exercise tolerance and SOB.

I did have my husband, an anesthesiologist look at her EKG and rhythm strip with me...so I am confident they are PAC's.

Plan right now is for a Holter and then a possible trip to cardiology .....

 

Another resource question.....does anyone have a list of lab codes they would like to share with me????

I cannot get the 2010 code books yet and so have no code books....am using the AAFP short and long list mostly.

There used to be a " medication management " code that I remember using for when I order liver enzymes on people taking statins etc. Also there was a " h/o anemia " code I used for ordering CBC  etc, " fatigue " for TSH...blah, blah, blah.

 

Again....thank you!

Dannielle

To:

Sent: Wed, December 30, 2009 8:51:07 PMSubject: Re: Reference websites

 

When I get pts w palpitations-  I ask about caffeine, drugs, lack of sleep, stress, drinking, smoking as possible triggers.

I order cbc for anemia, tsh, ekg and holter monitor if ekg is not helpful. Does PAC's bother her? SOB, CP, lightheaded, etc? Does a valsalva manuever help stop it? Could try a beta blocker or calan (constipating)  if bothersome PAC. We once presented a case of a 28 yo woman who had palpitations that lead to syncope in shower. She was having a fib.

Is she on too much estrogen? Would it be better to switch to E2 patch? Woman at age of 60 usually go off their estrogen, did this pt have all her male parts removed? ie no testosterone source? Some of these pts are high risk for STD. Elevated CRP- could be from many things- I have a lab book that I look up DDx. Here is a link to recent crp study http://www.medscape.com/viewarticle/712266?src=mp & spon=34 & uac=123726DT  Chol and sugar ok? What is her BMI? Google is a good source. Anyway never feel alone. This group always comes to the rescue. it has helped me alot. We love the clinical questions. I met many specialists by having lunch at the hospital and going to there meetings

Yes Uptodate is excellent, but expensive. I use it thru our hospital web site. Epocrates is nice too. I have it on my iphone

On Wed, Dec 30, 2009 at 1:08 PM, Dannielle Harwood <dharwood100@ sbcglobal. net> wrote:

 

Hi!

I am unoffically open for the past 10 days or so...have seen about 7 patients. I am feeling very rusty and a bit unconfident as I have been out of clinical practice for 2 years and have never practiced alone before. Also I am in practice in a town I have never practiced medicine in before so I do not know any of the specialist etc. That said, one of my first patients is a 60 y/o transgender woman with increasingly frequent PAC's. Overwirght, on estrogen, very physically fit...rides a road bike 35+ miles 3+ times/week. TSH is wnl as is chol but her CRP is 4..2

I am feeling challenged!

 What websites are you all using for resources??

Thank You!

Danniell Harwood, MD

 

-- M.D.www.elainemd. com

Office: Go in the directions of your dreams and live the life you've imagined.This email transmission may contain protected and privileged, highly confidential medical, Personal and Health Information (PHI) and/or legal information. The information is intended only for the use of the individual or entity named above.

If you are not the intended recipient of this material, you may not use, publish, discuss, disseminate or otherwise distribute it. If you are not the intended recipient, or if you have received this transmission in error, please notify the sender immediately and confidentially destroy the information that email in error.

-- PATIENTS,please remember email may not be entirely secure and that Email is part of the medical  record and is placed into the chart ( be careful what you say!)Email is best used for appointment making and  brief  questions

Email replies can be expected within 24 hours-Please CALL  if the  matter is more urgent .     MD         ph   fax

impcenter.org