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Knee Exam

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881. Where will you find happiness now?

of the mall. Within minutes, Pópo is flying past us! She grins as she strolls on the moving walkway, a conveyor belt that pushes patrons toward their shopping destination. Eventually, she reaches the end and gingerly hobbles off. We pass her. She grows smaller and smaller. We round a corner and she’s disappeared. After an hour, I meet Pópo at a wooden bench. I sit with her for a while. Patting her arthritic knees, she says that it will probably rain more today. She looks off into the distance. Then she (...) of withdrawal. As Pópo tells me, “The only good thing the Communists did was to get rid of drugs and prostitution.” Betrayed by her parents and by her country, my grandmother discovered that happiness was not an easy thing to find. Nor was unhappiness an easy thing to evade. Pópo escaped her unhappiness in brief spurts through dreams of education, through novels and through music. At 17, she finished the national university entrance exam and qualified for a government-sponsored education in electrical

2015 KevinMD blog

882. Telemedicine: Why professional concern shouldn’t be dismissed

Telemedicine: Why professional concern shouldn’t be dismissed Telemedicine: Why professional concern shouldn't be dismissed Telemedicine: Why professional concern shouldn’t be dismissed | | July 5, 2015 160 Shares The current state of telemedicine — that is, teleconferencing with a physician over one’s smartphone — worries many critics because it assumes patients can be evaluated without a physical exam. The critics are right that those with a financial interest in “disrupting” health care (...) and the mind. It’s not easy parenting an adolescent. Sophomoric self-righteousness, know-it-all smugness, and knee-jerk rebellion can be irritating as hell. Suddenly, adults are idiots and “just don’t understand.” The young person veers toward obvious trouble, but they have to learn for themselves. It’s nerve-wracking to balance freedom and reasonable risk; to refrain, except in extreme circumstances, from wagging a parental finger and chiding, “you have a LOT to learn!” And all these challenges grow

2015 KevinMD blog

883. The electronic chart turns us into data druggies

. Someone somewhere adds another question we are supposed to ask our patients. We get back on our hands and knees. We start sifting once again. Have you been to the continent of Africa in the last twenty-one days? Click. Do you or a loved one feel threatened at home? Click. How was your experience today? Click. In the background the blood pressure cuff inflates, the quiet hiss filling the room. The monitor beeps along with the patient’s pulse, each ding another penny tossed into the ever-growing bank (...) lock on to mine. I smile. “Hey, little buddy,” I say quietly. He smiles back with a toothless grin, and clear drool runs down his chin over my hand and onto his belly. I finish my exam. He is fine. I hold him on my hip while I wait for the parents to finish what they are doing. I can see Dad is playing a game on his phone. He is trying to slice pieces of fruit tossed across the screen. Strawberries spin in red bunches, bananas burst in yellow bombs, pineapples pop in showers of stars. I cannot

2015 KevinMD blog

884. Should radiologists disclose results to patients? The answer isn’t what you think.

, that we must make it clear we are “part of the team.” Then the patients will finally understand the important role we play, which will somehow translate into a stronger position for us at King ACO’s round table. Having become even more cantankerous in my old age and semi-retirement, I view this as little more than a desperate Hail Mary and a naive, knee-jerk response to the coming economic pressures of the (Un)Affordable Care Act. We are being asked to jump up on tables and shout, “We’re doctors, too (...) that patients the results of imaging exams from the physician who ordered them. I would urge everyone to read the entire report, but, in essence, the majority of patients surveyed “appear to prefer the current model of results delivery, in which ordering physicians provide results.” And this makes perfect sense. The usual course of events established decades ago is that results are communicated to the physician who ordered the study, and he or she then discusses them with the patient. There are only two

2015 KevinMD blog

885. Doctor saves patient from harm after her insurer tries save money

, they didn’t even inform me about the appointment. My patient later told me that the exam was exhaustive. The PA, who incidentally graduated school the day before and had never seen an actual patient as a licensed practitioner, poked and prodded the ninety-year-old woman for over an hour. He asked her about drugs and sexually transmitted diseases. He examined every joint and performed a Babinski test. A few days later I received a call from him. He tried to leave a message with my secretary, but I (...) intercepted the call. He had two recommendations. He thought I should do a better job of addressing the patient’s knee pain. When I asked if he thought it was a result of her polymyalgia, rheumatoid, or osteoarthritis, he had no idea. When I mentioned that the pain had been treated in the past with various medications (and physical therapy), and the patient had stopped them all due to fatigue (even Tylenol), he was surprised. When we discussed that she was in the hospital multiple times for pain control

2015 KevinMD blog

886. Bedside Ultrasound Case: Look Left and Right! #FOAMed, #FOAMus

Examination) is what I start with, after an ultrabasic history. So my first couple of views show a more-or-less normal IVC, and here is the parasternal long axis: Anything exciting here? Not really, nothing to hang your hat on at a glance. Ok, so thanks to FOAM, I recently decided to add the right parasternal view to my regular exam, both to look for lung sliding (I admit I sometimes skip this when not specifically looking for pneumothorax) but also to possibly see some right sided pericardial (...) abnormalities, etc… Here is what I see: Hmm… A large, vascular structure that seems to have two lumens… a flap? Back to the patient exam, and the left toe is upgoing and seems more flaccid in the left upper extremity… Lets creep up the vascular path to the neck vessels: Here, we can clearly see that most of the carotid lumen (lower right) doesn’t have any flow. That’s suboptimal. In fact, only a small crescent of flow between 3 and 6 o’clock is seen. Here is the CT: So here we can clearly see the dissected

2015 Thinking critical care blog

887. Enteral Fluid Resuscitation (EFR): Third-world medicine in the modern ED/ICU? (ORT part 2) – #FOAMed, #FOAMcc, #FOAMer

huge amount of fluids, but this has been done mostly in healthy but dehydrated athletes – not the case for most of our patients. I’ve been going with 250ml every 1-2h, as – for now – an adjunct to IV fluid therapy. This is conservative and completely arbitrary, but essentially a glass every hour or two certainly doesn’t seem excessively taxing. Who can I give this to? You do need a functional gut, so for now, my criteria are (1) essentially normal abdominal exam, (2) obviously no recent bowel (...) account. ( / ) Connecting to %s Notify me of new comments via email. Notify me of new posts via email. This site uses Akismet to reduce spam. . on Colin on on on on the best is yet to come. This site is the bee's knees where everything is up for debate . . . Brazilian Jiu Jitsu for Wrestlers Spheres of basic emergency medicine knowledge Critical discussions on critical care a blog for thinking docs: blending good evidence, physiology, common sense, and applying it at the bedside! Post

2015 Thinking critical care blog

888. How Can I Help You?

” not the x-ray or the family system sometimes? (ie did you ask him the question in front of them so they could hear also?) EOL – A referral to hospice? What indicated he only had 6 months of life left? AGE – What was “telling” about the exam? Did it clearly indicate he didn’t need surgery? Many patients in their 80’s have hip and knee surgery so what were the indicators that lead you to say “you might survive the surgery”. EMOTIONAL HEALTH Isn’t it possible he was simply afraid of the surgery? Did you (...) How Can I Help You? How Can I Help You? - Howard J. Luks, MD | Search for: How Can I Help You? Last Updated January 27, 2015 by Howard J. Luks, MD Related Posts Post navigation About the author: Howard J. Luks, MD A Board Certified Orthopedic Surgeon in Hawthorne, NY. Dr. Howard Luks specializes in the treatment of the shoulder, knee, elbow, and ankle. He has a very "social" patient centric approach and believes that the more you understand about your issue, the more informed your decisions

2015 Howard J. Luks, MD blog

889. Please forgive us for prescribing controlled drugs to just about everybody

by methamphetamine and prescription drug abuse. The little clinic in town is unwittingly a partner in this crime. Like the U.S. itself, this small community clinic has been generous with prescribing controlled substances for those who appear to need them. Sedatives in the benzodiazepine (Valium, Ativan and Xanax are brand name examples) family are prescribed for those with anxiety. Opiates, from the family that includes morphine, are prescribed for patients with back pain and knee pain and a host of other long (...) to study better. They have become extremely common on college campuses at exam time, since they also allow a person to go without sleep and sometimes without much food. One person with a regular prescription for this kind of medication can supply his or her friends with drugs as needed. Side effects can include heart rhythm disturbances and erratic behavior, especially in higher doses, as are sometimes used recreationally. Some of the patients in this little clinic get ADD drugs so they can work

2015 KevinMD blog

890. Patient Modesty: Volume 71

must be delusional), and so on. We hear that even more so when we reply with "You first." That response is because we can not believe that people who are so educated lack such basic common sense and empathy. I also have stated, and most of you agree with me, that it is not all providers that traumatize and the traumatizations may not always be intentional. What is even worse that we have all been missing is that we are told what happens to patients and how exams are performed IS ACCEPTABLE because (...) healthcare says IT IS ACCEPTABLE. When we question this, we are pointed to guidelines. Even when forced to reevaluate guidelines, which only happens from multiple law suits (DREs, Brian Persaud) or legislation (pelvic exams, ACA), most providers resist and ignore the guidelines because "That is the way we have always done it." Then physicians wonder why they have lost credibility, trust, prestige and face such high rates of burnout. It is paternalistic thinking like that that has relied on oligopolies

2015 Bioethics Discussion Blog

891. Patient Modesty: Volume 72

examiner and patient should settle on the positioning to be carried out. ..Maurice. At , said... It's interesting that the current topic happens to be about the digital rectal exam and the respective merits of the two positions. I remember my first rectal exam. Back then, I didn't know what it was, let alone what it was called. I just did what the doctor asked me to do. She asked me to lay down on my side, facing the wall, with my knees up. Odd... But I wasn't too worried. She must have been in a hurry (...) opportunity to write to the AAMC and express your concerns of the current system and your advice for the future. This will be your opportunity to "plant a good" which has a chance to flower. ..Maurice. Graphic: From Google Images and modified by me with Picasa3. posted by Maurice Bernstein, M.D. @ 206 Comments: At , said... I am going to be very cynical on this; if medical schools did not realize that conducting intimate exams on anesthetized patients without explicit consent was not trampling

2015 Bioethics Discussion Blog

892. You MUST have surgery

. Dawn :-) Thank you! says: I agree with you Dawn, his patients are very fortunate. I had to make a decision re knee surgery and after reading Dr Luks honest clinical point of view about surgery, I weighed up the options, and decided against the surgery. Should my condition deteriorate….I may think about the surgery then. I thank you Howard, for helping me to make an informed decision. Wish all surgeons were as people focussed as you. Carol. I had shoulder pain and my PCP’s physical exam immediately (...) You MUST have surgery You MUST have surgery - Howard J. Luks, MD | Search for: You MUST have surgery Last Updated December 19, 2014 by Howard J. Luks, MD Related Posts Post navigation About the author: Howard J. Luks, MD A Board Certified Orthopedic Surgeon in Hawthorne, NY. Dr. Howard Luks specializes in the treatment of the shoulder, knee, elbow, and ankle. He has a very "social" patient centric approach and believes that the more you understand about your issue, the more informed your

2014 Howard J. Luks, MD blog

893. Patient Modesty: Volume 67

? How many of us on this blog have taken this stance AFTER a negative experience in a healthcare setting? What were your attitudes about healthcare before your negative experience. All these questions as mentioned in my book, are issues that one must ask themselves. As I've mentioned before, I saw all medical personnel for who they were regarding medical ability without any thought to provider gender for all intimate exams, exploratory gynecological surgery. After my experience, I vowed never (...) or second year medical students "assisting" urologists for surgical procedures. They are still learning how to draw blood on each other. That experience will come in the 3rd and 4th year clerkships As I have written previously. first and second year instructors talk to the students about attention to modesty as the students learn to take a history and perform a physical exam on a real patient. The second year student also, as I have written, get the modesty issue presented in a direct super-impressive

2014 Bioethics Discussion Blog

894. Patient Modesty: Volume 64

and acts or frank sexual crimes by professionals. This behavior is clearly wrong for a physician or nurse behavior and requires notification of state professional boards in the United States and law enforcement as necessary. That is the solution for that behavior. To educate the patient to ask their provider "are you planning to manipulate my breast or genitals for your own pleasure or do you intend to rape me?" are ridiculous questions to ask at each medical exam or procedure. The way to feel (...) their policy. Misty At , said... Don, I agree with your proposal. However, our visitors should not include the name or identification of the provider for that report to be published. Thanks. ..Maurice. At , Anonymous said... Reading the description of this volume - that's not it at all. Women are taught to see their bodies as objects. They are there for other people's viewing pleasure and sexual pleasure. Women who "don't mind" pelvic exams tend to say that they detach themselves from their bodies during

2014 Bioethics Discussion Blog

895. Patient Modesty: Volume 68

complained to by my patients and I hadn't heard of any complaints by those colleagues I knew." ***** Written By Maurice on Sunday, August 03, 2014 3:17:00 PM Ever have a patient simply stop coming after a visit that involved exposure, or the presence of a chaperone / opposite gender nurse assistant? That, and the truly modest of us simply don't go to the doctor for something that would likely lead to exposure, hence the billboard campaign for prostate exams saying "don't die of embarrassment". Jason K (...) , as evidenced by the billboards. Talking to the doctor does little when it’s a 3rd party that performs the exam / procedure such as a surgical team, or the random lab tech doing an ultra sound (Ask Don about that one) . When it is brought up it’s usually dismissed with a “my way or the highway” attitude. Just look at Artigers posts... said he only had a female assistant, and he doesn’t work alone if a knife is involved. And that’s assuming the doctor isn’t just lying to us, and when we’re laying

2014 Bioethics Discussion Blog

896. Patient Modesty: Volume 66

them how the taste of the food was. Idiots! Hospital food is not supposed to taste good. Did your doctor take the time to answer your questions? If you read the article above about the injured physician she couldn't even get an answer about the injury to her knee in real time, while she was a patient. What's the point of calling a patient After they have left the hospital. Pressganey says " to capture the voice of the patient and transform the patient experience. Is that not the dumbest concept you (...) to Medscape is though you have to provide proof of your professional title to be a participant in the physician's forum. ..Maurice. From southerncookin: I usually try to think of this during breast exams for women, and with anorectal exams on all patients. I usually start by talking with such patients prior to having them disrobe, and at that time explaining that I will need to examine the area of concern, which will require removing some articles of clothing. For breast exams, I have my

2014 Bioethics Discussion Blog

897. Patient Modesty: Volume 65

? Imagine you go in for a routine exam with your female doctor because you don't want a male doctor. A male chaperone or student is brought in to the room to observe. You either ask for him to leave or because you were blind sided by it you say nothing and go through it. Only to be angry about it later. During your exam the doctor finds something and recommends a vaginal ultrasound. You ask for a female but there is only male sonographers that work there. You can say no or swallow your pride and do (...) it. Another male will be assisting you find out at the last minute. Time for a visit now to a gyn/urologist for a more invasive exam and a cytoscopy. Once again you choose a female doctor but when you arrive all the assistants will be male. You are found to need an operation. When you arrive a male will be prepping you and another male catheterizing you. By this time you hate the medical system for having to go through all these embarrassing procedures with so many males involved. You say nothing because

2014 Bioethics Discussion Blog

898. Evaluation of the Elderly Patient

extremities is also beneficial for overall function. Increased muscle tone, measured by flexing and extending the elbow or knee, is a normal finding in elderly people; however, jerky movements during examination and cogwheel rigidity are abnormal. Sarcopenia (a decrease in muscle mass) is a common age-related finding. It is insignificant unless accompanied by a decline or change in function (eg, patients can no longer rise from a chair without using chair arms). Sarcopenia affects the hand muscles (eg (...) , interosseous and thenar muscles) in particular. Weak extensor muscles of the wrist, fingers, and thumb are common among patients who use wheelchairs because compression of the upper arm against the armrest injures the radial nerve. Arm function can be tested by having patients pick up an eating utensil or touch the back of their head with both hands. Coordination Motor coordination is tested. Coordination decreases because of changes in central mechanisms and can be measured in the neuro exam

2013 Merck Manual (19th Edition)

899. Treatment of Pain

How to do a 4-Minute Neurologic Exam SOCIAL MEDIA Add to Any Platform Loading , MD, Mayo Clinic Click here for Patient Education NOTE: This is the Professional Version. CONSUMERS: Topic Resources Nonopioid and opioid analgesics are the main drugs used to treat pain. Antidepressants, anticonvulsants, and other CNS-active drugs may also be used for chronic or neuropathic pain and are first-line therapy for some conditions. Neuraxial infusion, nerve stimulation, injection therapies, and neural (...) because response varies from drug to drug. It is prudent during long-term NSAID therapy to monitor for occult blood in stool and changes in CBC, electrolytes, and hepatic and renal function. Topical NSAIDs may be applied directly to the painful region for disorders such as osteoarthritis and minor sprains, strains, and contusions. A 1.5% solution of diclofenac has been shown to effectively treat pain and limited joint function caused by osteoarthritis of the knees; dose is 40 drops (1.2 mL) applied

2013 Merck Manual (19th Edition)

900. Malnutrition

in the buttocks and thighs Skeletal Deformities usually a result of calcium, vitamin D, or vitamin C deficiencies Abdomen Distended – hepatomegaly with fatty liver, ascites may be present Cardiovascular Bradycardia, hypotension, reduced cardiac output, small vessel vasculopathy Neurologic Global development delay, loss of knee and ankle reflexes, poor memory Hematological Pallor, petechiae, bleeding diathesis Behavior Lethargic, apathetic Source: "Protein Energy Malnutrition" Cognitive development [ ] can (...) , rectal is recommended. Blood sugar levels should be re-checked on two hour intervals. Hypothermia [ ] can occur. To prevent or treat this, the child can be kept warm with covering including of the head or by direct skin-to-skin contact with the mother or father and then covering both parent and child. Prolonged bathing or prolonged medical exams should be avoided. Warming methods are usually most important at night. Epidemiology [ ] Main article: Percentage of population affected by undernutrition

2012 Wikipedia

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