Acebecker Posted February 26, 2015 Share Posted February 26, 2015 Alright - The longer I practice in medicine the more pet peeves I find I have. One of the biggest is regarding fevers. There is nothing which makes me want to growl at patients more than when they measure 98.6F orally and they tell me "That's a fever for me, cause I usually run a degree low." I read a paper on this at one point which elucidated how we in medicine came to the definition of fever, but I don't have the reference handy. Does anyone know the paper I'm talking about? Makes me crazy. Then again, it's my Friday and everything makes me crazy on this day. Carry on. Link to comment Share on other sites More sharing options...
LKPAC Posted February 26, 2015 Share Posted February 26, 2015 Amen, brother! Link to comment Share on other sites More sharing options...
gbrothers98 Posted February 26, 2015 Share Posted February 26, 2015 I hear you. I have a laundry list about a mile long of what patients say that range from just ignorant to sometimes dangerous. I always constructively correct the dangerous. The rest, I just smile and move on. I do take a bit of time to explain my reasoning behind my diagnosis. The fever thing I always interpret as a play for antibiotics on the patient's part. I address that pretty quickly with the viruses dont need antibiotics, viruses also cause fever. If that is what I think they have. Then I talk about symptom relief such as motrin or apap, cough med including prescription or other symptom directed interventions. I do believe patients when they say they had a fever at home or felt chilled, etc. May or may not drive my eval. As for a paper, no knowledge of this but could likely find with a google search. Prolly wont make a difference for many of your patients, they tend to do and think what they want regardless. G Brothers PA-C Link to comment Share on other sites More sharing options...
Acromion Posted February 27, 2015 Share Posted February 27, 2015 I don't understand why parents bring their kids in over and over for colds. I try to tell them the average kid gets a half dozen viral URI's per year, and they can last a couple weeks, doesn't need antibiotics etc, ect... but there is no convincing them. They are certain their kid is going to die every time he has a sniffle and a fever of 102. Link to comment Share on other sites More sharing options...
Acromion Posted February 27, 2015 Share Posted February 27, 2015 The longer I practice in medicine the more pet peeves I find I have. One of the biggest is regarding fevers. There is nothing which makes me want to growl at patients more than when they measure 98.6F orally and they tell me "That's a fever for me, cause I usually run a degree low." I'll take a drug seeker over a hypochondriac or psychosomatic patient any day. At least with the drug seeker I can pretty quickly figure out what they want and dispo them accordingly, either with a few norcos or empty handed (depending on how much grief they've put me through). The fibro patients are what really wear me down. They come in with a laundry list of vague unrelated complaints, never seem to get to the point of why they are in the ER, they are usually emotionally needy and histrionic, pushing the call light over and over and disrupting the nurses. When they start to get into potentially serious complaints like shortness of breath or chest pain or neuro deficits it really tests my patience. Link to comment Share on other sites More sharing options...
Acebecker Posted February 27, 2015 Author Share Posted February 27, 2015 I'll take a drug seeker over a hypochondriac or psychosomatic patient any day. At least with the drug seeker I can pretty quickly figure out what they want and dispo them accordingly, either with a few norcos or empty handed (depending on how much grief they've put me through). The fibro patients are what really wear me down. They come in with a laundry list of vague unrelated complaints, never seem to get to the point of why they are in the ER, they are usually emotionally needy and histrionic, pushing the call light over and over and disrupting the nurses. When they start to get into potentially serious complaints like shortness of breath or chest pain or neuro deficits it really tests my patience. Yes! How many times are you going to work up a possible PE because they feel SOB and have CP which gets worse with inspiration? I hear that. Link to comment Share on other sites More sharing options...
Evolute Posted February 27, 2015 Share Posted February 27, 2015 because they are not paying for the ED visit. Link to comment Share on other sites More sharing options...
Evolute Posted February 27, 2015 Share Posted February 27, 2015 Sorry, I was responding to the above post by acromion " Ii don't understand why parents bring their kids in over and over for colds". Link to comment Share on other sites More sharing options...
RetNavyPAC Posted February 27, 2015 Share Posted February 27, 2015 Alright - The longer I practice in medicine the more pet peeves I find I have. One of the biggest is regarding fevers. There is nothing which makes me want to growl at patients more than when they measure 98.6F orally and they tell me "That's a fever for me, cause I usually run a degree low." I read a paper on this at one point which elucidated how we in medicine came to the definition of fever, but I don't have the reference handy. Does anyone know the paper I'm talking about? Makes me crazy. Then again, it's my Friday and everything makes me crazy on this day. Carry on. Perhaps: Clin Infect Dis. 1994 Mar;18(3):458-67. Carl Reinhold August Wunderlich and the evolution of clinical thermometry. Mackowiak PA1, Worden G. I tried to get access to the full article through MyAthens at my institutions online Health Sci library but was unsuccessful I always love the look of shock and horror I often get in the Peds ED when educating parents (typically with their first child - but it can be their sixth) and I'm giving them my 'Feverphobia' spiel: 1 - "Fever is not a bad thing." 2 - "All fevers do not need to be treated". . . 3 - . . ."But if you do? Treat your kid - not the number." 4 - "It will never get high enough to 'cook' their brain" (no matter what 'Dr Grandma' says) 5 - "Stop alternating Tylenol & Motrin" 6 - "Tylenol works for 4 hours and Motrin 6 to 8." (dose 'em again if you need to) 7 - "It's UNreasonable to expect antipyretics to normalize a temp" (dropping it from 103.4 to 101.2 is success - because I bet your child looks a whole lot better) Link to comment Share on other sites More sharing options...
SocialMedicine Posted February 27, 2015 Share Posted February 27, 2015 there is a paper which studied a few hundred people without symptoms over a few weeks and temperatures ranged throughout the high 90's Link to comment Share on other sites More sharing options...
greenmood Posted February 27, 2015 Share Posted February 27, 2015 I'm working on getting my husband to stop telling me he has a fever when his temp is 99. Until I manage that with my highly educated, not hysterical, laid back hubby.... I don't feel I have a reasonable chance with my hospitalized patients. ???? Sent from my iPad using Tapatalk Link to comment Share on other sites More sharing options...
winterallsummer Posted February 27, 2015 Share Posted February 27, 2015 Yes I see this with the affluent type when I rarely encounter them. 98 is a fever because their normal is 96. I usually just nod in agreement and say "okay so maybe you have a low grade fever..." and discount it in my head. That being said I will pay attention to 99 or above. I have seen sick pts w/ multilobar PNA, sepsis, etc with normal temp or only abnormal vitals are a pulse of 95 and a temp of 99. So it is not ALL for the birds, but this is quite different from the totally fine, 1d of sinusitis with a 98 that is "high for me." Link to comment Share on other sites More sharing options...
gbrothers98 Posted February 28, 2015 Share Posted February 28, 2015 I'll take a drug seeker over a hypochondriac or psychosomatic patient any day. At least with the drug seeker I can pretty quickly figure out what they want and dispo them accordingly, either with a few norcos or empty handed (depending on how much grief they've put me through). The fibro patients are what really wear me down. They come in with a laundry list of vague unrelated complaints, never seem to get to the point of why they are in the ER, they are usually emotionally needy and histrionic, pushing the call light over and over and disrupting the nurses. When they start to get into potentially serious complaints like shortness of breath or chest pain or neuro deficits it really tests my patience. The problem giving seekers a few norcos is that they keep coming back to waste your time. Empty handed is the best disposition along with a brochure on local treatment options. You may find it in the parking lot on the way to your car but in the end you have done 2 things. Not added to the individual's problem. Not added to the local communities problem. As for the fibro patients, I find success with reviewing prior records, normal vitals, select testing and referral to the PCP. I personally quash the multiple call light thing quickly. I also send their name to the social workers to have them outreach to keep them out of the ED. It doesnt always work but at least when they get in front of me again, they realize that I wont be sucked into their vortex. Doing it all with a smile on my face is the tough part. GB PA-C Link to comment Share on other sites More sharing options...
cinntsp Posted March 1, 2015 Share Posted March 1, 2015 Yes I see this with the affluent type when I rarely encounter them. 98 is a fever because their normal is 96. I usually just nod in agreement and say "okay so maybe you have a low grade fever..." and discount it in my head. That being said I will pay attention to 99 or above. I have seen sick pts w/ multilobar PNA, sepsis, etc with normal temp or only abnormal vitals are a pulse of 95 and a temp of 99. So it is not ALL for the birds, but this is quite different from the totally fine, 1d of sinusitis with a 98 that is "high for me." 99 doesn't even meet SIRS criteria. You would have more going on than a pulse of 95 and temp of 99 to call someone septic, in which case that temp is still irrelevant. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted March 1, 2015 Moderator Share Posted March 1, 2015 As for the fibro patients, I find success with reviewing prior records, normal vitals, select testing and referral to the PCP. I personally quash the multiple call light thing quickly. I also send their name to the social workers to have them outreach to keep them out of the ED. It doesnt always work but at least when they get in front of me again, they realize that I wont be sucked into their vortex. Doing it all with a smile on my face is the tough part. GB PA-C I'm really tempted to try that ketamine infusion for fibro flares the pain management doc was advocating at sempa a few years ago....:) Link to comment Share on other sites More sharing options...
Febrifuge Posted March 1, 2015 Share Posted March 1, 2015 "5 Stop alternating Tylenol and Motrin." Why? I would much rather my patients with pain or fever take two doses of Tylenol and two doses of Motrin over the course of the day, than take four doses of either one. Link to comment Share on other sites More sharing options...
Moderator ventana Posted March 1, 2015 Moderator Share Posted March 1, 2015 Yesterday on call call "I have a ST again and I need ABX. I have a party tonight and I don't feel good" What I need to be seen? I know my body and it is ST again Ahh nope - not with out being seen Goes to the ER Rapid strep + Then the EMPA gives her CIPRO and PERCOCET ????????????????? Link to comment Share on other sites More sharing options...
medic25 Posted March 1, 2015 Share Posted March 1, 2015 "5 Stop alternating Tylenol and Motrin." Why? I would much rather my patients with pain or fever take two doses of Tylenol and two doses of Motrin over the course of the day, than take four doses of either one. I think the biggest worry is the risk of medication error. When you wake up at 3am with a crying infant, it's easy to forget which drug you gave 2 hours ago; not good to double up constantly on Tylenol. Link to comment Share on other sites More sharing options...
winterallsummer Posted March 1, 2015 Share Posted March 1, 2015 99 doesn't even meet SIRS criteria. You would have more going on than a pulse of 95 and temp of 99 to call someone septic, in which case that temp is still irrelevant. My point is pts can be septic even with normal vitals eg in neutropenia or immunocompromised pts. This is in contrast to a pt with a benign low grade or actually totally normal temp and subjective fevers. Link to comment Share on other sites More sharing options...
Moderator True Anomaly Posted March 1, 2015 Moderator Share Posted March 1, 2015 "5 Stop alternating Tylenol and Motrin." Why? I would much rather my patients with pain or fever take two doses of Tylenol and two doses of Motrin over the course of the day, than take four doses of either one. I think the point is that you can ideally use both Motrin and Tylenol to help control symptoms at the same time Link to comment Share on other sites More sharing options...
Moderator True Anomaly Posted March 1, 2015 Moderator Share Posted March 1, 2015 Yesterday on call call "I have a ST again and I need ABX. I have a party tonight and I don't feel good" What I need to be seen? I know my body and it is ST again Ahh nope - not with out being seen Goes to the ER Rapid strep + Then the EMPA gives her CIPRO and PERCOCET ????????????????? If she was going to a party, a couple drinks would've made her feel about the same Link to comment Share on other sites More sharing options...
gbrothers98 Posted March 1, 2015 Share Posted March 1, 2015 Yesterday on call call "I have a ST again and I need ABX. I have a party tonight and I don't feel good" What I need to be seen? I know my body and it is ST again Ahh nope - not with out being seen Goes to the ER Rapid strep + Then the EMPA gives her CIPRO and PERCOCET ????????????????? Maybe the Cipro choice was due to various allergies and affordability. While fluoroquinolones are NOT my first or 2nd line for strep, they likely will work. Cipro is also a Walmart $4 drug. As for Percocet, I am usually a bigger proponent of IM decadron but at times have given small amounts of vicodin and percocet to patients who have had an ugly looking throat and are obviously uncomfortable. Or this could be total BS practice but I would have to reserve judgement till I reviewed the note. G Brothers PA-C Link to comment Share on other sites More sharing options...
Moderator ventana Posted March 2, 2015 Moderator Share Posted March 2, 2015 Maybe the Cipro choice was due to various allergies and affordability. While fluoroquinolones are NOT my first or 2nd line for strep, they likely will work. Cipro is also a Walmart $4 drug. As for Percocet, I am usually a bigger proponent of IM decadron but at times have given small amounts of vicodin and percocet to patients who have had an ugly looking throat and are obviously uncomfortable. Or this could be total BS practice but I would have to reserve judgement till I reviewed the note. G Brothers PA-C very possibly, but last time I checked the only FQ that DID NOT COVER STREP was CIPRO......... ugh.... Link to comment Share on other sites More sharing options...
Febrifuge Posted March 2, 2015 Share Posted March 2, 2015 I think the biggest worry is the risk of medication error. When you wake up at 3am with a crying infant, it's easy to forget which drug you gave 2 hours ago; not good to double up constantly on Tylenol. Fair enough, but I print out a written version as well as verbally reviewing the plan: know the doses of the two meds (because volumes may not be the same, even though both are based on weight), and give one or the other every 3 or 4 hours. That way you're spacing two doses of the same med 6 or 8 hours apart. It's not totally idiot-proof, but if it turns out you gave Tylenol twice in 8 hours overnight it's less of a big deal. Not to mention, if you're not waiting the whole 6-8 hours between doses of something, it's more likely the little cherub will sleep longer and it'll be irrelevant. Link to comment Share on other sites More sharing options...
Febrifuge Posted March 2, 2015 Share Posted March 2, 2015 I think the point is that you can ideally use both Motrin and Tylenol to help control symptoms at the same time Then it's a grammar issue, because I would describe what you're talking about as alternating them: using them both together (on the same day) and overlapping their duration of effect... but not giving both meds at the same exact time. 12:00 Tylenol, 3:30 ibuprofen, 7:00 Tylenol again, 11:00 ibuprofen again... And I would think the risk of over-dosing would be way higher if parents stick to just one or the other. At least the two meds are toxic to different organs. So I would not be so comfortable telling people not to alternate the meds, because I'd worry they would empty the Tylenol bottle over a weekend or something. Link to comment Share on other sites More sharing options...
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