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mdebord

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About mdebord

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  1. For what it's worth, I think the steroid shots we give are something like $18 - not a booming profit and I'm not sure if I should take the implication personally or not. When I first started at my job I was unfamiliar with the practice. The patients were not. About a month into my job the office manager came to me because so many patients had complained to her that I was turning them down when they asked! I told her I would do some research and consider it. I generally use them now in cases where inflammation is the problem (allergies that are not responding to OTC tx, asthma, bronchitis, etc). I do not give them for URIs, which continues to be a sore spot between me, the patients, and the powers that be. As for the nasal steroids, I love them and take them personally. I cannot count the number of people who have refused to take them. Y'all may be starting to get the picture that I seem to have an unusually high number of difficult patients who were used to getting what they wanted before I started working here. It all goes back to a similar argument in a different thread: In a world that includes patient satisfaction surveys and pressure from employers, we are not always free to practice the best evidence-based medicine. I do what I can and I win people over sometimes. I also lose patients who will just go somewhere else and get what they want. There tends to be a lot of negativity and judging on this forum; I would just ask everyone to remember that we are not always familiar with the circumstances that others are operating within. Be kind.
  2. Call has been one week out of every 3-4 but we're transitioning to a new schedule where it's one week out of every 10-11, but that covers SEVEN CLINICS. Haven't had my turn yet so we'll see. And no additional pay for call. I really didn't mean to make this about me. My main point was that maybe it's more about the turn that modern medicine is taking and less about the cheaper new PAs.
  3. Is that from the state-specific AAPA report? I still don't have access, but putting off calling the AAPA to complain.
  4. Some of them somewhat meet the criteria (it's been almost ten days, they tell me they had fever last night, tenderness to percussion) but I'm suspicious. But sometimes it boils down to the fact that I have neither the time nor energy to have this argument ten times a day. And don't get me wrong - I am very thorough in explaining why I don't think they need Abx and also in my recs for OTC tx - but they are just not having it. It's an uphill battle.
  5. I started as a new grad in Texas FP 2 years ago. Well aware of the avg starting salary (78K at the time), I was happy to take 80. Much to my surprise, when my first anniversary rolled around, they did not plan to give me any kind of raise! I successfully argued how much more I was worth at this point, and they begrudgingly acquiesced. Now 2 years out I'm looking at a dramatically increased workload, and currently probably works out to about $38/hr. I'm not ready to look away from the profession yet, but definitely exploring other specialties. The interesting thing though is that there is no new PA grad to take my spot or drive down the salary. The powers that be just don't want to give up any more dough.
  6. I mostly use Zpaks now for the people I do not believe have an infxn but won't take no for an answer - sometimes in the form of a written Rx accompanied by "I really think it's just a virus, but if you don't improve over the weekend with the conservative therapy we discussed, you may start this." I recall reading a European study that found this was well-received and did cut back on some overuse. For true sinusitis, Augmentin. For the allergic, Omnicef (although I am aware the new guidelines call for dual therapy). For CAP, azithro 500 x 5 days plus or minus a Rocephin shot.
  7. Where are y'all seeing this? When I click on the link under data and statistics is says "content to be published." I tried following the front-page ad and I get "available for members only" - despite the fact that I'm already logged in!
  8. It depends who you ask... If I tell a patient that he has to take 2 unpaid days off work instead of 3 - he certainly deems it worthwhile to take the Tamiflu. Sometimes the risk/benefit analysis is not so clear.
  9. Agree with the above. Also - how supportive of their students is the program? I've been out long enough that I've heard some things about several of the programs in my state. The ones where the students feel "on their own" are the same programs where my interview left me with a bad taste in my mouth. The place that I chose was very warm and embracing during the interview and that held true throughout my tenure. After you've considered all the data, go with your gut!
  10. Very good! Exact tx plan will vary by provider preference, but here's what I did: Steroid shot in office, Rx tamiflu and azithromycin 500 x 5 days (could not with confidence exclude PNA so I treated with the caveat that if he worsened to go to ER). Rec Mucinex (my favorite if they have sputum) and AVOID DECONGESTANTS because of the BP. Start taking lisinopril again daily and f/u with me in 2 weeks. Rest, fluids, alternate tylenol and motrin every 3 hours for fever/aches. Also Rx Tamiflu prophylactic for wife and 2 year old daughter (don't forget this for the vulnerable!) There were a few reasons I wanted to discuss this. First, flu is common but many in the public don't realize how sick it can make you. Had this guy been elderly or even just LOOKED bad (he really didn't) I would have sent him to the ER. I had a 20 year old that ended up there with PNA last week; looked fine when I saw him and even had Tamiflu - so keep your guard up. Also, in thinking back on it, I didn't see much flu in PA school (just depends what season your IM rotations fall during), so I thought it would make for a good discussion. Thanks for the assist E! (I think the alternative he was referring to is the zanamavir). Thanks for playing guys!
  11. Alright! Now we're getting some good stuff. I mentioned the South Texas oilfield work because the patient did - It's not necessarily relevant, but that's up to you (like it was to me initially) to consider. As far as exposures go, the most common one there is poisonous gases. Of course UA COULD show Wegener's, but is that really a likely diagnosis here? Remember we don't want to order a lot of testing if we don't have to. The rest of the ROS is negative (I'm sorry, I should have stated that). Likewise, the rest of the PE is negative. Deep breaths limited by pain. CBC again not done because I don't have STAT labs, but definitely a good idea. OTC meds include phenylephrine per usual instructions but only once the night before. Wells score is 1.5 (for the HR only). Rapid flu is POSITIVE! So, let's move on to treatment plan.
  12. Previously well man with a cough; what would a UA show you? EKG shows sinus tach, otherwise nl. CXR would be excellent but we do not have the capability in office. Anything else?
  13. Good, although not all necessary. As this pt has fever, vitals are likely so elevated secondary to acute illness. Here's what I got: Const: well nourished, no acute distress, appears ill HEENT: PERRL, conjunctiva clear, turbinates benign, no nasal drainage, oral mucosa moist, pharynx WNL, TMs benign. No frontal or maxillary sinus tenderness. Neck: No LAD. CV: tachy, regular rhythm; pulses 2+ and symmetric; no peripheral edema Resp: CTAB, although breath sounds diffusely diminished due to pt not breathing deeply. I got the pulse ox at this point: 96% on RA. Abd: nl bowel sounds, no tenderness Any tests you'd like to run?
  14. Very good! Dyspnea only with coughing, denies the other acute symptoms (including chest pain). These are important, and usually what I ask first. If the patient is unstable, EMS gets called before we go any further! Patient is very vague with me about BP, says it's been "high," but won't quantify; did not take lisinopril today. No other meds or problems. Two other pertinent negatives: no asthma and a non-smoker. Okay, let's move on to the physical. What do you examine, what are you looking for?
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