Posted in Clinician Information

Tuberculosis Screening and Latent TB Treatment for Primary Care

Screening Recommendations for Tuberculosis in Healthcare Workers

In the May 17, 2019 MMWR, the CDC changed their recommendation on how to screen healthcare workers for TB. Here’s the short version of their recommendations:

  1. TB screening with an individual risk assessment and symptom evaluation at baseline (preplacement);
  2. TB testing with an interferon-gamma release assay (IGRA) or a tuberculin skin test (TST) for persons without documented prior TB disease or latent TB infection (LTBI);
  3. No routine serial TB testing at any interval after baseline in the absence of a known exposure or ongoing transmission;
  4. Encouragement of treatment for all health care personnel with untreated LTBI, unless treatment is contraindicated;
  5. Annual symptom screening for health care personnel with untreated LTBI;
  6. Annual TB education of all health care personnel.

Diagnosing Latent TB

If a person has a positive IGRA or TST, but has no symptoms of disease they meet criteria for Latent TB.

Treatment of Latent TB

Want to keep it simple? Treat latent tuberculosis with 4 months (120 doses) of once daily Rifampin. Dose is weight based. Adults are 10 mg/kg. Children must be age 2 years or older, their dose is 15-20 mg/kg. Rifampin (rifampicin; RIF) is formulated as 150 mg and 300 mg capsules. Max dose is 600 mg.

You can use these logs from the CDC to help the patient track their medications. CDC says that patients should be seen monthly to check for treatment-associated adverse events (systemic drug reactions, loss of appetite, vomiting, yellow eyes, tenderness of the liver, easy bruising, rash). Sounds like a good idea at least to have a telephone call with the patient each month. Don’t panic if the patient reports urine or saliva turning a reddish-orange color – it is not uncommon (although you should make sure that’s the only symptom they are experiencing).

There are great handouts and more information on the CDC website for Latent TB.

Reference:

  1. Health System Costs of Treating Latent Tuberculosis Infection With Four Months of Rifampin Versus Nine Months of Isoniazid in Different Settings, Annals of Internal Medicine
Posted in Fun

Normal Vitals Wall Decor

Have trouble remembering normal vitals for children of various ages? Try decorating with these wall photos and you’ll never forget again!

A day without demographics is like a day without sunshine
A day without demographics is like a day without sunshine
Fever = 100.4 F
Fever = 100.4 F
Minimum wet diapers in 24 hours: 3
Minimum wet diapers in 24 hours: 3
Newborn to 6 months: 120-150 bpm
Newborn to 6 months: 120-150 bpm
6 to 12 months: 110-140 bpm
6 to 12 months: 110-140 bpm
1-2 years: 90-130 bpm
1-2 years: 90-130 bpm
3-5 years: 80-120 bpm
3-5 years: 80-120 bpm
6-12 years: 70-110 bpm
6-12 years: 70-110 bpm
13+: 60-100 bpm
13+: 60-100 bpm
0-12 months: 30-50 breaths per minute
0-12 months: 30-50 breaths per minute
1-2 years: 25-40 breaths per minute
1-2 years: 25-40 breaths per minute
3-5 years: 20-30 breaths per minute
3-5 years: 20-30 breaths per minute
6 to 12 years: 16-25 breaths per minute
6 to 12 years: 16-25 breaths per minute
13 years and older: 12-20 breaths per minute
13 years and older: 12-20 breaths per minute
Posted in Patient Information

Eczema Home Treatment Plan

“The itch that rashes.”

Managing the symptoms at home can seem can seem daunting, but patients can take control of this condition with changes to the daily routine and a stepwise approach when symptoms worsen.

Prevention (do this every day, always):

Apply moisturizer twice a day.

  • Ointment – most effective, greasy, hard to apply. Won’t burn the skin if it is scratched and dry.
  • Creams – next most effective, thick.
  • Lotions – least effective, easiest to apply.

Apply the maintenance steroid cream once a week as a proactive treatment to prevent flares.

Avoid drying the skin when bathing

  • Shorter showers (not baths) are better.
  • Use cooler water, less than 104 °F (40° C).
  • Use a simple bar soap like a Dove bar. Fancy soaps have fancy chemicals.
  • Soap the Face, Armpits, Groin, Feet, Hands. Other areas do not need soap unless they are soiled or very dirty.

Minor flare – use your steroid every day!

  • Apply your regular steroid to all affected areas twice a day, Monday through Friday. Take a break on the weekend to ensure the steroid continues to be effective.
  • Continue to use moisturizers and avoiding long hot baths.

Severe flare – time for a stronger steroid!

  • Apply stronger steroid twice a day, again Monday through Friday.
  • As always, keep using the moisturizer, and maintain your normal skin therapies.
  • When symptoms improve you should work your way back to Prevention in steps. First treat as a Minor flare and only reduce your use of regular steroid when your symptoms are back under control.

Links

Topical Steroid Potency Chart: National Psoriasis Foundation

Posted in Patient Information

Benign Paroxysmal Positional Vertigo (BPPV) Treatment

RIGHT: Epley maneuver for self-treatment of benign positional vertigo

Treatment of Right Sided BPPV (Epley maneuver)
  1. Lie back quickly with shoulders on the pillow and head reclined onto the bed. Wait for 30 seconds.
  2. Turn your head 90° to the left (without raising it) and wait again for 30 seconds.
  3. Turn your body and head another 90° to the left and wait for another 30 seconds.
  4. Sit up on the left side.
  5. Start sitting on a bed and turn your head 45° to the right. Place a pillow behind you so that on lying back it will be under your shoulders.

LEFT: Epley maneuver for self-treatment of benign positional vertigo

Treatment of Left Sided BPPV (Epley maneuver)
  1. Start sitting on a bed and turn your head 45° to the left. Place a pillow behind you so that on lying back it will be under your shoulders.
  2. Lie back quickly with shoulders on the pillow and head reclined onto the bed. Wait for 30 seconds.
  3. Turn your head 90° to the right (without raising it) and wait again for 30 seconds.
  4. Turn your body and head another 90° to the right and wait for another 30 seconds.
  5. Sit up on the right side.

Post treatment care

This maneuver should be carried out three times a day. Repeat this daily until you are free from positional vertigo for 24 hours.

Wait for 10 minutes after the maneuver is performed doing activities. This is to avoid “quick spins,” or brief bursts of vertigo as debris repositions itself immediately after the maneuver. Don’t drive immediately after performing the procedure.

Sleep semi-recumbent for the next night. This means sleep with your head halfway between being flat and upright (a 45 degree angle). This is most easily done by using a recliner chair or by using pillows arranged on a couch (see figure). During the day, try to keep your head vertical. You must not go to the hairdresser or dentist. No exercise which requires head movement. When men shave under their chins, they should bend their bodies forward in order to keep their head vertical. If eye drops are required, try to put them in without tilting the head back. Shampoo only under the shower. Some authors suggest that no special sleeping positions are necessary (Cohen, 2004; Massoud and Ireland, 1996). We, as do others, think that there is some value (Cakir et al, 2006)

Sleep with your head halfway between being flat and upright (a 45 degree angle). This is most easily done by using a recliner chair or by using pillows arranged on a couch.

For at least one week, avoid provoking head positions that might bring BPPV on again.

  • Use two pillows when you sleep.
  • Avoid sleeping on the “bad” side.
  • Don’t turn your head far up or far down.
  • Be careful to avoid head-extended position, in which you are lying on your back, especially with your head turned towards the affected side. This means be cautious at the beauty parlor, dentist’s office, and while undergoing minor surgery.
  • Try to stay as upright as possible.
  • Exercises for low-back pain should be stopped for a week.
  • No “sit-ups” should be done for at least one week and no “crawl” swimming. (Breast stroke is OK.)
  • Also avoid far head- forward positions such as might occur in certain exercises (i.e. touching the toes).
  • Wait to start doing BPPV exercises (Brandt-Daroff) for 2 days following the Epley or Semont maneuver, unless specifically instructed otherwise by your doctor.

At one week after treatment, put yourself in the position that usually makes you dizzy. Position yourself cautiously and under conditions in which you can’t fall or hurt yourself. Let your doctor know how you did.

Links

Dr. Hain’s BPPV Info
Vestibular Disorders Association
Geriatric Depression Scale
Berg Balance Scale (PDF)
Dizziness Handicap Inventory (PDF)

Posted in Inpatient

COVID-19 Respiratory Failure Treatment

For inpatient treatment of COVID-19 pneumonia with acute respiratory failure (aka, people with a positive COVID-19 test who need oxygen to keep their SPO2 > 92%).

Oxygen therapy levels

  1. Titrate oxygen for SPO2 > 92%
  2. Oxygen delivery modalities, stepwise:

↑↑↑ Less oxygen delivered ↑↑↑

  • Simple face-mask (avoid)
  • Non-Rebreather (face-mask with bag, also avoid)
  • Nasal cannula
  • Venturi Mask / Oxymask
  • High-Flow Nasal Cannula
  • BiPAP
  • Intubation & Ventilator

↓↓↓ More oxygen delivered ↓↓↓

Non-medication adjuncts

  1. Incentive spirometry (IS) at bedside (how to use IS)
  2. Encourage patients to “self-prone” by changing position every 30 minutes, choosing between sitting up, left side, back, right side, stomach.  (Note: Qian et. al 2022 [PDF]suggests that self-proning in non-intubated patients may not confer benefit.)

For all patients requiring oxygen (respiratory failure)

  1. Dexamethasone 6 mg IV or PO q24 hours for 10 days
  2. Remdesivir 200 mg IV x 1, then 100mg IV q24 hours for 5 days, or

For high risk patients, or anybody that acutely worsens

It is not yet clear whether baricitinib or tocilizumab is superior. Choice depends mostly on availability and institutional practice.

  1. An anti-inflammatory medication, either:
  • Baricitinib 4 mg PO for 14 days, or
  • Tocilizumab 8mg/kg (weight >= 30kg) or 12mg/kg (weight < 30kg) IV infusion x 1 (max dose 800 mg)

If bacterial pneumonia suspected

2-3% of COVID-19 pneumonia patients also develop bacterial pneumonia.

  1. Ceftriaxone 2 gm IV q24 hours x 5 days,
  2. Plus pick one:
  • Usually: Azithromycin 500 mg IV q24 hours x 5 days, or
  • If concern for MRSA: Doxycycline 200 mg IV x 1, then 100 mg IV q12 hours for 10 days

For symptom relief

  1. Tessalon perles (aka benzonatate) PRN cough
  2. Guaifenesin (with or without codeine) PRN cough
  3. Ipratropium-albuterol nebulizer treatments PRN shortness of breath
  4. Acetaminophen PRN pain/fever/headache

DVT prophylaxis

  1. Pick your favorite prophylaxis:
  • Lovenox 30-40 mg SQ q24 hours (normal prophylactic dose, adjusted for renal function if necessary), or
  • If kidney injury: Heparin 10K units q8-12 hours

NIH COVID-19 Hospitalized Patient Management

Feature Image attribution: CDC PHIL #23354, downloaded on 3/14/2022

Posted in Procedures

Lipoma Removal

Equipment List

  1. Sterile gloves (1 pair)
  2. 15 Blade Disposable Scalpel (1)
  3. Iris Scissors, Straight (1 pair)
  4. Needle Driver (1 pair)
  5. Toothed Pickup (1)
  6. Suture: Assorted (if specific suture not requested by provider)
    • 3-0 Vicryl (1)
    • 4-0 Ethilon (1)
  7. 10 ml syringe (1)
  8. 18 gauge 1.5 inch needle (1)
  9. 27 gauge 1.25 inch needle (1)
  10. ChloraPrep 3mL stick (1)
  11. Alcohol Swabs (4)
  12. Sterile 4×4 gauze (5)
  13. Sterile 2×2 gauze (2)
  14. Paper Medical Tape (1 roll)
  15. Exam-room sheet (1 sheet, when necessary due to location of area to be excised)
  16. Chux Pads (1)
  17. Formalin cups (as many cups as specimens)
  18. 1% or 2% lidocaine: If fingers, toes, penis, or nose – then without epinephrine. Otherwise it is ok to have epinephrine. (1 vial with minimum 20 mL remaining)

Procedure Note

LIPOMA REMOVAL

The procedure was explained in detail and informed consent was obtained from the patient. The area was prepped and draped in a sterile fashion, and infiltrated with _ mL of _% lidocaine with_ epinephrine for local anesthesia. The lipoma was palpated superficially under the dermis. An incision was made directly over the lipoma, and gentle blunt dissection was performed to free and then remove the lipoma. The specimen was placed in specimen jar and sent for analysis. Closure was performed with _ simple interrupted sutures using _ type of suture. Petroleum ointment and a bandage were applied. EBL was less than 1 ml. Good hemostasis. There were no complications. Patient instructed to follow up for fever, erythema, swelling, pain, or purulent discharge from the wound. The patient voiced understanding. Suture removal in _ days.

Posted in Procedures

Skin Biopsy

Equipment List

  1. Nitrile Exam Gloves (1 pair)
  2. Sterile Gloves (1 pair)
  3. 15 Blade Disposable Scalpel (1)
  4. Iris Scissors, Straight (1 pair)
  5. Needle Driver (1 pair)
  6. Toothed Pickup (1)
  7. Suture: Assorted (if specific suture not requested by provider)
    • 3-0 Vicryl (1) – absorbable for deep or layered repair
    • 4-0 Ethilon (1) – for skin closure
  8. Sterile Medium Drape (1)
  9. ChloraPrep 3 mL stick (1)
  10. Alcohol Swabs (4)
  11. Sterile 4×4 gauze (5)
  12. 1% or 2% lidocaine: If fingers, toes, penis, or nose – then without epinephrine. Otherwise it is ok to have epinephrine. (1 vial with minimum 20 mL remaining)
  13. 10 ml syringe (1)
  14. 18 gauge 1.5 inch needle (1)
  15. 27 gauge 1.25 inch needle (1)
  16. Exam-room sheet (1 sheet, when necessary due to location of area to be excised)
  17. Chux Pads (1)
  18. Formalin cups (as many cups as biopsy specimens)
  19. Paper Medical Tape (1 roll)
  20. Sterile 2×2 gauze (5)

Procedure Note

EXCISIONAL/INCISIONAL BIOPSY

The procedure was explained in detail and informed consent was obtained from the patient. The area was prepped and draped in a sterile fashion, and infiltrated with _ ml of _% lidocaine with_ epinephrine for local anesthesia. An elliptical cision was performed to remove the lesion, and the specimen was placed in specimen jar and sent for analysis. Closure was performed with _ suture material. Petroleum ointment and a bandage applied. EBL less than 1 ml. Good hemostasis. There were no complications. Patient instructed to follow up for fever, erythema, swelling, pain, or purulent discharge from the wound. The patient voiced understanding. Suture removal in _ days.

Suture Removal Time Period

Face: 5-7 days

Neck: 7 days

Scalp: 10 days

Trunk & Upper Extremities: 10-14 days

Lower Extremities: 14-21 days

Sutures in wounds under greater tension may have to be left in place slightly longer.

Posted in Procedures

Endometrial Biopsy

Consent Forms

Ensure Patient is Not Pregnant

Equipment List

  1. Sponge forceps (1)
  2. Nitrile exam gloves (2 pair each)
  3. Exam-room sheet (1 sheet)
  4. Chux pads (4)
  5. Speculum (3 total: 1 white, 1 green, 1 blue)
  6. Lubricant gel packet (5)
  7. Pipelle (1)
  8. Os finder (1)
  9. Formalin cup (1 cup)
  10. Foxtail swabs (at least 5 or more)
  11. Sanitary pad (1)
  12. Iodine swab sticks (3)

Procedure Note

ENDOMETRIAL BIOPSY:

Procedure was discussed with the patient including indications, risks, benefits, and alternatives. The patient opted to go forward with procedure. Timeout completed and documented on paper chart.

After visualization of the cervix with a clean speculum the cervix was prepped with iodine swab sticks, a single tooth tenaculum was used to stabilize the cervix, then an endometrial biopsy pipelle was inserted through the cervical os. Uterus measured _ cm on the pipelle markings. Tenaculum removed. Pipelle plunger was withdrawn completely and a spiral motion of the pipelle was performed to sample the endometrial lining. A total of _ passes were performed until adequate sampling obtained. Pipelle removed. Tenaculum site was hemostatic. Minimal bleeding noted from cervical os. Patient tolerated procedure well. Return precautions given.

Followup per pathology results.

Posted in Procedures

Newborn Circumcision

Consent Form

Post Procedure Handout

Equipment List

  1. Gomco circumcision clamps:
    • 1.1 bell + 1.1 base (1 each)
    • 1.3 bell + 1.3 base (1 each)
    • 1.45 bell + 1.45 base (1 each)
    • 1.6 bell + 1.6 base (1 each)
    • Yoke (2 yokes)
    • Nut (2 nuts) 2, because these are easy to drop
  2. Mosquito forceps, curved (2 pair)
  3. Mosquito forceps, straight (1 pair)
  4. Iris scissors, straight (1 pair)
  5. 18 gauge 1.5 inch needle (1)
  6. 27 gauge 1.5 inch needle (1)
  7. Safety pins (2 pins)
  8. 15 Blade disposable scalpel (1)
  9. ChloraPrep 3 ml stick (1)
  10. 1% Lidocaine (withOUT epinephrine) (1 vial)
  11. EMLA Cream (1 tube), if EMLA cream is not available, then 2% Lidocaine hydrochloride jelly is acceptable replacement
  12. Petroleum ointment (Vaseline) (1 tube)
  13. Circumstraint papoose board (1 board) + Leg Straps (1 pair)
  14. Exam-room sheet (1 sheet), or baby blanket (2 blankets)
  15. Nitrile exam gloves (1 pair)
  16. Sterile gloves (2 pair)
  17. Plastic sterile drape with fenestration (1)
  18. Blue sterile drape (1 drape)
  19. Sterile 2×2 gauze (5)
  20. Sterile 4×4 gauze (5)
  21. Alcohol swabs (4)
  22. 1 ml syringe (1)
  23. Xeroform sterile petrolatum gauze dressing (1 package)
  24. Sweet-ease® Sugar Water (1)
  25. Bulb suction device (1)

Pre Procedure Preparation

Sterile Area:

In sterile fasion, place Gomco, sterile gauze, scalpel, safety pins, and all sterile surgical equipment (hemostats, scissors, etc…) on a blue sterile drape.

Non-Sterile Area:

In the 1 ml syringe, draw up 1 ml of 1% lidocaine WITHOUT epinephrine. Label the syringe with the contents (write: 1% lido w/o epi). Keep all remaining equipment unopened in the non-sterile area. Prepare the Papoose board with the leg restraints. Have the Sweet-ease and bulb suction at the head of the board for easy access.

Procedure Note

CIRCUMCISION, GOMCO TECHNIQUE

Parents of infant were counseled on the procedure, and all questions answered. Parents voiced their desire to proceed with the circumcision. Infant was placed on the Papoose board, legs secured with restraining straps, and infant’s upper torso and upper extremities were secured by swaddling with a baby blanket. Timeout performed. After cleansing skin with alcohol swab, 1 mL of 1% lidocaine without epinephrine was injected with a 27 gauge needle in a combination dorsal penile/ring block. Surgical site was sterilized with ChloraPrep and draped in sterile fashion. The foreskin was grasped at 3 and 9 o’clock with the curved mosquito hemostats. The preputial opening was stretched and the synechial adhesion were broken with a straight hemostat. The midline foreskin was clamped for 30 seconds, then a midline dorsal slit was made. The bell-shaped plunger was placed over the glans covering the entire glans. The shaft skin below the corona remained relaxed and supple. The plate of the clamp was applied at the level of the corona. Once in proper alignment the clamp was tightened and a circumferential incision was made with a cold knife. The clamp was left in place for 5 minutes to allow for clotting and coagulation to occur. The clamp was then removed and iodoform gauze was placed at the crush line. Good cosmesis and hemostasis was obtained. Size of Gomco: _. Amount of bleeding: < 1mL. Complications: none.

The infant was observed after the procedure, no further bleeding was noted. One time dose of 10 mg/kg oral baby acetaminophen (160 mg/ml concentration) was given. Handout on circumcision care given to parent, all questions answered. Infant allowed to return to care of parents with return precautions.

References

Newborn Circumcision Techniques – American Family Physician

Posted in Procedures

Vasectomy

Consent

Patient Information

Equipment List

  1. Vasectomy ring clamp (2)
  2. Vasectomy dissector (1)
  3. Mosquito forceps, curved (2 pair)
  4. Mosquito forceps, straight (1 pair)
  5. Iris scissors, straight (1 pair)
  6. Needle driver (1 pair)
  7. Nitrile exam gloves (1 pair)
  8. Sterile gloves (3 pair per provider)
  9. Sterile medium drape (3)
  10. Suture: 4-0 vicryl (2)
  11. Sterile towels (5 towels)
  12. Cautery pen (1)
  13. ChloraPrep 26 ml stick (1)
  14. Foam tape (1 new roll)
  15. Sterile 4×4 gauze (20)
  16. 1% lidocaine without epinephrine (1 vial with minimum 20mL remaining)
  17. 10 ml syringe (2)
  18. 18 gauge 1.5 inch needle (2)
  19. 27 gauge 1.5 inch needle (2)
  20. 15 Blade disposable scalpel (1)
  21. Exam-room sheet (1 sheet)
  22. Chux pads (2)
  23. Formalin cups (2 cups)

Room Preparation

  • Remove any unnecessary items from the room (stool, vitals machine)
  • Clean the room: wipe down all surfaces and wait the appropriate amount of contact time. Vacuum the floor.
  • Ensure the room temperature is set to 70 degrees Fahrenheit.
  • Turn on the surgical light.
  • Prepare a surgical tray in sterile fashion:
    • Medium drape
    • All sterile tools
    • Suture material, cautery pen, ChloraPrep stick, 10 cc syringes, 18 and 27 gauge needles (1 each)
  • Have all other equipment available on top of a chux pad, on top of the equipment drawers.

Patient Preparation

  • Check the patient in, and bring them to an exam room to review and sign the consent form. Once they have had a chance to ask any questions, bring them into the procedure room.
  • Make sure a chux pad is on the procedure table. Have the patient remove pants and underwear, and cover themselves with the sheet.
  • Have the patient apply foam tape to penis securing it against the abdomen.
  • Once provider enters, ensure TIMEOUT occurs.
  • Put on non-sterile gloves. Once provider starts, assist by elevating the scrotum while the provider sterilizes the skin with ChloraPrep. Provider will then place blue towels under and around the region, and finally cover the entire area with a a medium sterile drape to create a sterile field.

After the Procedure

  • Assist the patient with placing gauze over the scrotum and securing it with tape.
  • Answer any last questions, and assist the patient back to the waiting area, ensuring their driver is available or on the way.
  • If specimens were collected, check that they are labelled correctly and bring them to lab.

Procedure Note

VASECTOMY

Pre-procedure counseling completed, including risk discussion of bleeding, infection, need for repeat procedure, chronic pain, failure of sterilization. Timeout completed and documented on paper chart.

An examination of the genitals is normal; both testes normal without tenderness, masses, hydroceles, varicoceles, erythema or swelling.

Shaft normal, meatus normal without discharge. No inguinal hernia noted. No inguinal lymphadenopathy. Anatomic landmarks were confirmed

Under sterile conditions, a 1-2 cm wheal was made at the desired incision site with 1% lidocaine without epinephrine, administered to provide local skin anesthesia. The needle was then advanced through the wheal parallel and adjacent to the _left vas and toward the external inguinal ring. After gentle aspiration to ensure the needle is not in a blood vessel, _ cc of 1% Lidocaine without epinephrine was injected into the external spermatic fascia.

The vas was maneuvered to the desired location, and vas clamp was applied to isolated vas. The soft tissue was then bluntly dissected with a fine cured hemostat. The left vas was elevated and exposed. The vas was hemi-transected. Thermal cautery applied to a 1 cm length inside the lumen of the prosthetic end of the cut vas until blanching occurred. The vas was then completely transected and facial interposition achieved with a metal clip over the prostatic end and the testicular end. The area was inspected thoroughly and good hemostasis was noted before the vas was reduced back into the scrotum. The procedure was repeated on the right vas. The estimated blood loss was <2 cc. Petroleum jelly applied over areas of dissection to provide barrier protection. The patient tolerated the procedure well.

Patient instructed to return 8-12 weeks post procedure for semen analysis, after minimum of 25 ejaculations. Patient agreed and voiced understanding that sterility not confirmed until lab evaluation shows no sperm.