How often do you prescribe antibiotics?

[ggidgetzz]

I am an MSIV going into FM, and I have just finished a rotation with a rural, private family practice clinic and loved my time there. However, one thing that made me uneasy was the liberal use of (what I would consider) unnecessary antibiotic prescriptions. For example, ABs for 1-2 days of common sinusitis symptoms, ABs for a 3 day "forceful cough" in a 9 yr old without fever and just mild wheezes on exam, ABs for a couple days of URI symptoms without classic bacterial infection signs in an otherwise healthy older child or adult. Basically, a lot of ABs for what I would think are viral infections.

Upon questioning I was told this is the "real world", some ABs have anti-inflammatory properties, and that it's just what you do sometimes. This does not sit right with me considering the looming AB resistance problem and propagating misinformation to patients that every single time they feel any symptom at all they need ABs. But, I also realize that I am a student and don't have experience in the "real world". Can I get some other opinions?

---

Members don't see this ad.

 

[cabinbuilder]

When you are out in practice then you will be free to practice as you choose. Prob who you were working with got tired of fighting patients who think a Z-Pak will cure everything. Just like when I'm in Texas and folks there think a steroid shot will fix everything.

I know in urgent care patients expect to walk away with some kind of Rx because they have shelled out money to be there. Sometimes it's not worth the confrontation. However, I agree that dry cough in a 9 yr old doesn't need antibiotics. A lot of times the patients will say, "my regular doctor always gives me a Z-Pak for this". Well, they should have called their regular doctor then. Or I get, "Why can't I have antibiotics for all my kids when one has strep?" Doesn't work that way anymore. I do try to send them away with something. Cough medication or an inhaler or magic mouthwash for viral pharyngitis, etc.

Generally, I say to the patients that medicine is changing and that is not standard of care any more.

 

[midweststudent1]

I think this Is one of the negative consequences of "convenient" cares popping up in every grocery store and pharmacy, staffed with NPs who completed online degrees and can't come up with a proper differential dx. Head congestion? --4 rxs to make the pharmacist happy and $79 please. These places are like candy stores.

 

[VA Hopeful Dr]

Cabin is exactly right. It depends both on how much you enjoy fighting with these patients and how busy you are. If you have patients scheduled every 10 minutes, you aren't likely to want to take the time to explain why antibiotics aren't a good idea. It also will screw up your satisfaction scores, so best hope your job doesn't care about that too much.

 

[ggidgetzz]

Thank you for these insights. It is good to hear from multiple sources 'on the other side', so to speak.

 

[cabinbuilder]

Cabin is exactly right. It depends both on how much you enjoy fighting with these patients and how busy you are. If you have patients scheduled every 10 minutes, you aren't likely to want to take the time to explain why antibiotics aren't a good idea. It also will screw up your satisfaction scores, so best hope your job doesn't care about that too much.

Exactly true. Medicine today is all about customer service and how happy the patients are with your care and whether you give them what they want. Google is our worst enemy and every mo-jo has an online diploma on their wall.

 

[deleted87716]

I do my best to avoid unnecessary antibiotics. However, if we only treated infections that we were CERTAIN were bacterial, we'd miss the boat quite often.

In situations where I'm pretty sure something is viral, but the patient is pushing for an antibiotic, I'll sometimes give them a "backup prescription" along with instructions not to take it unless they're not improving or getting worse over a given period of time. In most cases, when I see them back at a later date for something else and ask them if they needed the antibiotic, they say "no."

 

[VA Hopeful Dr]

I do my best to avoid unnecessary antibiotics. However, if we only treated infections that we were CERTAIN were bacterial, we'd miss the boat quite often.

In situations where I'm pretty sure something is viral, but the patient is pushing for an antibiotic, I'll sometimes give them a "backup prescription" along with instructions not to take it unless they're not improving or getting worse over a given period of time. In most cases, when I see them back at a later date for something else and ask them if they needed the antibiotic, they say "no."

Yeah, I like both the post-dated script or the "call me if you get worse or aren't feeling any better by X date". Still won't please everybody, but it defuses quite a few.

Then again, I am urgent care so I hear at least a few times every day "I will just call my regular doctor and he will give me a z pack".

 

[cabinbuilder]

Yeah, I like both the post-dated script or the "call me if you get worse or aren't feeling any better by X date". Still won't please everybody, but it defuses quite a few.

Then again, I am urgent care so I hear at least a few times every day "I will just call my regular doctor and he will give me a z pack".

I hear ya. I get the same thing. My hardest issue is people coming to urgent care because they ran out of their bp meds, etc. Makes me crazy. Need to call your doctor, folks. Or the dental pain at 5 minutes to closing on a Friday night hoping to get some party pills.

 

[VA Hopeful Dr]

I hear ya. I get the same thing. My hardest issue is people coming to urgent care because they ran out of their bp meds, etc. Makes me crazy. Need to call your doctor, folks. Or the dental pain at 5 minutes to closing on a Friday night hoping to get some party pills.

I honestly don't know how you stand it. I've been doing urgent care for less than 1 year and absolutely hate it.

 

[cabinbuilder]

I honestly don't know how you stand it. I've been doing urgent care for less than 1 year and absolutely hate it.

Well, I do urgent care in rural places so I get a lot of crazy, cool stuff too. I run mine like a mini ER so I do CT's etc. It breaks up the monotony. Today I had a surgical back abscess, separated shoulder, I&D of an arm abscess, HFM disease, Flu B, RSV, then a bunch of head colds. Last week I had a guy who was SOB when laying down (this was new) ended up having a ruptured diaphragm on the right with eventration of the liver into the chest cavity. That was cool. I see urgent care as the safety net for people who won't go to the ER and/or don't have a doctor.

I really hate the mudane FP office - now THAT makes me crazy. Ugh, the diabetes, hypertension, anxiety, labs, preventative care. Just hatefully boring.. That's the beauty of FP, you can mold it however it makes you happy.

Plus, my assignments always have an end date as locums so it's ever changing for me.

 

[Bacchus]

As a resident I probably see 20-30 patients a week when on other rotations, about 50 patients a week or more when on ambulatory medicine. As soon as November rolled around the push for antibiotics was strong. I'd say I give less than 5-10% of the URI patients, etc antibiotics. I don't remember giving anyone antibiotics after they received them from an urgent care and were seeing me for follow up. I skirt the issue by offering other things, often cough medicines that are prescriptions.

 

[KnuxNole]

Well, I do urgent care in rural places so I get a lot of crazy, cool stuff too. I run mine like a mini ER so I do CT's etc. It breaks up the monotony. Today I had a surgical back abscess, separated shoulder, I&D of an arm abscess, HFM disease, Flu B, RSV, then a bunch of head colds. Last week I had a guy who was SOB when laying down (this was new) ended up having a ruptured diaphragm on the right with eventration of the liver into the chest cavity. That was cool. I see urgent care as the safety net for people who won't go to the ER and/or don't have a doctor.

I really hate the mudane FP office - now THAT makes me crazy. Ugh, the diabetes, hypertension, anxiety, labs, preventative care. Just hatefully boring.. That's the beauty of FP, you can mold it however it makes you happy.

Plus, my assignments always have an end date as locums so it's ever changing for me.

Yeah, it definitely feels like a safety net. People come in to the urgent care because "The ER takes 4 hours to get in, you guys see me in 10 mins!", or people who don't go to their regular doctor. And the influx of "Oh, I don't have a doctor, I come to urgent care for follow ups!"...I did tell people that Obama wants everyone to get a PCP, so I tell them to sign up with a family doctor if they don't have one.

 

[drcrispmd]

I prescribe a lot of Zyrtec or Claritin and Flonase. Also give a sample of sinus rinse with a coupon. Most patients have been receptive. I have a packet that included why antibiotics won't treat a col and another article from Cleveland clinic on what the color of snot means. Of course I have those who think a steroid shot cures everything and those who what a steroid and rocephin shot for their sinusitis because that is what they have been getting from the PA's who have been running the clinic the last 5 years.

 

[styphon]

I am very sparse with my abx. I have very specific rules I follow which are baised on a collection of guidelines/articles/cochrane reviews.

CAVEAT: Patients want/expect you to do SOMETHING now. Some will be happy with OTC recommendations - like NSAIDs, sudafed, afrin nasal spray, etc. Others demand a prescription, literally ANY prescription - in that case I use nasal steroids, anti-histamines. For severe sore throat discomfort I will give dexamethasone (there are cochrane studies on this). For asthma/COPD with bronchitis I will give medrol dose paks. For parents with kids with mild AOM I will give POST DATED abx scripts.

REMEMBER: Also all of this is very tiring and it drains the life out of you, you do not see this as a medical student or even as a resident. How often do you want to argue/fight with people convinced that abx can cure literally EVERYTHING. Especially when the other part of your day is spent arguing with drug seekers? How much time do you want to spend arguing with a parent about their kids common cold when you have 10 people in the waiting room? How deep will you go into discussion of eustaschian tube dysfunction when you know the next room is a complex laceration requiring layered closure which will likely take you an hour? When you are on the end of 12 or 24 hour shift and the patient is arguing every tiny point (studies show doctors prescribe more abx/pain meds towards the end of the shift) how long will you last? How much of your son's baseball game are you willing to miss to discuss the finer points of viral vs bacterial conjunctivitis with a very irated patient?

 

[cabinbuilder]

REMEMBER: Also all of this is very tiring and it drains the life out of you, you do not see this as a medical student or even as a resident. How often do you want to argue/fight with people convinced that abx can cure literally EVERYTHING. Especially when the other part of your day is spent arguing with drug seekers? How much time do you want to spend arguing with a parent about their kids common cold when you have 10 people in the waiting room? How deep will you go into discussion of eustaschian tube dysfunction when you know the next room is a complex laceration requiring layered closure which will likely take you an hour? When you are on the end of 12 or 24 hour shift and the patient is arguing every tiny point (studies show doctors prescribe more abx/pain meds towards the end of the shift) how long will you last? How much of your son's baseball game are you willing to miss to discuss the finer points of viral vs bacterial conjunctivitis with a very irated patient?

This totally made my day. I had a PA student come out and tell me I give too much rocephin in urgent care. I told him to get out of my office and keep his comments to himself (he was rotating with me as a courtesy). He's lucky I was not evaluating him.

 

[VA Hopeful Dr]

This totally made my day. I had a PA student come out and tell me I give too much rocephin in urgent care. I told him to get out of my office and keep his comments to himself (he was rotating with me as a courtesy). He's lucky I was not evaluating him.

My counterpoint to that...

My wife is a hospitalist literally next door to the urgent care I work at. In the last month, she's admitted 2 patients that my antibiotic-happy boss gave c diff to and one just today whose INR went through the roof (and hgb down to 5) from the 2 weeks of back-to-back zithromax and augmentin for bronchitis.

 

[cabinbuilder]

My catch of the week: 7 year old with vomiting for 5 days and palpable rash on arms and legs (trunk is spared). Seen in small hospital ER up the road and treated for chicken pox with Valtrex. Mom frantic he is not getting better and still vomiting with high fever. I wasn't sure what it was but I knew it wasn't chicken pox. I sent him to my ER.

The verdict: Henoch-Schonlein Purpura. First case I have ever seen. D-Dimer was 3.8 Admitted.

 

[styphon]

My catch of the week: 7 year old with vomiting for 5 days and palpable rash on arms and legs (trunk is spared). Seen in small hospital ER up the road and treated for chicken pox with Valtrex. Mom frantic he is not getting better and still vomiting with high fever. I wasn't sure what it was but I knew it wasn't chicken pox. I sent him to my ER.

The verdict: Henoch-Schonlein Purpura. First case I have ever seen. D-Dimer was 3.8 Admitted.

Interesting they confused VZV with HSP...

I had a PA treat a patient I thought had HSP w/ PCN as the dad loved to file complaints against people.

 

[primadonna22274]

And I'm a PA (now DO) who's diagnosed 4-5 cases of HSP over the past 15 yr. It's not that rare and it's a very classic presentation as described by Cabin.

 

[cabinbuilder]

Interesting they confused VZV with HSP...

I had a PA treat a patient I thought had HSP w/ PCN as the dad loved to file complaints against people.

Well, there is more to the story that is being investigated currently that cannot be discussed here.

 

[cabinbuilder]

I honestly don't know how you stand it. I've been doing urgent care for less than 1 year and absolutely hate it.

Today I can't stand urgent care. I have seen 11 patients, 9 of which are sinus, congestions. WTF?? No one knows how to get Sudafed, nasal spray, and sinus medication off the shelf at Wal-Mart anymore? IT"S ACROSS THE STREET FROM THE CLINIC. Sigh........debt free in 3.

 

[VA Hopeful Dr]

Today I can't stand urgent care. I have seen 11 patients, 9 of which are sinus, congestions. WTF?? No one knows how to get Sudafed, nasal spray, and sinus medication off the shelf at Wal-Mart anymore? IT"S ACROSS THE STREET FROM THE CLINIC. Sigh........debt free in 3.

And they all got antibiotics, right?

 

[cabinbuilder]

And they all got antibiotics, right?

Not all but most. What to do? Hard to fight when they know all the key words: bloody green drainage, teeth pain, post nasal drainage. Hard when you can't prove a lot of them.

 

[VA Hopeful Dr]

Not all but most. What to do? Hard to fight when they know all the key words: bloody green drainage, teeth pain, post nasal drainage. Hard when you can't prove a lot of them.

I'm quite the stickler for URI antibiotics, and my key words are "temperature 101" and "at least 1.5 weeks".

A few months back, in a passive aggressive move, I bought my more antibiotic generous colleagues a copy of the IDSA Rhinosinusitis guidelines pocket cards. Between that and a lovely Cleveland Clinic handout, its helped me quite a bit in this area.

http://my.clevelandclinic.org/healt...ns/hic_i_feel_so_sick_dont_i_need_antibiotics

 

[BDUS]

I have not yet worked in private practice. As a pediatric resident it often helped to say these few words to the parents
Child has symptoms suggestive of viral infection. The body is able to fight this off on its own.
They came to you for ...something... So give them tasks. Tell them to watch for X signs/symptoms. Tell them to use nasal saline. Tell them to monitor fluid intake and urine output. Calculate for them the dose of Tylenol PRN for the child and provide it. If they push for antibiotics tell them about side effects eg. diarrhea. Whereas antibiotics overuse leads to resistance I feel that people don't see it as an immediate adverse outcome affecting them personally in the immediate/near future so they disregard that caution.

 

[VA Hopeful Dr]

There are any number of tricks we've all developed to talk patients (or parents) out of antibiotics. You run into 2 problems with this though.

1. Some people want what they want and nothing you say is going to change their minds. It is then a matter of how much do you (or your bosses) care about pissed off patients.
2. Its much more time consuming to do all of this than it is to just hand over a z-pack script. Once again, how tight have you (or your bosses) set your schedule.

 

[BDUS]

Agree with the above. Sometimes after having spent the time educating the patient/parents. It seemed it went into one ear and right out the other.

 

[cabinbuilder]

I'm quite the stickler for URI antibiotics, and my key words are "temperature 101" and "at least 1.5 weeks".

A few months back, in a passive aggressive move, I bought my more antibiotic generous colleagues a copy of the IDSA Rhinosinusitis guidelines pocket cards. Between that and a lovely Cleveland Clinic handout, its helped me quite a bit in this area.

http://my.clevelandclinic.org/healt...ns/hic_i_feel_so_sick_dont_i_need_antibiotics

The fever doesn't phase me anymore. I have a group of "viral syndrome kids" with undulating fevers that have come through. Every thing is negative (flu, RSV, strep, ears clear). I just tell the parent that they fall into the "other" group of the no name virus. Rest, fluids, Tylenol/advil, vitamin C, chicken soup, etc. I have at least 2-3 kids a day who fall into this group. Been seeing a lot of viral pharyngitis with severe pharyngeal/uvular edema. Giving more steroids than I would like but streps are neg and they aren't even red.

 

[VA Hopeful Dr]

The fever doesn't phase me anymore. I have a group of "viral syndrome kids" with undulating fevers that have come through. Every thing is negative (flu, RSV, strep, ears clear). I just tell the parent that they fall into the "other" group of the no name virus. Rest, fluids, Tylenol/advil, vitamin C, chicken soup, etc. I have at least 2-3 kids a day who fall into this group. Been seeing a lot of viral pharyngitis with severe pharyngeal/uvular edema. Giving more steroids than I would like but streps are neg and they aren't even red.

Ah, yeah kids are different. I often tell parents that kids will spike a fever if you look at them funny. For them, its viral unless I have a pretty good reason to think that it isn't.

I've also been seeing lots of nasty viral sore throats, and handing it 3 day courses of prednisone like its candy. Beats antibiotics or narcotics though.

 

[cabinbuilder]

Ah, yeah kids are different. I often tell parents that kids will spike a fever if you look at them funny. For them, its viral unless I have a pretty good reason to think that it isn't.

I've also been seeing lots of nasty viral sore throats, and handing it 3 day courses of prednisone like its candy. Beats antibiotics or narcotics though.

Me too, nasty nasty throats. Lots of edema. Some emergently sent to ENT upstairs since I had fear for their airway. What are you doing for the sinus pressure besides Sudafed and Flonase? Any other tricks?

 

[VA Hopeful Dr]

Me too, nasty nasty throats. Lots of edema. Some emergently sent to ENT upstairs since I had fear for their airway. What are you doing for the sinus pressure besides Sudafed and Flonase? Any other tricks?

This is going to sound patronizing, but I've found that if I really talk up a treatment it tends to work better. At the same time, I also explain that even the best medicines will not completely fix symptoms, otherwise we wouldn't care if we got sick. So build up hope while setting expectations reasonably. Then again, my satisfaction scores suck so maybe you shouldn't listen to my way of doing things

Outside that, make sure they get the behind the counter Sudafed (Sudafed PE has never impressed me). Something about having to ask the pharmacist for the special Sudafed seems to help as well.

 

[cabinbuilder]

This is going to sound patronizing, but I've found that if I really talk up a treatment it tends to work better. At the same time, I also explain that even the best medicines will not completely fix symptoms, otherwise we wouldn't care if we got sick. So build up hope while setting expectations reasonably. Then again, my satisfaction scores suck so maybe you shouldn't listen to my way of doing things

Outside that, make sure they get the behind the counter Sudafed (Sudafed PE has never impressed me). Something about having to ask the pharmacist for the special Sudafed seems to help as well.

So sorry that your patient's give you bad marks. Mine are usually but then again most folks I see wouldn't have medical access otherwise. I generally send over sudogest 60mg bid. I have found that works better. Plus I never know what all the rules are in what state I am regarding Sudafed (Oregon requires and Rx, etc) so I just send it over the wire so both the pt and pharm remember to give it out. I, too, tell them that there is no "magic pill" and a lot of it is trial and error of the OTC meds out there since "everybody's chemistry is different". That usually works. Keep on.

 

[cabinbuilder]

Case of the day: Guy comes in today 27, forest fire fighter. Looks well. Only complaint was tea colored urine. UA show ketones and large bilirubin. Sent him to the ER for w/u. LFT"s were in the 4000 & 6000 range. Mono was POSITIVE.

Dx: Mononucleosis induced hepatitis. Seriously??? How do these people find me?

 

[Promethean]

This weekend, I talked a girl out of using fish antibiotics because her doctor wouldn't write for antibiotics for her. Will every patient who is determined to abuse antibiotics go to that extreme? No, probably not. But enough of them are determined enough to get what they want, by any means necessary.

There are antibiotics that we have rendered basically useless against real pathogens. At this point, why not write for one of those? If it paved the way for a better relationship and the ability to have a few educational conversations along the way.

 

[ggidgetzz]

There are antibiotics that we have rendered basically useless against real pathogens. At this point why not write for one of those? If it paved the way for a better relationship and the ability to have a few educational conversations along the way.

In situations like that, which antibiotic would you write for? This seems like a good idea when someone is determined to leave with one.

 

[VA Hopeful Dr]

This weekend, I talked a girl out of using fish antibiotics because her doctor wouldn't write for antibiotics for her. Will every patient who is determined to abuse antibiotics go to that extreme? No, probably not. But enough of them are determined enough to get what they want, by any means necessary.

There are antibiotics that we have rendered basically useless against real pathogens. At this point, why not write for one of those? If it paved the way for a better relationship and the ability to have a few educational conversations along the way.

Couple reasons. First, c diff. Second, patients already talk about which antibiotics don't work for them so you're not likely to be able to get them to actually believe that penicillin will help them.

 

[deleted87716]

In situations like that, which antibiotic would you write for? This seems like a good idea when someone is determined to leave with one.

 

[oldanddone]

given that group a beta-hemolytic strep is actually still 100% sensitive to penicillin after 50 years....excellent?
just make sure it 'really should be' the benzathine penicillin IM depot. and, although it's very likely not strep, let's just be safe and not trust that literature
now bend over...it won't hurt a bit.

edit: except that as in the case of b12 shots, injections seem to have a higher placebo effect. no pain no gain... could backfire with a big lineup waiting for the penicillin shot, cause that has to be better than some lousy old oral abx!

edit 2: as long as there's none of that terrible immunization cr** in there - that stuff'll kill ya!

 

[Promethean]

IM Penicillin shots for the folks who really insist on antibiotics? I like it!

"You know, antibiotic resistance is becoming more and more of a problem, because people are abusing these once powerful drugs by taking them for viral infections. Antibiotics don't work against viruses, but people (not you, of course!) want them anyhow. What these people are doing is helping the germs get better at surviving antibiotics, so that drugs that used to work very well aren't working at all anymore, and people are dying of what used to be easily treatable infections. We have to keep using stronger and stronger antibiotics, drugs that can have terrible side effects and hurt the person as well as the germs.

Now, in a case like yours, we have several treatment options. You can try a natural approach, support your own immune system to beat the bugs. To do that, you should rest at home for at least the next 1-3 days, drink plenty of water, juice, soup, and other beverages, and we can manage your symptoms with some medications... or, if you want to use antibiotics, well, we really do need to be sure that we use something very strong that will kill all the bugs, so that we don't help breed stronger ones. I'm afraid that at this point, that your best option for that is going to be an injection, into a big muscle, like your buttock, with this large needle...

So, how do you want to proceed?"

I don't think that would end up backfiring. Too many needle-phobes and people who are shy about showing their butts. For the handful of hypochondriacs who want an injection every month or two... well, just transition them on to B-12 injections, again with some handwavium about supporting their bodies natural blahblahblah and collect your fee. I'm not saying that one should actively peddle voodoo... just if that is what your patient really wants and is going to get somewhere one way or the other, you may as well make them happy while trying to gently educate and improve your rapport with them so that maybe they will listen when you really do need to draw a line.

 

[Promethean]

Couple reasons. First, c diff. Second, patients already talk about which antibiotics don't work for them so you're not likely to be able to get them to actually believe that penicillin will help them.

Oh, right. C. diff. That motherless endosporeforming so-and-so. Yeah.

I guess I will just keep hammering away at the "natural, support your immune system" mumbo jumbo. I mean, it isn't untrue. It is just that you have to use a few buzzwords to sell it. If you just give it as straight up, common sense advice: Rest, plenty of fluids, symptom support, then they don't want to hear it. You have to make it sound like they are getting some kind of special therapy, to justify the expense and trouble of asking a doctor to advise them on the matter. P. T. Barnum had a point.

 

[ggidgetzz]

Maybe you could explain the risk of antibiotic related C. Diff in horrible, extremely gory detail before offering the IM penicillin. It seems like these patients will get their drugs one way or the other if theyre determined, might as well educate/scare them a little first..

 

[cabinbuilder]

Oh, right. C. diff. That motherless endosporeforming so-and-so. Yeah.

I guess I will just keep hammering away at the "natural, support your immune system" mumbo jumbo. I mean, it isn't untrue. It is just that you have to use a few buzzwords to sell it. If you just give it as straight up, common sense advice: Rest, plenty of fluids, symptom support, then they don't want to hear it. You have to make it sound like they are getting some kind of special therapy, to justify the expense and trouble of asking a doctor to advise them on the matter. P. T. Barnum had a point.

Just had a patient hospitalized for unrelenting exudative pharyngitis that keep re-occurring with cyclical c.Diff. She has either had throat infection, mono, or C.diff since Mid- December. Nasty, nasty illness I wouldn't wish on anyone.

 

[VA Hopeful Dr]

Maybe you could explain the risk of antibiotic related C. Diff in horrible, extremely gory detail before offering the IM penicillin. It seems like these patients will get their drugs one way or the other if theyre determined, might as well educate/scare them a little first..

That's the thing, like 90% of people are reasonable about this; especially if you give them a time line, a plan if they're not any better, and defined things to do to help with symptoms. Oh, and a script for something - doesn't usually even matter what (God bless Bromfed).

Its the other 10% that just plain suck and they want what they want and your knowledge be damned.

 

[cabinbuilder]

So true: Bromfed is lovely as is Delsym. Or 1/2 tsp of orapred daily for croupy cough.

 

[JustPlainBill]

And a zpack is the best antiviral known to man :wink:

 

[cabinbuilder]

And a zpack is the best antiviral known to man :wink:

Apparently not today. Just had a lady come in with "chest congestion and sinus drainage". Seen 5 days ago at another urgent care and given Robitussin AC, prednisone, and Z-Pak. She is not any better and her sister got Omnicef and was "cured". She wanted that. Ummm nooooooo.

 

[drcrispmd]

So true: Bromfed is lovely as is Delsym. Or 1/2 tsp of orapred daily for croupy cough.

Love delsym. It does work and actually lasts longer than 4 hours. However I get "it's not covered by my insurance and I can't afford it". In which I follow up with "how many packs of cigs are you smoking a day now".

 

[JustPlainBill]

Apparently not today. Just had a lady come in with "chest congestion and sinus drainage". Seen 5 days ago at another urgent care and given Robitussin AC, prednisone, and Z-Pak. She is not any better and her sister got Omnicef and was "cured". She wanted that. Ummm nooooooo.

Quite obviously it was the molecular interactions of the Robitussin AC with the ZPACK that negated the overall superiority of said ZPack thusly directly contributing to the lack of response and in no way influenced by the viral nature of the disease process as I'm sure your Readers Digest/WebMD quoting patient informed you.....sort of like the chest oain/DOE case that is "certain" that it's noncardiac due to a negative stress test 6 months ago..... remember, as my mother in law informed me one day when I was post call and went directly to a family function...1 Readers Digest article trumps 4 years of undergrad, 4 years of med school, 3 years of IM residency, a cardiology fellowship, board certification and 10 years of clinical practice....my response, which included lots of compound complex profanity led to a distinct lack of invitations to family gatherings where she would be present....

 

[cabinbuilder]

OMG. @JustPlainBill thanks for making me laugh every day.