Intern resolutions

[billypilgrim37]

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I made three resolutions when I graduated medical school.

1) I will never prescribe Xanax, except to keep somebody who is already addicted from withdrawing, or continuing someone's home medication on a short medical stay,

2) I will never prescribe Seroquel for sleep, except for continuing someone's home medication on a short medical stay, and

3) I will never assess a patient with a MMSE unless I can't convince my attending of how inferior a cognitive assessment it is compared to the MOCA or the Addenbrooke long form.

Since I am a creature of habit and arbitrary declaration, I was wondering what would be some similarly curmudgeonly axioms I could fold into my arsenal. Since there is no shortage of opinion on this forum, I anticipate some serious wisdom.

 

[OldPsychDoc]

4) I will never start a patient on paroxetine, except for the exceptions named above.

 

[Doc Samson]

5) I will never recommend anything other than intravenous haloperidol for delirium unless the patient has: 1) a documented anaphylactic allergy (in which case they get Risperdal), or 2) Lewy Body dementia/Parkinson's disease (in which case they get Seroquel).

 

[Solideliquid]

I made three resolutions when I graduated medical school.

1) I will never prescribe Xanax, except to keep somebody who is already addicted from withdrawing, or continuing someone's home medication on a short medical stay,

2) I will never prescribe Seroquel for sleep, except for continuing someone's home medication on a short medical stay, and

3) I will never assess a patient with a MMSE unless I can't convince my attending of how inferior a cognitive assessment it is compared to the MOCA or the Addenbrooke long form.

Since I am a creature of habit and arbitrary declaration, I was wondering what would be some similarly curmudgeonly axioms I could fold into my arsenal. Since there is no shortage of opinion on this forum, I anticipate some serious wisdom.

A few questions - what do you like to use for insomnia in your outpatient cases? Please list your top five.

Also, why don't you like the MMSE? I mean for me if you've got an 85 year old demented person using the MMSE is a good way to be able to say this person probably has dementia and using the scoring system is a decent way to document your findings. It's also pretty easy to explain to families how you came up with dementia as a diagnosis. If you have a 20 year old with cognitive impairment it is probably best to employ psychological diagnostic testing instead of a five minute MMSE or MOCA.

 

[billypilgrim37]

A few questions - what do you like to use for insomnia in your outpatient cases? Please list your top five.

Lol, I certainly don't have the expertise to list a "top five," but I was raised in a trazodone hospital, where it was favored mostly because it somehow didn't mess with sleep architecture nearly as much as other antihistamines. There's not much wrong with benadryl for folks who just need a rare bit of help. Seroquel, at the sleep doses, is really just an infinitely expensive antihistamine. And benadryl, and even trazodone, is really cheap.

My pharmacist is trying to sell me on restoril, but he doesn't have me there yet. Old people, maybe it's a little safer than Ambien, which will be a wonderful drug once it's off patent. Inpatient, it has its perks.

Also, why don't you like the MMSE?

Just because the MOCA is so much better at everything the MMSE tries to do. It has the sensitivity to pick up MCI, tests executive function much better in severe dementia, doesn't take much longer to administer than the MMSE, and has those cute pictures of animals.

 

[billypilgrim37]

Double post, silly SDN.

 

[strangeglove]

Just because the MOCA is so much better at everything the MMSE tries to do. It has the sensitivity to pick up MCI, tests executive function much better in severe dementia, doesn't take much longer to administer than the MMSE, and has those cute pictures of animals.

This may be true, but then you are stuck with the problem that you will be the only person in the hospital who knows what the hell you are talking about.

 

[michaelrack]

A few questions - what do you like to use for insomnia in your outpatient cases? Please list your top five.

1. Ambien
2. Lunesta
3. Rozerem
4. temazepam

For resistant cases, and in special circumstances, I will use Xyrem (don't try this yourself unless you are very familiar with the medication).

 

[billypilgrim37]

This may be true, but then you are stuck with the problem that you will be the only person in the hospital who knows what the hell you are talking about.

As if that would be a first 🙄

 

[MBK2003]

4) I will never start a patient on paroxetine

6) I will never start a depressed or anxious child or adolescent on the following medications as first line pharmacotherapy:
a) Paroxetine
b) Venlafaxine
c) Duloxetine
d) Any time of tricyclic antidepressant

 

[Solideliquid]

4) I will never start a patient on paroxetine, except for the exceptions named above.

If you wouldn't start someone on this, why would there be a reason for you to use this as a second tier or third tier drug?

 

[OldPsychDoc]

If you wouldn't start someone on this, why would there be a reason for you to use this as a second tier or third tier drug?

I don't see it as a 2nd or 3rd tier drug. I see it as a problematic 1st tier drug.
So the exception (from the OP) is that the patient is already on it.

 

[Solideliquid]

As long as we're talking about what we WON'T do, let me pose this.

What would it take for you consider starting an adult on a stimulant for what they call ADHD?

I have a few patients on Ritalin LA daily now and I can't seem to make them part ways with it. I mean it's really comedy gold to see in the note "Using ritalin for augmentation to wellbutrin and will consider tapering this medication once depression and anxiety are stable". Looking at the record this person has been on Ritalin for EIGHT years. LOL I'm not even going to put up a fight when I see her next week.

 

[OldPsychDoc]

As long as we're talking about what we WON'T do, let me pose this.

What would it take for you consider starting an adult on a stimulant for what they call ADHD?
....

1) a reasonable history of ADD or ADHD sx causing impairment at least before the age of 10, if not 7 as the criteria state.

2) evidence of current functional impairment now.

3) at least a year of sobreity from meth, cocaine, and alcohol.

4) willingness to comply with a titration, starting with longer-acting, slower-onset agents (e.g. Concerta, Ritalin LA). (i.e. if you start out asking for Adderall--try another doctor.)

5) willingness to comply with monthly face to face visits for at least 6 months before allowing phone refills.

Of course I know that patients can and will lie through their teeth about all of this stuff--but the risk of starting out with a low dose of methylphenidate is pretty low, and if "bad behavior" emerges, we'll set limits and they won't be back.