Sir, do you think it could be allergies?

[FrustratedFamDoc]

"I've got the sinus (yes, singular) again doc!"

Why is the suggestion that this "sinus infection" is really just allergies almost fightin' words? My area is notoriously bad for seasonal allergies but to ask most of my patients to try allergy medicine feels like I'm selling ice cubes to an Eskimo.

Mr X, I've seen you every May for the last 5 years for this same thing. You got a Zpack from the immediate care 3 weeks ago and are still no better. Have you tried Zyrtec, Claritin, Flonase, etc? This is usually followed by a very puzzled look.

/rant

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[TableMD]

Zpac is part of the cocktail. In order to see 300 patients a day, everyone gets:
- IV Ceftriaxone x 1, followed by 5 days of Cefdnir
- A Zpack
- 7 days of Prednisone
- 10 days of Ativan
- 10 days of Norco
- Testosterone patch AND/or Androgel
- Vitamin D injection

If that doesn't work I send them to the ED.

 

[JustPlainBill]

Zpac is part of the cocktail. In order to see 300 patients a day, everyone gets:
- IV Ceftriaxone x 1, followed by 5 days of Cefdnir
- A Zpack
- 7 days of Prednisone
- 10 days of Ativan
- 10 days of Norco
- Testosterone patch AND/or Androgel
- Vitamin D injection

If that doesn't work I send them to the ED.

Sounds like Parkland ED intake pack --

CBC/CMP/Lactate,, trops, amylase/lipase/ggt, 1L NS, EKG, CXR, Rocephin 1g, Morphine 5mg, US abdomen, diet order ---

For OP -- usually it's 8/80 for allergies plus a z pack.....for symptoms <2days ---- no, it's not good medicine.

 

[cabinbuilder]

"I've got the sinus (yes, singular) again doc!"

Why is the suggestion that this "sinus infection" is really just allergies almost fightin' words? My area is notoriously bad for seasonal allergies but to ask most of my patients to try allergy medicine feels like I'm selling ice cubes to an Eskimo.

Mr X, I've seen you every May for the last 5 years for this same thing. You got a Zpack from the immediate care 3 weeks ago and are still no better. Have you tried Zyrtec, Claritin, Flonase, etc? This is usually followed by a very puzzled look.

/rant

Yep, and Texas is the Z-Pak, steroid shot addict capital of the world. I fight this every single day in central Texas. Nobody takes their allergy meds or their nasal spray. It's always, "I get this once a year and I'm here for my steroid shot". Um no........... if you want a steroid, see your PCP and discuss the necessity or lack thereof. It's not on the menu in urgent care today.

 

[deleted87716]

Yep, and Texas is the Z-Pak, steroid shot addict capital of the world. I fight this every single day in central Texas. Nobody takes their allergy meds or their nasal spray. It's always, "I get this once a year and I'm here for my steroid shot". Um no........... if you want a steroid, see your PCP and discuss the necessity or lack thereof. It's not on the menu in urgent care today.

Steroid injections are on my "nope" list.

 

[JustPlainBill]

One of my colleagues up here smack in the middle of suburban North Dallas has been fatigued into compliance. He came in from elsewhere outside of Texas and the daily requests/demands/whining/cajoling for steroids has finally beat him down. He's got a great otc cold/allergy handout but most use it for scratch paper and want the 8/80 Zpack combo.... It's no longer even a debate..

 

[deleted87716]

Yep, and Texas is the Z-Pak, steroid shot addict capital of the world. I fight this every single day in central Texas. Nobody takes their allergy meds or their nasal spray. It's always, "I get this once a year and I'm here for my steroid shot". Um no........... if you want a steroid, see your PCP and discuss the necessity or lack thereof. It's not on the menu in urgent care today.

One of my colleagues up here smack in the middle of suburban North Dallas has been fatigued into compliance. He came in from elsewhere outside of Texas and the daily requests/demands/whining/cajoling for steroids has finally beat him down. He's got a great otc cold/allergy handout but most use it for scratch paper and want the 8/80 Zpack combo.... It's no longer even a debate..

This is hilarious: Kingwood Underground - the heart and soul of our Kingwood, Texas family

Note to self: Don't move to TX.

 

[JustPlainBill]

This is hilarious: Kingwood Underground - the heart and soul of our Kingwood, Texas family

Note to self: Don't move to TX.

Yeah, 7-10 days of symptoms from a viral with OTC therapy is not in the lexicon of acceptable terms here in North Dallas -- heck, I've had people demand levaquin and a steroid injection because they had a "tickle" in their throat that morning (on Sunday) had a busy week ahead of travel for work and "couldn't afford to be sick". If you declined, they complained to corporate and you got talked to by the CMO of the UC company.

 

[EMDOC17]

Just out of curiosity why are you all opposed to a steroid? I get side effects of steroids especially in diabetics and long term use of steroids but why the hesitancy for a steroid? Granted I don't often give them for allergies I do often for sore throat (even viral, I know, extrapolating), obviously COPD, and occasionally the allergic patient. Sometimes I think I give them so I can "do something." Maybe it is that I can give them something and I feel a dose of decadron is the answer. Granted most of them say "my doctor gives mea z-pack for this". Well great then go to your doctor. When it comes to antibiotics vs. steroids I will be more willing to give steroids.

 

[VA Hopeful Dr]

Just out of curiosity why are you all opposed to a steroid? I get side effects of steroids especially in diabetics and long term use of steroids but why the hesitancy for a steroid? Granted I don't often give them for allergies I do often for sore throat (even viral, I know, extrapolating), obviously COPD, and occasionally the allergic patient. Sometimes I think I give them so I can "do something." Maybe it is that I can give them something and I feel a dose of decadron is the answer. Granted most of them say "my doctor gives mea z-pack for this". Well great then go to your doctor. When it comes to antibiotics vs. steroids I will be more willing to give steroids.

First, because it's not indicated.

Second, even short courses have side effects.

Third, the lesser or two evils isn't good medicine

 

[deleted87716]

Just out of curiosity why are you all opposed to a steroid?

I'm not so much opposed to steroids in general as I'm opposed to IM steroids. I'll Rx oral Medrol DosePaks or prednisone tapers for all of the usual stuff (sciatica after failing NSAIDs, moderate-severe poison ivy, asthma/COPD exacerbations, etc.), but IM steroids are a no-go as far as I'm concerned, especially for something totally lame like allergic rhinitis, where better/safer options (e.g., non-sedating antihistamines and nasal steroid sprays) are available OTC.

 

[EMDOC17]

First, because it's not indicated.

Second, even short courses have side effects.

Third, the lesser or two evils isn't good medicine

Touche. What I have a problem with is the patient that tells me I "always get a z-pack" and I find that they often do. Now I am the one that will not do anything for their symptoms. Usually I prescribe zyrtec or flonase. Very rarely a dose of decadron when I feel my back is against the wall. Sometimes we all get backed into a corner. Same with otitis media. I look like a tool when I don't give them abx and their pediatrician does. You look like a tool when they show up in my ED and I give it to them. No win situation.

 

[EMDOC17]

I'm not so much opposed to steroids as I'm opposed to IM steroids. I'll Rx oral Medrol DosePaks or prednisone tapers for all of the usual stuff (sciatica after failing NSAIDs, moderate-severe poison ivy, asthma/COPD exacerbations, etc.), but IM steroids are a no-go as far as I'm concerned, especially for something totally lame like allergic rhinitis, where better/safer options (e.g., non-sedating antihistamines and nasal steroid sprays) are available OTC.

Right. I don't do IM/IV unless significant asthma/COPD everything else gets PO decadron.

 

[deleted87716]

Touche. What I have a problem with is the patient that tells me I "always get a z-pack" and I find that they often do. Now I am the one that will not do anything for their symptoms. Usually I prescribe zyrtec or flonase. Very rarely a dose of decadron when I feel my back is against the wall. Sometimes we all get backed into a corner. Same with otitis media. I look like a tool when I don't give them abx and their pediatrician does. You look like a tool when they show up in my ED and I give it to them. No win situation.

That's what the "backup Rx" is for (e.g., "Here, but don't fill this unless...").

 

[JustPlainBill]

We've literally got either a UC or freestanding ER almost every 2-3 blocks for 3 miles along this one street. Virtually every day I get at least 1-2 new patients who've been Zpacked, 8/80 and guaifenesin AC'd by one of these places a week ago with no improvement in symptoms and now I get to fix it. The looks I get when I say," Viral/allergic--start mucinex,zyrtec, Flonase otc" are almost humorous.....I sometimes try to 'splain it....but usually they want a "more powerful" abx.....

 

[Druggernaut]

Yeah, 7-10 days of symptoms from a viral with OTC therapy is not in the lexicon of acceptable terms here in North Dallas -- heck, I've had people demand levaquin and a steroid injection because they had a "tickle" in their throat that morning (on Sunday) had a busy week ahead of travel for work and "couldn't afford to be sick". If you declined, they complained to corporate and you got talked to by the CMO of the UC company.

Sure, one "tendon rupture special" coming right up!

 

[VA Hopeful Dr]

Had a patient seen for hospital follow up yesterday. I saw her last week, diagnosed allergies. She didn't believe me and didn't even try the Zyrtec I gave her. Went to UC, given augmentin, anaphylaxis resulted in an overnight hospital stay. The hospitalists gave her Claritin which resolved her symptoms.

 

[TableMD]

Had a patient seen for hospital follow up yesterday. I saw her last week, diagnosed allergies. She didn't believe me and didn't even try the Zyrtec I gave her. Went to UC, given augmentin, anaphylaxis resulted in an overnight hospital stay. The hospitalists gave her Claritin which resolved her symptoms.

Seems very cost effective although, must be a bunch of cowboys at that place since they didnt consult ENT and allergy.

What next, therapy for depression?!?

 

[jm192]

"I've got the sinus (yes, singular) again doc!"

Why is the suggestion that this "sinus infection" is really just allergies almost fightin' words? My area is notoriously bad for seasonal allergies but to ask most of my patients to try allergy medicine feels like I'm selling ice cubes to an Eskimo.

Mr X, I've seen you every May for the last 5 years for this same thing. You got a Zpack from the immediate care 3 weeks ago and are still no better. Have you tried Zyrtec, Claritin, Flonase, etc? This is usually followed by a very puzzled look.

/rant

In short, someone once told them it was a sinus infection and gave them antibiotics.
After a few days of the treatment, it got better (whether or not the Z-pack actually made a difference is besides the point).
Therefore, they've learned that Runny nose=antibiotics, and they know how to fix that. They just can't write the drugs.

When you disagree, you're fighting decades of runny nose knowledge. You're practically insulting their intelligence.

 

[deleted87716]

In short, someone once told them it was a sinus infection and gave them antibiotics.
After a few days of the treatment, it got better (whether or not the Z-pack actually made a difference is besides the point).
Therefore, they've learned that Runny nose=antibiotics, and they know how to fix that. They just can't write the drugs.

When you disagree, you're fighting decades of runny nose knowledge. You're practically insulting their intelligence.

Yup. When patients show up c/o runny nose x2 days and get a Z-Pack, they're usually better by the time they finish taking it. Why? The antibiotics, of course!

I usually tell people something along the lines of, "It's a virus. You're going to be sick for a week with or without antibiotics. Do you want to ride it out with symptomatic treatment, or risk inviting a yeast infection or C. Diff. to the party?"

 

[FrustratedFamDoc]

Yup. When patients show up c/o runny nose x2 days and get a Z-Pack, they're usually better by the time they finish taking it. Why? The antibiotics, of course!

I usually tell people something along the lines of, "It's a virus. You're going to be sick for a week with or without antibiotics. Do you want to ride it out with symptomatic treatment, or risk inviting a yeast infection or C. Diff. to the party?"

And they'll sit there attentive as can be, and you think you're actually on the verge of a breakthrough and then the next line:

So can you call it in to the 24 hour CVS?

... very frustrating.

 

[TableMD]

I feel I get out of most of these situations with a SCRIPT for Flonase most of the time, along with Allegra D, Zyrtec (whichever one they haven't tried) and Affrin and Nasal Irrigation.

For the few, legit crazy ones that wont accept that. I date a med for what would be 10 days of symptoms and they can fill it then.

 

[VA Hopeful Dr]

Yup. When patients show up c/o runny nose x2 days and get a Z-Pack, they're usually better by the time they finish taking it. Why? The antibiotics, of course!

I usually tell people something along the lines of, "It's a virus. You're going to be sick for a week with or without antibiotics. Do you want to ride it out with symptomatic treatment, or risk inviting a yeast infection or C. Diff. to the party?"

If they want a z-pack, I don't usually mind - fairly low risk as far as antibiotics go (I'm sure it happens, but I've never seen a zithromax-caused c. diff). Its the folks that z-packs don't work for but they know that Levaquin does...

 

[septoplasty]

If they want a z-pack, I don't usually mind - fairly low risk as far as antibiotics go (I'm sure it happens, but I've never seen a zithromax-caused c. diff). Its the folks that z-packs don't work for but they know that Levaquin does...

Yea.. until you get that guy who gets an arrhythmia from it

So back in my urgent care days.. I resorted to giving them Pen V literally for URI's that "could only be cured with antibioics"

Patient's suck when it comes to URI's/Non-Specific viral infections.

 

[Bacchus]

Steroid injections are on my "nope" list.

Same, especially for this dermatitis. Sigh. If you need steroids for your poison it will either be topical or oral depending on your TBSA involved or the areas involved.

 

[Bacchus]

Yeah, 7-10 days of symptoms from a viral with OTC therapy is not in the lexicon of acceptable terms here in North Dallas -- heck, I've had people demand levaquin and a steroid injection because they had a "tickle" in their throat that morning (on Sunday) had a busy week ahead of travel for work and "couldn't afford to be sick". If you declined, they complained to corporate and you got talked to by the CMO of the UC company.

I tell patients an upcoming vacation is not an acceptable indication for antibiotics. They get PO'd but IDGAF.

 

[cabinbuilder]

Yep, had a lady yesterday who was seen a week before for "sinus" and "cough" , never picked up the cough medicine. Had a steroid shot and put on cefdinir. "Not any better". Didn't start the allergy meds as instructed. I tell her, "You feel worse now cuz the steroid shot has worn off", I would advise not to do that again. She agrees. I sent her away with sudogest, singulair, and cheratussin. It never ends.