"The Customer Is Always Right" Kills

[VA Hopeful Dr]

That makes no sense, unless they have symptoms consistent with a bacterial illness. If it's just run of the mill URI, it can last for 2 weeks, especially if they smoke.

Agree wth apollyon below about smokers. For healthy people, I usually say 7-10 days because I rarely have people show up who haven't had symptoms for at last 3-4 days before coming to see me. In my 2 years of FM residency, I've had exactly 2 patients come back after those 7-10 days asking for abx so I feel pretty OK with how I do things.

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[deleted109597]

Most opinion disagrees with this, at least for those < 24 months of age. Here is one of several recent articles on the topic.

http://www.nejm.org/doi/full/10.1056/NEJMoa0912254

Sorry, left out the necessary "for the >2 yr old population."
However, Auralgan/tylenol/motrin helps them sleep better at night than the first dose of Amoxil/Augmentin/Omnicef.

 

[GeneralVeers]

Agree wth apollyon below about smokers. For healthy people, I usually say 7-10 days because I rarely have people show up who haven't had symptoms for at last 3-4 days before coming to see me. In my 2 years of FM residency, I've had exactly 2 patients come back after those 7-10 days asking for abx so I feel pretty OK with how I do things.

Evidence? Science?

Just because it lasts longer than 10 days doesn't make it any more likely to be bacterial. Can you think of a bacterial infection that causes runny nose, cough, congestion, and sore throat?

 

[RustedFox]

Smokers... ugghh...

This is completely off-topic and is just therapeutic b!tching, but there's nothing that gets under my skin more than smoking. Every time I see a smoker on the street, in their car, wherever - in my mind I just scream - "There you go, keep at it... see you soon when you show up and say 'I cant breathe!', and you wonder why... and now all of a sudden its MY responsibility to make sure that you get the air that you're entitled to."

I hate even being in the exam room with them. They smell, so badly....

Part of me wants to say - "just make it illegal, its no good for anyone" but of course being the libertarian that I am, I can't agree with myself - but if you're going to be on the public dole when it comes down to your healthcare, then I think it might not be unreasonable to cede your "right to smoke and use drugs" as well.

 

[Apollyon]

Evidence? Science?

Just because it lasts longer than 10 days doesn't make it any more likely to be bacterial. Can you think of a bacterial infection that causes runny nose, cough, congestion, and sore throat?

Bordetella pertussis, Chlamydia pneumoniae, and Mycoplasma pneumoniae all have an incubation period longer than 14 days. From here, a pediatrician states "Symptoms persist longer than the expected 10-14 days a virus tends to last".

Bacterial infection causing rhinitis, cough, congestion and sore throat? I don't have one, but cough, congestion, and sore throat? Pneumonia, and the vast majority of pneumonias are bacterial, not viral, versus the vast majority of URIs being viral, not bacterial. Rhinitis, cough, and sore throat with a bacterial cause? Sinusitis.

It's not quite a slam dunk as you make it out to be. Close, but not absolute.

 

[GeneralVeers]

Bordetella pertussis, Chlamydia pneumoniae, and Mycoplasma pneumoniae all have an incubation period longer than 14 days. From here, a pediatrician states "Symptoms persist longer than the expected 10-14 days a virus tends to last".

Agree with you there, but there has to be a spectrum of symptomology consistent with those infections

Bacterial infection causing rhinitis, cough, congestion and sore throat? I don't have one, but cough, congestion, and sore throat? Pneumonia, and the vast majority of pneumonias are bacterial, not viral, versus the vast majority of URIs being viral, not bacterial. Rhinitis, cough, and sore throat with a bacterial cause? Sinusitis.

It's exactly what I was referring to. I don't know of any BACTERIAL INFECTIONS that cause cough, runny nose, sore throat, and congestion. Pneumonia usually causes pulmonary symptoms, but not rhinitis.

Sinusitis might be bacterial, but again all recent evidence has debunked the use of antibiotics for ANY uncomplicated sinus infection.

 

[WilcoWorld]

I don't know of any BACTERIAL INFECTIONS that cause cough, runny nose, sore throat, and congestion.

That's actually how pertussis typically presents in adults. As such, I treat for pertussis in adults who have had those symptoms for >2 weeks (even though that just decreases spread, and doesn't actually help the patient in front of me). URI symptoms <2 weeks get ibupofen +/- albuterol and a pat on the head.

Uh-oh, did I just agree with Apollyon?

 

[Apollyon]

Uh-oh, did I just agree with Apollyon?

Now you're ******!

 

[la gringa]

Smokers... ugghh...

This is completely off-topic and is just therapeutic b!tching, but there's nothing that gets under my skin more than smoking. Every time I see a smoker on the street, in their car, wherever - in my mind I just scream - "There you go, keep at it... see you soon when you show up and say 'I cant breathe!', and you wonder why... and now all of a sudden its MY responsibility to make sure that you get the air that you're entitled to."

I hate even being in the exam room with them. They smell, so badly....

Part of me wants to say - "just make it illegal, its no good for anyone" but of course being the libertarian that I am, I can't agree with myself - but if you're going to be on the public dole when it comes down to your healthcare, then I think it might not be unreasonable to cede your "right to smoke and use drugs" as well.

love this Fox.... as i always say, i'm not just a non-smoker, i'm the ANTI-smoker. i have literally started coughing while examining smokers... ugh ugh ugh.

 

[RustedFox]

love this Fox.... as i always say, i'm not just a non-smoker, i'm the ANTI-smoker. i have literally started coughing while examining smokers... ugh ugh ugh.

It drives me so friggin' batty. I struggle to think of more socially irresponsible things (drinking and driving comes to mind), but smokers aggravate me to no end. I'm sick of seeing them bring their kids in with asthma attacks/URIs and demand that "I" make their offspring better/cure them.

TRY QUITTING SMOKING, *****HOLE. They say outstandingly dumb things, too like - "Well, we don't smoke in the house." Meanwhile, the kid reeks of smoke, skin and hair discolored with tar and nicotine... you get the picture.

Women who smoke... just.... grraAAAH !

1. Its not attractive, its not sophisticated, its downright repulsive. I don't know how they think its at all alluring.
2. If I don't treat you (you, smoking females) while you're young for your pulmonary issues... I'll see you when you're old, kyphotic, and your bone density is that of a graham cracker and listen to you complain about your compression fracutres.. but never did it occur to you to... you know... take care of yourself.

* Soooo maaaad *

and yeah, I can't be in the same exam room with them, either.

Sorry for the poor train of thought. Trying to watch a movie as well.

 

[GeneralVeers]

That's actually how pertussis typically presents in adults. As such, I treat for pertussis in adults who have had those symptoms for >2 weeks (even though that just decreases spread, and doesn't actually help the patient in front of me). URI symptoms <2 weeks get ibupofen +/- albuterol and a pat on the head.

Uh-oh, did I just agree with Apollyon?

Sore throat is not typical of pertussis.

 

[8654Marine]

The penultimate is the smoker who comes in w/ coryza/cough who also brings in the rest of the family w/ sniffles.

Then wants antibiotics cause "my doctor always gives me that, umm, pill that starts w/ a Z."

THEN, wants a script for Tylenol cause then our state welfare system will pay for it.

THEN, demands a cab voucher or they'll write to the CEO.

 

[username456789]

The penultimate is the smoker who comes in w/ coryza/cough who also brings in the rest of the family w/ sniffles.

 

[GeneralVeers]

The penultimate is the smoker who comes in w/ coryza/cough who also brings in the rest of the family w/ sniffles.

Then wants antibiotics cause "my doctor always gives me that, umm, pill that starts w/ a Z."

THEN, wants a script for Tylenol cause then our state welfare system will pay for it.

THEN, demands a cab voucher or they'll write to the CEO.

I tell them to go ahead and write the CEO. I even give them my card so they can spell my name correctly.

 

[8654Marine]

Good catch. Long shift.

 

[Birdstrike]

I read this awhile ago and hadn't had time to share it. I didn't write it. It was written by Dr WhiteCoat (also of EP Monthly's White Coat's Call Room, who has let me guest post a little on both of his sites). It's an excellent post on the folly of "patient satisfaction" websites and surveys, and details the case of a doctor who was so bad, he got convicted and sentenced to life in prison for maiming and killing his patients, all while maintaining near perfect "patient satisfaction" scores. I think it's pretty relevant to this thread. A must read, if you haven't read it already:

"Press Ganey and HealthGrades.com Are Medicine’s Fake News"

>> Press Ganey and HealthGrades.com Are Medicine's Fake News - Dr. WhiteCoat <<

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[d2305]

I just thought of something. Giving a z pak ad lib treats their chlamydia (at least until their next sexual contact).