Pearls are short, practical medical tips submitted by readers that may not be widely known but can be used to solve everyday clinical problems. Following are selected Pearls from past issues.

"Magic feather" can aid pediatric venipuncture

Administering injections or taking blood can be agonizingly difficult if a small child is reluctant to cooperate. A useful method to improve the success rate of pediatric venipuncture is the "magic feather" technique, which uses visual imagery to distract a patient from the painful procedure.

1. Try not to be embarrassed. (This requires quite a bit of role-play!)
2. Hand the child an imaginary magic feather and describe it in detail.
3. Show the child that by blowing gently on the invisible feather, it can be suspended in the air above the child's head.
4. Ask the child to continue blowing to keep the imaginary feather in the air, so its magic power doesn't disappear.
5. When the child is deeply engrossed in playing with the magic feather, venipuncture can be carried out, often--amazingly--without the patient even noticing.

I have used this technique in a number of difficult cases involving patients between the ages of 3 and 5 years, and it really does work.

Steven E. Bradshaw, MD
Cambridge, United Kingdom

A different approach to percussion

Legions of physicians have been taught the traditional technique of percussion used in physical examination: strike the terminal phalanx of the middle finger of the nondominant hand with the tip of the middle finger of the dominant hand. I have found that striking the nondominant middle finger with a reflex hammer offers several advantages over the traditional method. It is easier to perform, is more easily reproduced, provides more audible notes (especially important in a noisy setting such as the emergency department), and is less painful to the struck phalanx. Physicians with long fingernails will most appreciate this fact.

Michael W. Rich, MD
Akron, Ohio

Cotton swabs can prevent eye injury

Treatment of verruca vulgaris, papules, minor cysts, or verruca plana in the eyelid area with cryotherapy or electrodesiccation carries the risk of damaging the globe of the eye. Thermal damage to the eye during such procedures can be prevented by inserting the cotton tip of an applicator (thickened by an additional layer of cotton swab) between the inner surface of the eyelid and the sclera. Patients who wear contact lenses may want to remove them before the procedure to avoid contact between the lens and the applicator.

Sody Naimer, MD
Goosh Katif, Israel

Identifying cardiac sounds

There are occasions when it is clinically difficult to distinguish a systolic cardiac outflow murmur, a proximal carotid bruit, and a proximal left subclavian bruit from one another. Placing a blood pressure cuff on a patient's left arm and inflating it past his or her systolic pressure provides physicians with an additional tool in their clinical armamentarium. I have found that this maneuver attenuates an ipsilateral subclavian bruit (by reducing blood flow, and thus turbulence, through that vessel); augments an ipsilateral carotid bruit (by shunting more blood to that vessel); and does not appreciably affect a cardiac outflow murmur.

Michael W. Rich, MD
Akron, Ohio

Lubricant for sutures

When suturing in a hairy area such as the scalp, use of a lubricant such as Surgilube to smooth down the hair around the wound can keep the hair out of the way. Vaseline can also be used, but it can't be cleaned up as easily.

Mark Cohen, MD
Penfield, New York

Candy can relieve constipation

When dealing with constipation in children, I often advise parents to give their children Gummy Bears (or other gummy candies) as long as the constipation is not a chronic problem that would involve bowel retraining. Gummy candies contain sorbitol and can help "move things along" while the child is none the wiser. Sugar-free gummy candies can be used as well.

Timothy S. Neidigh, RN, MSN
Moss Bluff, Louisiana

Crossover test can detect temperature differences

The crossover test is a bedside test that can help reveal subtle differences in temperature between two body parts. Place one hand on the body part to be tested for warmth and the other hand on the contralateral body part. After 30 to 60 seconds, cross each hand over to the opposite side. Even subtle temperature differences can be discerned in this manner. This test is especially useful for examining patients with suspected inflammatory arthritis. Of course, if there is an equal amount of warmth bilaterally, there will be no discernible difference in temperature.

Timothy J. Drehmer, MD
Dayton, Ohio

"Birthday candles" help auscultation

When trying to auscultate lung sounds on an uncooperative child, ask him or her to pretend to blow out candles on a birthday cake. Use your fingers as the candles, folding them down as the child blows and repeating as many times as needed for adequate auscultation.

Joan Grother, RN
Asheboro, North Carolina

Another approach to dermabrasion

Patient can treat their scaly feet at home with 120-grit drywall sanding screens. Have patients cut two 2 X 4-in pieces, place them together, and brush them across the dead skin with short back-and-forth strokes. Patients intuitively learn the correct amount of force to apply and know when normal epidermis is exposed. When the mesh fills with debris, patients can tap the screens lightly to empty them and resume the abrading. The mesh also can be shaped for uneven areas. Patients should apply emollient cream to the abraded areas.

Allen Sklar, MD
Reno, Nevada

Heeding a clue to possible dementia

Formal mental status testing is time-consuming and often unnecessary for general medical evaluations. However, I have observed that if a patient with reasonable hearing acuity looks at his or her companion more than twice before answering when directly questioned during history taking, there is a strong likelihood of incipient dementia. In these cases, administering cognitive screening tests such as the Mini-Mental State Examination (1) is indicated.

J. A. Van Gerpen, MD
New Orleans

Reference

1. Folstein MF, Folstein SE, McHugh PR. "Mini-mental state": a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12(3):189-98

Ensuring drier male infant exams

A problem I have encountered while examining infants is that they tend to pass urine when their diaper is removed. Female infants usually deposit their urine on the linen saver or diaper underneath them. However, males tend to spray all over the place, which can be disconcerting. I place a urine bag over the penis of the male infant after his diaper is removed so that I can examine him at leisure with complete peace of mind.

Martin Baigel, MRCP, DCH
Farrarmere, South Africa

Mnemonic aids diabetes care

Time constraints in today's busy outpatient practice create challenges in maintaining the standard of care. I find the following mnemonic useful in addressing diabetes during patient examinations.

Kumara Sidhartha, MD
South Dennis, Massachusetts

Remember B-ABC for opiate overdoses

When managing an unconscious suspected heroin user, I keep in mind the mnemonic B-ABC--Boots, standard Airway, Breathing, and Circulation--to promote safety among emergency department staff members. I have found that a large proportion of such patients wear heavy boots, some of which have steel toe caps! Removing a patient's boots before administering naloxone reduces the medical staff's risk of injury from a kick when the patient eventually regains consciousness.

Steven E. Bradshaw, MD
Cambridge, United Kingdom

How to lessen the pain of venipuncture

I have observed that you can reduce the pain your patients experience from venipuncture by asking them which arm they prefer you use. By allowing patients this simple choice, you are helping them regain some control over their healthcare. The more control they have, the more compliant they are and the better the outcome.

Neil Baum, MD
New Orleans

Determining the severity of abdominal pain in children

Differentiating the severity of abdominal pain in children can be difficult. Two techniques can help determine whether a serious underlying disorder is present. During history taking, ask the child what his or her favorite food is, and then ask if he or she would want to eat the food if you had some. Chances are, seriously ill children would not want to eat even their favorite food. On physical examination, ask the child to stand and hop up and down a few times. The ability to do this significantly reduces the probability of true peritonitis.

Atma Persad, MD
Stefan Grzbowski, MD
Vancouver, British Columbia

Help for unsteady hands

Freezing a small lesion with liquid nitrogen can prove challenging for physicians without steady hands. However, with use of the plastic earpiece normally reserved for the otoscope, liquid nitrogen spray can be funneled directly onto the lesion without fear of damaging the surrounding tissue.

Carol Healy, MD
Oceanside, California

Waiting room tools can calm kids

While doing a rotation at a pediatric center, I learned that placing old stethoscopes, patella hammers, and other "discarded" tools of the trade in the waiting room helps to calm kids. As young patients get acquainted with these instruments, they are less fearful when the doctor uses such tools on them during physical examinations.

This idea, coupled with an occasional shedding of the white coat during pediatric consultations, is tremendously helpful to children who are prone to the "white coat" or "doctor's office" syndrome.

Ayodele Erinle, MD
Blue Bell, Pennsylvania

Treating fiberglass dermatitis

One of the most itchy and annoying injuries I have encountered is fiberglass dermatitis. Once the glass is embedded in the skin, it gets progressively worse and often makes its way to the eye.

A solution I discovered is to apply a thin layer of wood glue to the affected skin and let it dry. The dried glue peels away in a layer, taking with it the glass splinters, which are otherwise nearly impossible to remove. For best results, apply the glue as soon as possible after exposure to the fiberglass.

Michael E. Zionts, MD
Buffalo, New York

An overlooked cause of anemia

The most common cause of anemia is iron deficiency. Possible explanations include gastrointestinal bleeding, menorrhagia, malabsorption secondary to small-bowel mucosal disease, surgical resection of the proximal small bowel, and use of nonsteroidal anti-inflammatory drugs. The exact cause of anemia in many patients, however, remains a mystery even after an extensive diagnostic evaluation. An overlooked explanation, in my experience, is blood donation. This procedure results in the loss of 200 to 250 mg of iron per unit of donated blood. In patients who already are predisposed to iron depletion for the reasons noted above, two or three trips to the blood bank annually can lead to iron deficiency.

Richard R. Babb, MD
Palo Alto, California

Eliciting deep breaths in children

Most children are familiar with the fairy tale about the three little pigs and the big, bad wolf. I have my pediatric patients play the part of the huffing and puffing wolf when I need to elicit deep inspirations for auscultation. Even timid, first-time patients are put at ease with this exercise, and I am able to evaluate their breath sounds more accurately.

Ralph Morgan Lewis, DO
Findlay, Ohio

Preventive maintenance for crutch handles

Patients using wooden crutches after an acute injury or surgery often wonder how to clean the rubber handgrips. Skin oils and perspiration penetrate the rubber, making the handles look dirty and smell bad. I tell patients to prevent the problem by folding two washcloths in half and securing one around each handle with adhesive tape. Patients can change the washcloths daily and sprinkle powder on them for freshness. The cloths absorb perspiration, and the extra padding makes using the crutches more comfortable as well.

Patricia Carroll, RNC, CEN, MS
Meriden, Connecticut

Prepare children for ear exams

Before I use an auroscope during a pediatric examination, I gently stroke the patient's tragus a couple of times with my thumb. This seems to be comforting and gets the child used to the rustling noise of the instrument's insertion.

John Darcy, MB, BS
Cowfold, West Sussex, United Kingdom

Outstretched arms equal height

When I need to obtain the height of a patient who cannot stand by himself or herself because of orthopedic problems, I measure the distance between the end of the third finger of one hand and the end of the third finger of the other hand. The spread is practically equal to the patient's height.

José Lamparelli, MD
Buenos Aires

Clues to acute mesenteric embolism

Acute mesenteric embolism is an elusive diagnosis associated with high morbidity and mortality. Consider this diagnosis in patients who present with the three A's:

The only clue in elderly patients with abdominal pain and a history of atrial fibrillation may be unexplained metabolic acidosis. Other red flags include severe abdominal pain disproportionate to physical examination findings, leukocytosis, and thumbprinting on the abdominal radiographic film. If acute mesenteric embolism is suspected, immediate arteriography is indicated to confirm the diagnosis.

Francis Q. Almeda, MD
Chicago

Laughter's therapeutic effect

While examining apprehensive patients with elevated blood pressure, I have found I can help them relax by telling a joke (in good taste, of course!). This directs their attention away from themselves and can result in normalization of their blood pressure. It also allows me to build rapport with my patients while reinforcing the old adage that laughter is the best medicine.

Stanley T. Bohinski, DO
Wilkes-Barre, Pennsylvania

Sphygmomanometer helps determine pulses

Pulsus alternans and pulsus paradoxus can be easily diagnosed with the help of a sphygmomanometer as follows: Elevate the mercury above the patient's systolic pressure and then slowly deflate, bringing the mercury down. When the Korotkoff sounds appear, hold the pressure static. If the Korotkoff sounds disappear with inspiration and reappear with expiration, pulsus paradoxus is present. If pulsus alternans is present, the Korotkoff sounds initially appear at a rate that is half the pulse rate. On further lowering of the mercury, the rate of Korotkoff sounds will suddenly double and equal the pulse rate.

Quamruddin Ahmad, MBBS, FCPS
Rajshahi, Bangladesh

Alleviate pruritus with ice

I tell patients who can't help scratching itchy skin lesions that it's okay to scratch only if they use an ice cube instead of their fingers. The ice is nearly frictionless, and the cold helps relieve the itch.

Gloria Adams, DO
Phoenix

Quick pointers on MDI use

• Shake the MDI well before use.
• Using the MDI is similar to smoking a cigarette, except that the "smoke" is inhaled instead of exhaled.
• If after inhaling, you observe smoke exiting the top of the MDI, it means that little medication has entered your body; you may need another dose.
• If smoke exits rather than enters the MDI more than two times a week, return to the office for a full demonstration.

Seema Gupta, MD
Florala, Alabama

"Socks first" deters spread of infection

Patients with tinea pedis should be reminded to put on their socks before their underwear when getting dressed. Failing to do so can lead to contamination of the groin with dermatophytes.

Christy Flory, RN, MS, NP
Waltham, Massachusetts

Augmented Valsalva's maneuver terminates tachycardia

In patients with hemodynamically stable supraventricular tachycardia, vagotonic techniques can be tried before drugs as the initial therapeutic option. Valsalva's maneuver has been shown to be the most effective vagotonic technique; its efficacy can be increased by applying firm pressure to the right side of the hypochondrium during the expiration phase at the end of the maneuver. This increases the venous return to the right side of the heart and augments the effect on cardiac stretch receptors, thereby increasing the chance of successful arrhythmia termination.

Andrew R. J. Mitchell, BM, MRCP
Eastbourne, England

Chart color coding ensures accuracy

Our office uses manila-colored patient charts, and occasionally a mix-up has occurred with charts of patients who have the same or similar names. However, since we started using red charts for those patients, we have had no episodes of pulling the wrong chart or misfiling examination results. A red chart alerts everyone--from the chart-puller to the physician--to double-check the chart. This system has worked well for us and is easy to institute.

Eugene P. York, MD
Harrisburg, Pennsylvania

Remember your ABCs when reading chest films

When reading chest films, I have found the following alphabetical guide helpful to ensure that I don't rush and forget something.

Jeffrey M. Edmondson, MD
Harker Heights, Texas

Ethyl chloride substitute found in office product

Neil Baum, MD
New Orleans

A less traumatic reduction for dislocated shoulders

I have found that to reduce dislocated shoulders, it is best to fight the urge to use brute force, which entails much pain for the patient and no less sweat for the physician. Instead, I gently lay the patient prone with the ipsilateral arm dangling over the edge of the table. This in itself invariably reduces pain. Reassuring the patient and encouraging him or her to relax also are helpful. After achieving patient comfort, I leave the room for a few minutes. On returning, I find a shoulder that, if not fully self-reduced, needs only a subtle maneuver.

Yonatan Grossman, MD,
Moshav Ya'ad, Israel

Planning ahead helps cardiac patients during emergencies

For cardiac patients who have a history of significant electrocardiographic changes (eg, an old infarction, bundle branch block, second- or third-degree conduction block, ventricular hypertrophy, atrial flutter or fibrillation), I have a wallet-sized copy of their most recent electrocardiogram, along with a list of their medications and their attending physician's name and phone number, laminated for them to carry in their purse or wallet. Many patients suffer a cardiac event away from home, and this precaution offers the treating physician an opportunity to compare findings with previous conditions. This is extremely helpful in recognizing changes.

Morton Krakow, PA-C,
Homewood, Illinois

Avoid trauma while removing nasal foreign bodies

J. Madison Clark, MD
Portland, Oregon

Cold compresses beat heat in treating chalazions

For years, I followed textbook advice on treating chalazions--which included application of warm compresses and topical antibiotic therapy--with unsatisfactory and unpredictable results. I have found that cold compresses applied early in the process and every 2 hours for at least 2 days can rapidly resolve nearly all chalazions in 2 to 3 days. I still instruct patients to apply a thin film of antibiotic ointment nightly for 3 to 5 days. Using this technique, I rarely have had to refer patients for ophthalmologic evaluation or surgical removal.

Jeffrey M. Edmondson, MD
Harker Heights, Texas

Stickers can aid fundus examination

Visualizing the fundi of young children can be an exercise in futility. But I have found that the following pearl overcomes this: Place a glow-in-the-dark sticker of any object (eg, pumpkin face, rocket ship, the moon) on a wall a few feet from the exam table at about eye height to a sitting child. Instruct the patient to look at the glow as you turn off the lights. Children will hold this "fun" vision as you ask them questions about it, giving you plenty of time to accurately evaluate the disks. It really works!

Gary M. Gorlick, MD, MPH
Los Angeles

Warning signs for healing wounds

When all goes well, I do not see patients until the scheduled suture removal, but they have an easy way to remember what would warrant an earlier wound check by their DOCTOR.

Terry Kind, MD
New York

Easing the burden of blood pressure monitoring

For patients with hypertension, at-home self-monitoring of blood pressure between office visits is as important as in-office treatment from a doctor. Patients often get lazy in their record keeping, though, especially when office visits are 4 to 6 weeks apart. Instead of asking patients to keep track of their blood pressure for the entire period, I instruct them to bring to the next office visit a record of measurements taken the week before the visit. This helps them remember to check their blood pressure and eases the burden of record keeping.

Rahul Gupta, MD
Florala, Alabama

Less painful toenail excision

I have found a way to ease patients' pain and discomfort during toenail excisions. Before digital block with local anesthetic is performed, I spray ethyl chloride over the site to be infiltrated. Historically, ethyl chloride spray has been used by many osteopathic physicians during myofascial release manipulation. You will find patients thanking you for using this relatively inexpensive pain saver.

Steven N. Glavas, DO, MPH
Muskegon, Michigan

How to elicit a deep breath

Patients, especially pediatric patients, often will not--or do not understand how to--take a deep breath when I am trying to auscultate the lungs. To overcome this problem, I call attention to the paper towel dispenser located on a counter several feet away. I tell patients to take a good breath and try to make the paper towel move. All the while, I am listening, of course, to a much better inspiratory and expiratory effort.

Chris Wommack, MD
Pinson, Alabama

Arm drop test for parkinsonian rigidity

In patients who have muscle ridigity associated with parkinsonism, a simple arm drop test can help confirm the diagnosis. To test arm drop, have the patients hold their arms straight out to the sides, parallel to the ground. Tell them to drop the arms to their sides. In patients with ridigity, the arms descend slowly and do not make the slapping sound against the thighs that this maneuver normally makes.

Bruce L. Saltz, MD
Boca Raton, Florida

Swabs can affect endocervical sampling

When obtaining an endocervical sample for gonorrhea culture, the specimen should be obtained by use of a swab that has a wire shaft and either a calcium alginate or synthetic fiber tip. Swabs with wooden shafts or cotton tips may be toxic to N gonorrhoeae.

Jeffrey T. Kirchner, DO
Lancaster, Pennsylvania

Kinking to cut the backflow

During some surgical procedures, the blood pressure cuff must be used on the same arm as an indwelling IV cannula (eg, during mastectomy, upper limb surgery). As the cuff is inflated, the increased pressure in the venous system can cause backflow of blood through the cannula and tubing and up to the IV bottle, resulting in contamination. To avoid this problem, we secure the IV tubing between the layers of the cuff, so that inflation causes kinking and compression of the IV tube. This prevents any flow until the pressure in the cuff is released and normal circulation through the venous system is reestablished.

Charu Deva, MD, and Savita Bansal, MD
Chandigarh, India

Look under the tongue

The current popularity of smokeless tobacco use among adolescents and adults has increased the incidence of oropharyngeal cancer, especially in the region of the floor of the mouth, gingiva, and vestibule. During a routine oral examination, premalignant and malignant lesions under the tongue can easily be missed. As teachers, we have observed that sometimes this important area is neglected. We recommend that looking under the tongue be a consistent part of the routine oral examination. It only takes a small amount of time, and it can detect disease that may be curable.

Raymond M. Massengill Jr, EdD, Bristol, Tennessee, and
Nathan A. Ridgeway, MD
Kingsport, Tennessee

Evaluating lipid panel results

I try to remember these helpful points as I evaluate the results of lipid panel studies:

• Total cholesterol and high-density lipoprotein (HDL) levels are more accurate when samples are from nonfasting patients.
• Triglyceride levels should be measured only in samples from fasting patients, because triglycerides increase after a fatty meal.
• Low-density lipoprotein (LDL) is usually indirectly calculated, using this formula:
  
  Total cholesterol minus HDL minus triglycerides
  divided by 5
  
  
• LDL values cannot be accurately calculated when the triglycerides rise above 400.

It is important to keep in mind that the higher the triglycerides, the lower the calculated LDL. Thus, be aware that the LDL may be falsely low in the nonfasting state, rather than elevated as is sometimes assumed.

Daniel Lee, MD
Santa Monica, California

Check septum after trauma to nose

After blunt trauma to the nose, be sure to carefully examine the nasal septum for septal hematoma. A hematoma can usually be treated by simple aspiration, but if left untreated it may lead to permanent nasal deformity and nasal obstruction caused by necrosis of the nasal septal cartilage.

Antonio C. Galian, MD, Emerita A. Galian, MD
Natick, Massachusetts

Focus on the fundus

Here's a trick to help if you are having difficulty getting a clear view of the fundus during a funduscopic examination or if you are unable to focus when you use the diopter lenses of the funduscope. Have the patient put on his or her eyeglasses and repeat the exam through the eyeglass lenses. The glasses often help focus on the retina and make the examination much easier.

William Sullivan, DO
Orland Park, Illinois

Understanding high blood pressure

Patients sometimes have a difficult time understanding why high blood pressure is a cause for concern. This example may help. As you measure a person's blood pressure, inflate the cuff to just over the systolic pressure. Explain that this is how much pressure there is on the heart and in the blood vessels supplying the brain. This gives a hands-on example of what blood pressure means and may help patients understand why it is important to take their medication regularly.

Emmanuel A. Venkatesan, MD
St Louis

When not to call a cup a cup

I discovered that the idea of "peeing in a cup" can be frightening to young children. One parent told me her child associated the word "cup" only with drinking juice at home and was afraid the urine cup might turn up on the breakfast table the next day. To allay fears, I now show a youngster the urine container and tell him or her that it will be thrown away after the urine is tested. This won't always work, but some kids might feel better about the process.

Trevor Hacker, MD
Sacramento, California

Pocket salt shaker

One of my heart patients carries his salt substitute in the chamber of a disposable plastic pen. He removed the ink cartridge and inserted plugs in each end, leaving one end partially out. He perforated the sides of the partially extended plug, then capped the pen with the usual pen cap. He can now "salt" his food as he wishes.

Paul Reynolds, MD
Chapel Hill, North Carolina

A birthday reminder to maintain health

We used to have trouble keeping up with health maintenance in our busy office practice. To make sure everyone gets the routine checkups he or she needs, we now ask all patients to make an appointment during the month of their birthday for routine care--when there is no "fire to put out." This gives us the time needed to focus on preventive care, such as adult immunizations, cancer screening, and health education. It also eases the burden of dealing with preventive and curative medicine simultaneously.

Emmanuel A. Venkatesan, MD
St Louis, Missouri

Put on a happy face

A crying infant might provide a good opportunity to examine the throat, but when you need to calm the baby down, it helps to have a few tricks handy. One that works for me is to blow up a latex exam glove and draw a happy face on it. I often ask the parent to hold the balloon and move it from side to side to help me with the examination of the child. This seems to calm everyone down.

Thomas G. Greidanus, MD
Camp Carroll Troop Medical Clinic, Korea

Aim is important with nasal sprays

Septal perforation is rare in patients using corticosteroid nasal sprays for allergic rhinitis or rhinosinusitis. Nonetheless, patients should be warned about this possibility. The risk can be minimized by directing the spray toward the lateral nasal wall and away from the septum.

Berrylin J. Ferguson, MD, and Jonas T. Johnson, MD
Pittsburgh

Is it ester or amide?

True allergic reactions to local anesthetics are rare and usually involve an ester agent. Allergic reactions are seldom caused by amide anesthetic agents. An easy way to determine whether an agent is an amide or an ester is to look at the spelling of the generic name. Any "-caine" anesthetic containing the letter i (as in amide) in the prefix is an amide agent (eg, prilocaine). The ester agents do not contain an i in the prefix.

Dwight W. Smith, MD, Matthew R. Peterson, MD, and Scott C. DeBerard, DO
Anchorage

Tremor in Graves' disease

Tremor is an important feature of hyperthyroidism but can be subtle and difficult to detect accurately. We have found that placing a sheet of paper on the patient's outstretched palms provides helpful information. This "paper shaker" phenomenon illustrates tremor more clearly than does viewing the hands alone.

Michael W. Felz, MD, and Peter P. Stein, MD
Augusta, Georgia

Making the acetaminophen antidote more palatable

The mainstay of therapy for acetaminophen poisoning is administration of acetylcysteine, which can pose problems. Acetylcysteine smells like rotten eggs, and swallowing it can be a challenge. We have found that the oral solution can be made more palatable by diluting it to 5% with soda or juice. Other ways to improve palatability include diluting the solution even more, changing the diluent, chilling the solution, sipping slowly, using a straw, and drinking from a covered container.

Anup Dev T. Salgia, DO, and Shawn David Kosnik, DO
Camp Lejeune, North Carolina

Stopping leaks after paracentesis

Persistent leakage of ascitic fluid is a common problem after abdominal paracentesis. Neither bandages nor drainage bags seem to help. To prevent leakage, we apply benzoin tincture around the site and place five or six Steri-Strips circumferentially around the tap site. We make sure the tap site is near the midpoint of each strip. With half of the strip adherent to the benzoin, the other half is pulled taut and stuck down. This acts as a "drawstring" to cinch the site closed and can be removed 2 or 3 days later. We have used this method on about 15 patients with no further leakage.

Mark Swaim, MD, PhD, and Bobbi Wilkins, PA-C
Durham, North Carolina

Reducing pain with lidocaine injections

We have found that the least painful method of lidocaine infiltration is deep dermal infiltration of a warm, buffered solution over 10 seconds with a 30-gauge needle. Buffering the slightly acidic lidocaine with sodium bicarbonate in a 10:1 ratio (10 mL of 1% lidocaine to 1 mEq/mL of sodium bicarbonate) has worked well for us.

Dwight W. Smith, MD, Matthew R. Peterson, MD, and Scott C. DeBerard, DO
Anchorage

Keeping inhalers straight

Patients and caregivers can be reminded about when and how to use inhalers by labeling them as "rescue," "reliever," or "controller." This can save confusion in an emergency.

Neil L. Kao, MD
Beavercreek, Ohio

Accurate blood pressure readings

Measuring diastolic blood pressure can be difficult in patients in whom the fifth Korotkoff sound is indistinct because of poor arterial turbulent blood flow. If this is the case, I have the patient lift up his or her arm and clench the fist about 10 times. This drains the blood from the forearm. Then, as the patient keeps the arm raised, I inflate the occlusion cuff until the pressure rises above the systolic point. I then have the patient lower the arm, and I take the pressure as I normally would. This makes the fifth Korotkoff sound much more distinct.

Gary Chee, MBBS
Singapore

How much Viagra?

The recommended dose of sildenafil citrate (Viagra) is 25 to 100 mg, taken at least 1 hour before anticipated sexual intercourse and not exceeding once in 24 hours. However, many patients with mild erectile dysfunction find that a smaller dose (6.25 to 12.5 mg) is sufficient. Each sildenafil tablet costs about $10, regardless of dose; thus, 100-mg tablets are the most economical. Patients should use a pill cutter to divide each tablet into eight pieces and increase the dose by one eighth of a tablet at least 24 hours apart to determine the dose needed to achieve a satisfactory erection.

Mahendr S. Kochar, MD
Milwaukee

Auscultation for pleural effusions

Students and residents are taught to percuss a posterior hemithorax to assess the fluid level before thoracentesis in patients with pleural effusion. However, the perception of dullness to percussion is not always clearly discernible. I have found that percussing the sternum with one or two fingers while listening with the diaphragm of the stethoscope over the posterior hemithorax can more easily allow the listener to hear dullness replace tympany when the level of the effusion is reached. This allows greater confidence when performing the thoracentesis.

David Wisinger, MD
Phoenix

Stretch to quell the cramps

Painful leg cramps often spoil a good night's sleep. Over-the-counter quinine may alleviate these symptoms, but it has many side effects, including tinnitus. I have found that leg stretching exercises before bedtime alleviate painful legs cramps as effectively or more effectively than quinine--with no untoward side effects.

Gopi Rana-Mukkavilli, MD
New York City

The challenge of compliance

To ensure that our "difficult" patients keep their appointment or show up for important tests, we maintain a "compliance book." This contains details, such as the patient's phone number or that of a friend or relative, and information about medications and appointments. These patients are called daily by a staff member to inquire about their progress, to remind them to do certain tests (eg, blood glucose), or to help them remember scheduled visits.

Kwabena Adubofour, MD
Stockton, California

Simple test for sensory loss

In patients with neuropathy, nylon monofilament can be used to administer a simple test of sensory loss. The end of the monofilament is touched against the bottom of the foot and moved toward the foot until the monofilament buckles, thus ensuring that a known and consistent force has been applied. Patients who cannot feel a pricking sensation from the monofilament have increased risk of neuropathic foot injury.

Tania J. Phillips, MD
Boston

A new twist on Pap smears

In the past, I have had Pap smear samples returned because of inadequate endocervical cells. I discovered that if I rotate the cytobrush in the opposite direction of that used to brush across the slide plate, I get better results. For example, if I move the brush across the plate from left to right, I rotate the brush counterclockwise. Since I changed my technique, I have very few inadequate samples.

Earl I. La Kier, MD
Palm Beach Gardens, Florida

That aching knee

When you suspect osteoarthritis of the knee in a patient whose weight-bearing posteroanterior (PA) radiographs of the knee are essentially unremarkable, a 45° PA flexion weight-bearing radiograph can provide more answers. This view is more accurate, specific, and sensitive for joint-space narrowing than the conventional radiograph. It is also helpful for better defining overall degenerative changes of the joint.

Joseph P. Garry, MD
Greenville, North Carolina

Keep the healthy lung down

In patients with unilateral lung disease, positioning the healthy lung down--in the most dependent position possible--may improve the ventilation-perfusion "mismatch" and raise oxygen saturation levels. This can buy valuable time and turn an emergent situation into an urgent one that allows proper preparation.

Michael J. Dacey, MD
Pittsburgh

Don't forfeit the fetor

When you see a patient with suspected alcohol or other substance abuse, there is no substitute for simply smelling the patient's breath. Physicians sometimes relinquish the benefits of such an examination because they believe it is impolite or insulting to get close enough to the patient to get a good whiff.

In this situation, I usually examine the optic fundi with the ophthalmoscope, whether such an examination is indicated or not. This allows me to get as close as possible to the patient. Even a cheating declared nonsmoker can be detected this way. At the same time, the fundi may provide valuable information as well.

Naimer Sody Abbey, MD, DN
Hof Gaza, Israel

Superbill signals who's next

With several examination rooms to keep track of, it is sometimes difficult to determine which patient to see next. A simple solution is to ask the nurse or patient coordinator to place the chart for the "next" patient with the charge slip or superbill facing out, toward the hall. All other charts have the charge slip facing the door. Now it is easy to spot who is next.

Neil Baum, MD
New Orleans

Two shots for one stick

If you need to give two injections, especially in the buttocks, hold both syringes together and insert both needles at the same time. Aspirate both and then deposit the medication. Your patients will love you for this one.

David DeGruy, RN, and Neil Baum, MD
New Orleans

Beware of bismuth subsalicylate and aspirin

Patients using bismuth subsalicylate therapy (Bismatrol, Pepto-Bismol) receive almost 2 g of salicylates from the usual dosage of 8 tablets per day. Therefore, they should be cautioned to decrease their use of aspirin or other salicylates while taking these tablets.

David Y. Graham, MD
Houston

Easing the eyedrops

If your patients have trouble using eyedrops, here is a suggestion. Have them either lie down or tilt the head back and put the drops in the corner of the affected eye, near the nose. Then tilt the head to the left for the left eye and to the right for the right eye. The drops flow directly into the eye.

Richard W. Kalmansohn, MD
Los Angeles

Bitter meds for toddlers

What should you do if a restless, opinionated 2-year-old refuses to take medicine? In my experience, the best way to minimize tears and spillage is to divide the total dose into 6 or 7 portions and give them with a dropper. Each of the doses should be followed by a refreshing and palate-cleansing sip from the water bottle.

Vadim Tikhomirov, MD
Danbury, Connecticut

Managing medication the easy way

Tracking and removing expired medications is time-consuming, yet managed care organizations grade offices on performance in this area. Instead of listing every medication and its expiration date, try this easier and approved method. Keep a sheet of paper attached to the cabinet door where medications are kept. On the sheet include the date samples were reviewed, usually on a monthly basis, and the initials of the employee who reviewed them.

Neil L. Kao, MD
Beavercreek, Ohio

Tricks of the trade for children's exams

During my 20 years of seeing children, I have come across a few tricks to entertain them and ease the exam. Here's what to do while performing specific parts of the exam:

• Ears: "Let me see if any Gummy Bears or Smurfs are hiding in there."
• Lungs: Listen for "Rice Krispies and their snap, crackle, pop."
• Heart: "Did you swallow a clock? Something is ticking in there."
• Abdomen: Look for "livers, spleens, kidney beans, and the gooshy stuff in between."

For general relaxation, try "Piggy went to market" on their toes. Finally, for
the hard-to-settle-down 2-year-olds, tell them a secret and then bump foreheads gently. They settle down and cooperate. However, you may have to repeat this action several times because they really enjoy it.

Luke Pruitt, MD
Columbia, South Carolina

Can we talk?

Curious about patient satisfaction? A good time to call patients is the day after an office visit. This allows you to start by asking them if they have any questions. Patients often appreciate the follow-up.

Neil L. Kao, MD
Beavercreek, Ohio

Potassium replacement, ACE inhibitors, and diabetes don't mix

Diabetic patients with some renal insufficiency may occasionally have disproportionate hyperkalemia and metabolic acidosis. Many of these patients have hyporeninemic hypoaldosteronism. Their plasma renin levels fail to rise as expected after suitable sodium restriction or upright posture.

The mechanisms behind this syndrome are not clear but may include defective conversion of renin precursors into renin, intrinsic renal disease (most available evidence points to this), extracellular volume expansion, or autonomic neuropathy.

Serious unexpected elevations of serum potassium levels may occur after routine potassium replacement or even gentle ACE inhibitor therapy in affected diabetic patients. Because ACE inhibitors help control microalbuminuria, many sick diabetic patients are given these drugs. When serious hyperkalemia occurs, therapy consists of scaling back on potassium replacement and ACE therapy as needed.

Jeffrey C. Spencer, MD
Cleveland, Ohio

Thinking outside the box, storing charts inside

Wondering how to maintain charts on currently inactive patients? Here's an idea. Store the charts in boxes labeled with the physician's name. Then mark each box with the approximate span of years and range of surnames contained in it. Finally, keep a master list of names, so charts can easily be located if needed or shredded promptly after the statute of limitations has expired.

Neil L. Kao, MD
Beavercreek, Ohio

Getting the best of the barb

Using wire cutters to remove a fish hook could present dangers. The barb could fly up and hit someone, potentially spreading inoculum, or the barb could lie on the floor and stick an unsuspecting person. To avoid such hazards, place a saline-soaked 4 X 4 gauze patch over the barb directly above where you are cutting. This will embed the barb in the gauze and protect you and others.

Luke Pruitt, MD
Columbia, South Carolina

Giving teddy bear the once-over

Next time you need to calm a toddler for an examination, try the technique we use in our office. First, run through a practice exam on a stuffed animal the child is holding or on an older sibling or a parent. Then, during the exam, search for characters the child can relate to (eg, Teletubbies, Muppets, Disney characters). Children get involved in the game and their stress lightens.

Dan Severa, MD
Lawrence, Kansas

Bandages pose choking threat

Use of bandages on children younger than 2 years of age presents a possible choking hazard. Often, bandages are placed on the fingers and hands of young children after routine blood tests. Inevitably, the bandaged hand or finger goes into the child's mouth, creating the potential to choke. Always caution parents to closely supervise children who are wearing such bandages, and tell them to remove bandages promptly once bleeding has stopped.

Michael P. Poirier, MD
Norfolk, Virginia

Poor man's patient triage

Have you ever walked down a hallway of filled exam rooms, uncertain which patient is the next to be seen? You could use a system of colored plastic flags or expensive lighting operated by toggle switches. However, we suggest a simpler and more economical system: Have your nurse or patient coordinator turn all charts in the chart holders to face the wall, except for one. The chart facing the hallway indicates the next patient.

Marc Iseri, MD, Ontario, Oregon
Neil Baum, MD, New Orleans, Louisiana

Sip helps locate the thyroid gland

When you are checking out a lump in a patient's neck, it is sometimes difficult to delineate the thyroid gland. Having the patient swallow a sip of water is often helpful in locating the thyroid gland and defining the anatomy more precisely.

William B. Armstrong, MD, and Mark F. Giglio, MD,
Orange, California

Check the pulse in suspected paradoxus

Pulsus paradoxus is an important prognostic sign in cardiac tamponade, bronchial asthma, chronic obstructive pulmonary disease, and other disorders. A quick bedside test to check for its presence consists of feeling the pulse and noting whether or not it changes with respirations. The test is positive if you can feel the pulse diminish in amplitude and even disappear during inspiration. On the other hand, a normal-volume pulse during inspiration rules out significant pulsus paradoxus.

Anis Shahmiri,
Ocala, Florida

When ear preparations irritate

Some ototopical agents are acidic and can irritate the ear canal, especially if the tympanic membrane is perforated. When patients complain that the otic preparations are irritating, try using ophthalmic preparations instead. These contain less acid and usually cause less irritation.

Jack A. Shohet, MD, and Joseph E. Scherger, MD, MPH,
Irvine, California

Vision problems can complicate visits

Visually impaired patients sometimes appear to be uncooperative or confused when you see them in your office. In fact, they simply might be frightened because they don't see clearly. The following tips may help you and your office staff:

• Stand close to the patient and speak directly in a normal tone of voice.

• Introduce yourself. The patient may not be able to distinguish between physicians, nurses, and technicians.

• Do not use gestures or hand signals. Instead, tell the patient where he or she is going and be sure the patient can see objects in the room.

• Avoid the use of glaring light in examining rooms.

Eleanor E. Faye, MD
New York City

Calming the crying infant

As I struggled to examine a crying infant one day, I turned him onto his belly while keeping his head elevated. To my surprise, the baby remained calm during the rest of the examination. Since then, I am careful to approach a baby from the front. At the first whimper, I turn the baby onto his or her stomach while keeping the baby's head elevated. This usually works well as long as my hands are warm and the baby cannot see me. I have found this to be very helpful, especially when examining a wheezing infant.

Niharika Khanna, MD
Baltimore

Seizing control of parenting

Patients with uncontrolled seizures need to take certain precautions in parenting. You can help ease their minds and keep children safe by advising them to avoid bathing their child alone, to minimize stair climbing, and to use a portable changing pad on the floor. They should also refrain from using a front or back infant carrier.

Joyce Liporace, MD
Philadelphia

Check the teeth to view the throat

If a patient, adult or child, needs a throat examination, I start by asking to look at the teeth. After a few seconds, the tongue relaxes and the pharynx can be easily examined as well.

Robert F. McCool, MD
Clarion, Iowa

More comfortable endoscopy

To provide effective topical anesthesia before an endoscopic or other invasive procedure through the mouth, I use the following method.

• Ask the patient to take a deep breath and hold it.
• Spray the aerosolized anesthetic into the posterior oral cavity.
• Have the patient purse his or her lips and breathe out.
• Ask the patient to gargle and swallow or expectorate.

The forceful exhalation before gargling releases a lot of the gas and flavor of the spray, thus avoiding the unpleasant taste and irritation that often occur. This method helps reduce initial gagging and makes the patient more comfortable.

Karen Szauter, MD
Galveston, Texas

Soothing the sore throat

In my experience, symptoms of sore throat can often be alleviated and even resolved by use of a gargle containing two regular-strength aspirin tablets in a small amount of warm water. Relief from viral, allergic, and even some bacterial throat infections usually lasts several hours. A coated or buffered aspirin should not be used, and acetaminophen does not work as a gargle.

Marjorie A. Voith, MD
Chevy Chase, Maryland

Relaxing the gag reflex

Gagging can be troublesome when you need to do a throat exam. This trick has worked for me many times, in both kids and adults.

Have the patient blow out all the air in the lungs through the mouth. Then ask him or her to open wide and inhale very slowly (preferably through the nose, but the mouth works too if the nose is congested). The patient will not gag as long as he or she is inhaling. Once the inhalation is stopped, the gagging often recurs.

Randy Cordle, MD
Allentown, Pennsylvania

Pinch prepares child for local anesthesia

When anesthetizing a wound in an older, anxious child, I have found it helpful to calmly and slowly, but not unexpectedly, "pinch" the child's arm. Before the pinch, I explain that this is the amount of pain that can be expected during the numbing procedure.

Experiencing the minor intensity and short duration of the pain often alleviates most of the child's anxiety and apprehension. This usually improves cooperation during the procedure and helps achieve complete local anesthesia to the wound.

Michael P. Poirier, MD
Norfolk, Virginia

No stick in the throat--revisited

In a previous pearl (see June 1997, page 34), I suggested having children pant like a dog or feign yawning to provide a good view of the throat. At a recent exam of a febrile 15-month-old infant, neither of these techniques was appropriate.

As I was reaching for the old standby tongue depressor, the patient's mother picked the child up and turned him upside down. Giggling, the child dropped his mouth wide open, giving me a good view of an erythematous pharynx. "Turning kids upside down always gets them to open their mouths," this mother told me. I thought I should pass this on, since it has worked for me several times since that first experience.

Jonathan Bertman, MD
Providence, Rhode Island

Banishing blemishes

Patient education is an important part of acne treatment. Patients should be told that improper diet or inadequate hygiene is not the cause of their acne. They should be encouraged to wash affected areas with any standard soap once or twice a day and after strenuous physical activities. I also warn them against using harsh detergents, scrubs containing granules, rubbing alcohol, and topical exfoliants, because these products provide no noticeable benefit and may so irritate the skin that use of effective topical preparations must be temporarily suspended.

Ken Landow, MD
Las Vegas

Help for a hairy situation

Keeping a patient's hair away from a scalp wound about to be sutured can be tricky. I have found that paper tape works quite well in this situation. Beginning near the laceration, I use as many as four strips, laying down the hair as I move away. The tape stays in place until I am finished and then is easily removed by pulling it away from the laceration.

Roland Larrabee, MD
Quarryville, Pennsylvania

Acting against aspiration

Patients receiving mechanical ventilation can be at risk for gastric aspiration if kept in a supine position for too long. Maintaining such patients in a semirecumbent position to reduce gastric aspiration has been shown to be of benefit.1 Therefore, we suggest that these patients be maintained in an upright position.

Jennifer R. Lomotan, MD, Sandy S. George, MD, Robert D. Brandstetter, MD
New Rochelle, New York

Reference

1. Torres A, Serra-Batlles J, Ros E, et al. Pulmonary aspiration of gastric contents in patients receiving mechanical ventilation: the effect of body position. Ann Intern Med 1992; 116(7):540-3

Sure-to-please low-fat cheese

Here's a tip to help patients cut down on fat and still enjoy tasty food. Sliced fat-free cheese doesn't melt well because it becomes dehydrated. However, simply marinating the cheese for 2 minutes in either water or broth allows it to melt. When placed over a low-fat burger, the marinated cheese promises to "ooze" all over.

Richard E. Collins, MD
Omaha

Medicine that's easier to swallow

For patients who can't swallow pills, drugs that do not have an elixir form can mean trouble. The patients must try to break or crush the pills into sections. I recommend three solutions to accomplish this: a hammer and screwdriver, a pestle and mortar, and a coffee grinder. The coffee grinder works best. It grinds any pill into a fine powder, which patients can then sprinkle onto any palatable food.

Craig G. Burkhart, MD
Sylvania, Ohio

Cooling the itch

Incessant pruritus is one of the most bothersome symptoms of atopic dermatitis, and popular folklore often encourages a hot bath to alleviate it. In reality, this unwise activity precipitates further itching and leads to a downward spiral that often culminates in widespread dermatitis. Cooling the skin with a cold compress wrapped in plastic or with a cold can from the refrigerator or freezer is more likely to ease pruritus without worsening the dermatitis.

Ken Landow, MD
Las Vegas

Localizing lesions

Once a local anesthetic has infiltrated the injection site, it can be difficult to localize small subcutaneous lumps for removal. I have found that use of a 30-gauge needle to impale the lesion exactly in its center prior to injection helps localize the lesion and guide incision, despite the fact that I cannot palpate the lesion after anesthesia. This technique causes the patient little discomfort and does not rupture even tiny cysts, which can be removed intact.

Roland Larrabee, MD
Quarryville, Pennsylvania

Double-gloving for hand dermatitis

Ken Landow, MD
Las Vegas

Stopping scabies from spreading

Richard W. Parkinson, MD, Orem, Utah
Glen C. Griffin, MD, Mapleton, Utah

Vasectomies made easy

Walter W. Rucker, MD
Athens, Tennessee

Instant hearing aid

David L. Smull, DO
Cleveland, Ohio

Vibrating pager tests nerves

An inability to feel vibration often is an early sign of peripheral neuropathy. When a low-pitched tuning fork is not available, I use my pager, set on vibratory mode, to see if a patient can feel vibrations over bony prominences. This simple test has proved quite valuable.

Alex Mechaber, MD
Washington, DC

Puffing out the penlight

When listening to the lungs of my younger patients, I have them "blow out" my penlight. When deeper inspirations are needed, I simply ask them to "blow harder." This invariably brings big smiles all around and accomplishes the task of taking deep breaths for little ones who might not understand.

Ron Christensen, MD
Anchorage

Cut down on nasal irritation

A local otolaryngologist gave me this suggestion for decreasing mucosal irritation in patients using nasal corticosteroids. First, have the patient use a saline spray to moisturize the mucosa. Then, have him or her spray the corticosteroid in an upward and outward direction, toward the ipsilateral maxillary sinus area. This gets the medicine where it needs to go and avoids septal irritation.

Eric Clark, MD
Medford, Oregon

Avoiding the niacin flush

Niacin is a good and inexpensive medication for managing hypercholesterolemia. However, patients often stop using it because of flushing and palpitations. These side effects can be avoided if the patient takes aspirin (usually 2 to 5 grains) before taking the niacin. I provide guidelines about how much aspirin to use, but then I encourage the patient to adjust the aspirin dose as needed to control flushing and rapid heart rates. This seems to work well for helping patients stick with the niacin regimen.

Winston W. Tan, MD
San Antonio, Texas

Otitis externa solution

If otitis externa is taking a long time to heal and a whitish, mildew-like substance is seen, I have found that local application of 1% clotrimazole solution (Lotrimin, Mycelex) can help. Apply the solution with a cotton swab twice daily for about 2 weeks.

A. Z. Syed, MD
Somerset, Pennsylvania

Central line insertion

When placing a central line in the internal jugular vein, I first use a thin, small-bore (eg, 22-gauge) needle to puncture the vein. Making sure good return of the blood is present, I keep this needle in place, along with the syringe. I then use this needle to guide placement of the larger central-line needle. Once free flow of blood is established in the central-line needle, I remove the small needle. This method is less traumatic for the patient and reduces the number of attempts needed to place the central line.

Ravinder Singh Panesar, MD
Caribou, Maine

Pediatric throat exams revisited

To encourage a reluctant child to cooperate in a pharngeal examination, I give the youngster a tongue blade to hold. I then ask the child to stick out his or her tongue and pant like a dog. I demonstrate how it's done. This does wonders for the mood in the room and allows a good view of the throat without actually using a tongue blade. Having control of the tongue blade seems to give the child a sense of security and empowerment.

Jeff Blau, MD
Taylor Mill, Kentucky

Create your own nasal speculae

In the university hospital clinic where I volunteer, the patient examination rooms are well equipped with wall-mounted instruments, including a dispenser of ear speculae. However, the clinic does not supply nasal speculae. To convert a plastic ear speculum to a nasal one, I use a bandage scissors to snip off about half the tip. This has met my needs very nicely.

Marvin Wells, MD
Albuquerque

Avoiding tummy tickles

Examination of the abdomen can be difficult in a ticklish patient. You can solve this problem by taking advantage of the fact that no one can tickle himself or herself. To eliminate the tickling, place your hand on top of the patient's hand, with your fingers between the patient's fingers. You can then easily reach into the depths of the patient's abdomen without resistance.

Harris Hyman III, MD, and Neil Baum, MD
New Orleans

Disarming the fishhook

Here is my technique for removing a fishhook. Using a digital block if needed, push the hook out to avoid having the barb take hold. Then cut off the barb and retract the hook. This works particularly well when the barb is close to the skin's surface.

Paul Brigel, MD
Victoria, British Columbia, Canada

Central venous access

For easier central venous access, I place a small pillow or towels between the patient's shoulder blades. This technique allows better access to vessels for both the subclavian and the internal jugular approach.

Keivan Edalat, MD
Prentiss, Mississippi

Grasping the flat lesion

Sometimes it is difficult to hold a flat lesion with forceps so you can cut around it. If I know I am not sending the tissue to the pathology laboratory, I simply pierce the lesion with the needle I used to infiltrate the local anesthetic, instead of using forceps. This gives me a good hold and allows me to cut neatly all around the lesion and shave it off.

Rashmi Abhyankar, MD
Terre Haute, Indiana

Better bone biopsy

Bone marrow biopsy in an obese patient is often difficult. I have found that inserting a spinal needle to mark the biopsy site and to guide the biopsy needle simplifies the procedure. Having an assistant available to push the muscle and tissue away from the biopsy site is also helpful.

Winston W. Tan, MD
San Antonio, Texas

Getting to the facts about drinking

When taking an alcohol history, I have learned to avoid such vague terms as "social drinker" or "occasional drinker." Instead, I specifically ask about amounts of alcohol used and any associated problems, such as alcohol-related arrests, concerns expressed by family or friends, history of drug or alcohol treatment, and involvement with Alcoholics Anonymous. This takes a few minutes longer, but I have found it yields valuable information.

Thomas R. Barringer, MD
Fridley, Minnesota

Tickle can relax toddlers

It can be difficult to gain the cooperation of toddlers undergoing ear examinations. I have found it helpful to ask children if they are ticklish as I gently tickle their ribs, axilla, or neck. I explain that the ear examination may tickle the same way, so they expect to feel something. While I check the ears, I whisper the words "tickle, tickle" and tell them it is okay to giggle but not to wiggle. I find they usually laugh but often can sit still.

Michael Jervis, DO
Jacksonville, Florida

Saving the sentimental ring

Removing a ring from the finger of an ill or injured patient can be emotionally traumatic. Most patients would rather not have the ring cut, and wrapping a swollen finger with string or dental floss can lead to cuts or, worse yet, tangles and secondary constriction.

In the absence of open fractures, burns, infection, or malignancy, try wrapping the finger from distal to proximal with a fairly wide rubber band that has been cut. Once the finger is wrapped, apply a little lubricant and work the ring off over the band. Hold on to the loose end and unwrap the slippery band as you go. In nearly 7 years of experience, I have never had to cut a ring off except in the circumstances mentioned earlier.

Charles E. Powell, EMT
Moscow, Idaho

Try the Trendelenburg

When central venous puncture is needed in a hypovolemic patient, I put the patient in Trendelenburg's position and ask him or her to contract the abdominal muscles during the puncture. This maneuver may expand the central veins, making them easier to reach.

Afonso M. C. Amorim
Recife, Brazil

The cough of congestive failure

I have always found a pearl given to me by an attending physician when I was a medical student some 30 years ago to stand me in good clinical stead: A persistent night cough can be a symptom of subtle congestive heart failure, especially in the elderly.

Eugene Guazzo, MD
Chaptico, Maryland

Local anesthetics for abscess?

Many of us have been taught that local anesthetics are unreliable when used in the acidic environment of an abscess. I use a double-buffered solution of 2 mL of bicarbonate with 8 mL of lidocaine. It works.

Ernest Hansen III, MD
Metairie, Louisiana

A shortcut for earwax

For faster, easier, cleaner, and nontraumatic removal of impacted earwax, I have devised a technique that uses a headlight and fine-tipped alligator forceps. This has proved effective for me and has saved time and eliminated the hassle of lavage. Patients are very impressed.

Barry K. Hull, MD
Indianapolis

Helping them breathe deeply

Encouraging a youngster to take deep breaths sometimes is a frustrating exercise. I discovered that balloons can help, provided the child is old enough to not be at risk for swallowing the balloon. When I want to listen to a child's lungs, I pull a balloon out of my pocket and ask the child to blow it up. This works like a charm, and the children have something to show for their efforts.

Michael Herman
fourth-year medical student
Orlando, Florida

Finding the foreign bodies

A colposcope provides excellent light and magnification for finding and removing foreign bodies from the eye, particularly the cornea. The instrument can also guide removal of the foreign body when you use the tip of a plastic cannula and can help you assess the extent of corneal damage. I have had a good success rate with this technique in my practice.

Ashley Sharma, MD
Leesburg, Florida

Relieving reliance on nasal sprays

Patients with chronic sinusitis often become dependent on nasal sprays.
To ease withdrawal from these sprays, I tell patients to buy saline nasal spray and use two puffs in each nostril four times a day. This helps break the rebound effect of nasal sprays, provides nasal irrigation, and assists with behavior modification.

William G. Marzullo, MD
El Paso, Texas

A second look at the eyes

After staining an eye with fluorescein, I always check it with UV light as usual, then irrigate the eye to remove the stain. I then check it again with the UV light. Many times an abrasion or defect that did not show up originally can be seen with the second look. This also helps demarcate the abrasion.

Michael Glick, DO
Albuquerque

Float the medicine right down

I learned this trick from a child with cystic fibrosis, and it has helped me teach dozens of patients to swallow capsules. Because pills have a tendency to float, I have the patient place a capsule in the mouth, take a mouthful of water, look down, and swallow. Usually the capsule floats to the back of the throat and can be effortlessly swallowed without gagging. If possible, I have the patient try this with a drug sample while I coach. Some people are so phobic about gagging that they can't swallow any pills, but most are surprised and grateful to learn this skill.

Deborah L. Morris, MD
Cary, North Carolina

Let 'em ham it up

To ease pharyngeal examinations in frightened, uncooperative children, I tell them to stick their tongue out at the doctor. This usually gains their confidence and allays anxiety, permitting a thorough examination.

Pamelia J. F. Gibson, RN
San Carlos, Arizona

Listening for the cause of leg pain

Pain in the lower extremities can cause tricky diagnostic dilemmas. To be sure I don't miss a diagnosis of peripheral vascular disease, I always place my stethoscope over the superficial femoral arteries on the anteromedial surface of the hip. Although bruits are unusual at this site, they are specific for peripheral vascular disease. The test takes just a few seconds.

Vadim Tikhomirov, MD
Danbury, Connecticut

Warmer, softer hands help

Before I do a breast examination, I rub lotion on my hands to make them softer and warmer. This also decreases the friction between my skin and the patient's, making for a better and more comfortable examination.

Christina A. Stasiuk, DO
Huntington Valley, Pennsylvania

"Cool" ideas for ice packs

Kids sometimes aren't happy about keeping an ice pack on a bruise or sprain. Here are some tricks that I have found helpful.

• Place a shot of rubbing alcohol and some ice in a locking freezer bag. Ask the child to pick his or her favorite food coloring and add a few drops to the bag. The alcohol allows you to refreeze the bag to a slurry, since it will not freeze completely, and the color makes it fun for the child to use.
• For young children, cut cellulose sponges into fun shapes, wet the sponges, and then freeze them. They are not as cold as ice packs but still help relieve pain and swelling.

John Canalizo, MD
Ormond Beach, Florida

Try the Rockwell approach

The famous Norman Rockwell picture of a doctor examining a doll as a little girl watches gave me a practical idea. If an obviously anxious child comes into the office clutching a doll or stuffed animal, I examine the toy first. I tell the child what I am doing as I listen to the toy's heart and lungs, touch the tummy, feel the glands, check the eyes, ears, and so on. The child often relaxes and allows a similar examination on himself or herself. A picture of an animal or a cartoon character on the child's shirt or sweater also works if a toy is not available.

Basil Rodansky, MD, Lincoln Park
Michigan

Blood pressure cuff for venipuncture

Instead of applying the usual thin elastic band to the upper arm for venipuncture, I use a blood pressure cuff inflated to between 20 and 35 mm Hg. This has several advantages:

• The pressure is measurable, and the risk of "blowout" from overdilated, fragile veins is avoided.
• The procedure is easier for personnel who do not perform venipunctures often.
• The patient is more comfortable, and there is no need to tighten or "pump" the fist.

I am curious as to why this method is not used more often. If there are disadvantages, I would like to be enlightened.

Ray Balan, MD
Morrow, Georgia

Simpler eyedrop administration

It's not much fun to try to instill eyedrops in an uncooperative or frightened child. A trick I use and share with parents is to have the child lie supine, with eyes closed. I then place one or two drops of medication in the pocket by the medial canthus. When the eyes are opened, the drops flow in. No need to aim at a blinking eye. (This technique is also helpful for adults who have a brisk blink reflex or poor hand-eye coordination.)

Pamela A. Vnenchak, MD
Lafayette, New York

Extending the cytobrush

Inserting the handle of a povidone-iodine swab into the handle of a cytobrush extends the length of the tool. This is useful for prepping the cervix for endometrial biopsies and other procedures.

Debra K. Lebo, DO
San Bernardino, California

Puffing away shots

Before giving a child an injection, ask him or her to blow small puffs of air at a parent or guardian. This relieves anxiety and distracts the child while the injection is given.

Evelyn Rosemore, MD
Plano, Texas

No more bloody shirts

Patients sometimes leave the phlebotomy area with a blood-stained shirt because pressure was not applied over the puncture site after blood was drawn. This can be easily remedied by applying an adhesive strip and then using the tourniquet to provide mild compression over the site. It is important to make sure the tourniquet is directly over the puncture site and not proximal to it, which would increase bleeding. The tourniquet is left in place while the technician completes the paperwork or for a few minutes longer if the patient is taking anticoagulants.

Neil Baum, MD
New Orleans

FDA puts lid on Skin-Cap

Skin-Cap, a popular over-the-counter psoriasis remedy imported from Spain and marketed as a spray, a shampoo, and a cream, has been found by the Food and Drug Administration (FDA) to contain clobetasol propionate, a potent topical corticosteroid that can cause side effects related to steroid toxicity. The steroid ingredients are not listed on the product label. The FDA has issued a warning and a nationwide import alert for detention of these products. Psoriasis patients should be alerted as well, since they may have purchased the product before the risks were recognized. Cessation of use should be done under medical guidance because of the risks involved.

Kristiina M. Burkhart, Craig G. Burkhart, MD
Sylvania, Ohio

Easing ear battles

Gaining the cooperation of a young child for an ear exam is often a challenge. When I ask the child if I can check his or her ears, the answer usually is an emphatic "No!" To reduce tension, I always save the ear exam for last. With the patient sitting on the parent's lap, I ask, "Which ear should I check first?" This simple question gives the child a sense of control and an understanding of what is going to happen next. I have had far fewer battles.

Pamela A. Vnenchak, MD
Lafayette, New York

Checking accuracy of glucose tests

Home blood glucose measurements are extremely important for controlling diabetes. However, most patients have doubts about whether they are doing their home monitoring correctly, especially when they first start using a meter. I encourage them to take their glucose meter with them each time they go to the lab and to ask the lab technician for a drop of the blood to test in their own meter. They then know precisely how accurate their meter is and feel much more secure about home testing.

Joseph W. Young, MD
Franklin, Indiana

Tips for managing hangover headache

To avoid the headache and queasy stomach that often accompany use of alcoholic beverages, try eating some honey. Honey supplies fructose, which helps the body metabolize alcohol and reduces hangover symptoms. Honey on a cracker or piece of toast, before or after drinking, may prevent a hangover.

If you do wind up with a headache, drink fluids that contain minerals and salts that alleviate dehydration. For example, a cup of bouillon replaces fluid and usually does not cause nausea. And the vasoconstrictor effects of the old standby, coffee, actually do shorten headaches for many people.

National Headache Foundation
Chicago

Freeze and tweeze the ticks

A simple procedure for removing a tick and all of its body parts is to apply liquid nitrogen for 20 seconds. Then use a tweezers to lift the tick from the skin. The method works especially well with blood-bloated ticks. In a miniseries of 10 such attempts, tick parts remained in the skin in only one patient.

Harold J. Galena, MD, PhD
Norwalk, Connecticut

Glow-in-the-dark eye exam

To visualize the fundi of even very young children, secure a glow-in-the-dark sticker at about eye level a few feet away from the exam table. Turn the lights out and ask the child questions about the glowing object as you examine one eye and then the other. This works great.

Gary M. Gorlich, MD, Los Angeles

Halting estrogen patch itch

A recent Postgraduate Medicine article (Connell EB. Transdermal estrogen therapy. 1997;101(6):115-34) mentions that rash is a common problem with the estrogen patch. When this occurs, I usually give my patients a sample nasal corticosteroid inhaler and tell them to spray once on the area where they are going to place the patch, let the area dry, and then apply the patch. I also always remind patients to change the location of the patch at each new application.

John Capps, MD
Gastonia North Carolina

Macarena assesses shoulder pain

When evaluating shoulder injuries, I often ask patients to do the current dance fad known as the Macarena. This takes them through a full range of shoulder joint motion. I also sometimes use this technique to evaluate the effectiveness of a local injection of marcaine hydrochloride. If the patient can comb his or her hair, can clean his or her behind, and has a negative drop test, I generally do not consider a disability significant.

Michael A. Ahearn, MD
Peoria, Illinois

Removing corneal foreign bodies

For removing foreign bodies from the cornea, I use a sterile plastic (Silastic) 20- or 22-gauge catheter tip instead of a traditional needle or eye burr. I feel much more comfortable and confident with a plastic tip than with a sharp needle--and patients also seem relieved. My success rate is excellent.

Tony Meriano, MD
London, Ontario, Canada

Deltoid vs forearm for PPD testing

The volar surface of the forearm is traditionally used for purified protein derivative (PPD) testing. I have found that patients have less pain when PPD is applied over the deltoid surface, which has fewer nerve fibers than the volar surface. Also, I believe the chance of inadvertent subcutaneous injection is reduced because the skin is thicker over the deltoid. The site is also less visible and more acceptable to patients.

Anil V. Daxini, MD
Flushing, New York

The case of the puzzling drug test

I was recently asked by a company to examine a potential employee who seemed to be an upstanding citizen. He tested positive for chemical abuse. He swore he did not use drugs or alcohol--and he was so personable that I believed him. Careful questioning disclosed that his Russian immigrant mother did all the cooking and baking for the family. On the day of the testing, she had served fresh, homemade poppy seed bread. There was the opium. So leave no stone unturned when faced with a puzzling test result. (The patient got the job!)

Rudi Kirschner, MD
Phoenix

Cleansing contaminated wounds

Studies have shown that only irrigation with a forceful stream of saline solution, rather than just soaking, effectively decreases the rate of wound infection. If a commercial device is not available, this simple method can help control irrigation and prevent splashing: Drive an 18-gauge needle through the botton of an inverted urine cup and attach a 10-cc syringe. This works nicely to prevent possibly contaminated irrigation fluid from splashing on mucous membranes.

Khosro Pourkavoos, MD
Louisville

Tricks for zeroing in on abdominal pain

Acute abdominal pain is a common problem. Despite the increasing use of imaging procedures, the hallmark of correct diagnosis continues to be a detailed history and thorough physical examination.

Careful observation of the patient and gentle percussion and palpation of the abdomen looking for tenderness, guarding, and rigidity are well-known techniques. The psoas and obturator signs may also be useful. Searching for rebound tenderness is not needed and may be unnecessarily painful for the already ill patient. (1,2).

I would like to describe five additional diagnostic maneuvers that may be helpful. As an aside, their use also increases the intellectual enjoyment of physical diagnosis.

• Heel-drop jarring test (3): The patient stands, then goes up on his or her toes for 15 seconds, and then comes down with full weight on his or her heels. The patient is then asked if this maneuver causes abdominal pain and, if so, where. The location of the pain indicates underlying infection or inflammation in that part of the abdomen.
• Abdominal wall tenderness test (4): While the patient is supine with abdominal muscles relaxed, the examiner palpates the tender spot. The patient is then asked to tense the abdominal muscles, and the tender spot is palpated once again. If the tenderness is worse, the abdominal wall muscles are most likely the source of the pain, rather than the underlying abdominal cavity.
• Hover sign (5): The examiner places his or her hand just above the area of abdominal pain or touches this area with the fingertips. If the patient grabs the hand, grimaces in anticipation of more pain, or guards the tender area with his or her hand, the abdominal wall is the site of pain.
• Cough sign (6): The patient is asked to cough and then questioned as to whether this causes abdominal pain and, if so, where. If pain is reproduced in a specific location, this is a sign of underlying peritoneal irritation.
• Closed eyes sign (7: The examiner observes the patient's eyes before and during the abdominal examination. Those with specific intra-abdominal disease keep their eyes open, fearful that the examining hand will cause even more pain. Those with less serious, nonspecific abdominal pain problems tend to keep their eyes closed.

Richard R. Babb, MD
Palo Alto, California

References

1. Silen W. Cope's early diagnosis of the acute abdomen. 19th ed. New York: Oxford University Press, 1996
2. Moustafa MH, Newton E. Does this patient have appendicitis? (Letter) JAMA 1997;277(8):625; discussion 626-7
3. Markle GB 4th. A simple test for intraperitoneal inflammation. Am J Surg 1973;125(6):721-2
4. Thomson H, Francis DM. Abdominal-wall tenderness: a useful sign in the acute abdomen. Lancet 1977;2(8047):1053-4
5. Hershfield NB. The abdominal wall: a frequently overlooked source of abdominal pain. J Clin Gastroenterol 1992;14(3):199-202
6. Bennett DH, Tambeur LJ, Campbell WB. Use of coughing test to diagnose peritonitis. BMJ 1994;308(6940):1336
7. Gray DW, Dixon JM, Collin J. The closed eyes sign: an aid to diagnosing nonspecific abdominal pain. BMJ 1988;297(6652):837

Preparing a well-trimmed cast

In the process of applying a short-arm, thumb-spica cast, such as would be used for a navicular fracture, a fenestration is usually made in the stockinette for the thumb. After the casting material is applied, the distal aspect of the thumb portion is bare and not neatly finished. Try placing a gauze tube over the thumb before applying the forearm stockinette. The finished cast can then be well trimmed, including the thumb portion.

Thomas Screnock, MD
Osseo, Wisconsin

Getting the hook out

The easiest, least traumatic way to remove a fishhook is to slowly numb up the area with lidocaine, using a 27- to 30-gauge needle. Then slip an 18-gauge needle on the same syringe and through the hole already made by the fishhook, cover the barb, and remove the fishhook and needle as a unit.

Keith Guinn, MD
Rutler, Alabama

Tell them when to stop taking drugs

During my 30 years in the practice of cardiology, I have seen many patients who were never advised to withhold their medications or to call their physicians when an acute illness develops. Continued use of diuretics or other hypotensive agents, including alpha blockers, can lead to serious hypotension and life-threatening arrhythmias in patients with fever, poor fluid intake, or excessive perspiration. It's a good idea to tell patients to call when they have an illness, even though they may think the problems are totally unrelated to any drugs they are taking. This can save many visits to the emergency department and hospital admissions.

Arnaldo G. Carvalho, MD
Springfield, Illinois

Hugs for a frightened child

To help comfort infants or small children, I ask the parent to hug the child, chest-to-chest. The baby's arms are down at the sides, held by one of the parent's arms, and the head is held by the parent's other arm. This makes for easy examination of the ears. Also, you can see the oropharynx when the child is crying. I usually listen to the baby's lungs when the parent first walks in holding the baby. The youngster need not lie on the table until the abdominal exam starts. Children are much more comfortable this way.

John Canalizo, MD
Ormond Beach, Florida

Nasal therapy may require double dose

When starting a patient on an inhaled anti-inflammatory agent (ie, corticosteroid), I find that significant turbinate edema and faulty technique reduce the medication's effectiveness. I begin the patient on a topical decongestant, such as oxymetazoline 0.05%, to be used twice daily before the inhaled anti-inflammatory. I instruct the patient to point the inhaler's nozzle backwards and not upward in the nasal passage while taking a deep breath. After one inhalation of the decongestant in each nostril, the patient is to lie down with his or her head tilted back for 1 minute. This is repeated once. At this point, the nasal mucosa should have shrunk enough to allow the anti-inflammatory to fully enter the nasal passages. The patient is instructed to stop the decongestant after 4 days but to continue the anti-inflammatory.

Yehia Y. Mishriki, MD
Allentown, Pennsylvania

Penis in the zipper

Glans penis skin clipped into a zipper is a rare but potentially harmful problem, especially in boys who have not been circumcised. Usually skin gets stuck in the zipper right at the zipper clip. Trying to unlock the zipper right away can be very painful and may leave a linear ulcer and later fibrosis on the glans skin. A simple trick is to place the tip of a hemostatic forceps in the triangular zipper box and then open the forceps, which will destroy the zipper box. The zipper can then be gently pulled apart, releasing the skin.

Rajesh Trivedi, MD
Evanston, Illinois

Open wide but don't cough

I am always uncomfortable when patients with upper respiratory infections cough in my direction. I have found that asking them to take a deep breath tends to open their airway sufficiently to allow adequate examination of the oropharynx without using a tongue depressor or having them cough towards me.

With children, I use a stick of bubble gum for the examination. They tend to open their mouth gracefully and keep it open, allowing an adequate examination. They also seem to cry less when they see me coming.

Michael A. Ahearn, MD
Galva, Illinois

No stick in the throat

Here are some tricks to help you avoid sticking a tongue depressor down the throat of pharyngitis patients. I often ask adults to yawn, which gives an unobstructed view of the pharynx about 90% of the time. For children, panting like a dog often drops the tongue and opens the mouth for a clear view. If a child is unwilling to pant, I feign a yawn, which often triggers the same response and allows a clear, although brief, look at the throat.

Jonathan Bertman, MD, Providence, Rhode Island

Confirming ulnar patency

When inserting a radial arterial line in a comatose patient in the intensive care unit, it is often difficult to assess ulnar patency. The patient may not be able to open and close the hand. Instead, I place the pulse oximetry probe on the second finger. After I see an adequate waveform on the monitor, I compress both radial and ulnar pulses until the waveform is lost. At that point I release pressure on the ulnar artery and evaluate the waveform. If it returns, ulnar patency is confirmed.

Rachel Vanek, RN, MS
Chardon, Ohio

Warm up your tools

Most gynecology examination tables have drawers at the foot--a perfect spot for a small heating pad. Plug the pad in and use it to warm up your metal speculae. Your patients will be extremely pleased.

Gail Frances, RN, MSN, nurse practitioner
Kensington, Maryland

Knife injuries can mimic thromboses

If you see a patient with unilateral swelling of an extremity, make sure to ask about a history of trauma with a knife. Such an injury can cause painful swelling resembling deep venous thrombosis, while the problem actually may be traumatic arteriovenous fistula. Careful auscultation over the site of old stab incisions may reveal continuous murmurs, suggesting the traumatic arteriovenous fistula. Diagnosis is confirmed by a Doppler ultrasound of the extremity. Correct diagnosis is important to prevent inappropriate use of heparin.

Amit Kumar Ghosh, MD
Minneapolis, Minnesota

Otoscope games ease exam

Ear exams can be very difficult in frightened infants. A trick I use is to show the baby the light, first touching it to my hand, then to the parent's hand, and finally to the child's leg. I slowly work my way to the ears, touching various parts of the child with the light along the way. The baby often is distracted or is no longer frightened by the otoscope, allowing an easier exam.

Steven Horvitz, DO
Cherry Hill, New Jersey

Freezing the cervix

For cryotherapy to the cervix, I use a wooden tongue blade along each vaginal side wall while inserting the cryogun. The blades act as insulating material against the wand portion so vaginal mucosa does not stick to it. Also, I have less arm and hand fatigue.

Renae S. Schuler, MD
Newton, Kansas

That's entertainment

Physicians' waiting and exam rooms can be very boring for children. To help solve this problem, my colleagues and I encourage the kids to entertain themselves while they are waiting. We supply amusements such as books, puppets, drawing tools, and even some electronic games.

In especially apprehensive youngsters, we show them what we are going to do by demonstrating on the parent or perhaps a sibling first. We also explain each device as we use it, such as the otoscope, stethoscope, and ear thermometer.

Dan Severa, MD
Lawrence, Kansas

The first step for anxiety and palpitations

Don't forget to check for hyperthyroidism in patients with frequent episodes of palpitations and anxiety. I was reminded of this after seeing a 30-year-old woman who had had these symptoms for the past 2 years. She had seen several physicians and was being treated with antidepressants. A thyroid function test showed readily treatable hyperthyroidism.

Winston W. Tan, MD
Stephenville, Texas

Hemorrhoid relief

For 15-second relief from nonthrombosed hemorrhoids, try viscous lidocaine hydrochloride 2% jelly (Xylocaine). Apply to the rectum after defecation, using a covered finger or tissue.

Walter C. Lang, DO
Clawson, Michigan

Objects in the ear

I have two solutions for removing foreign objects that turn up in people's ears and are not amenable to simple forceps maneuvers.

1. Place a tiny dot of Krazy Glue on the end of a cut cotton-tip applicator, being careful not to touch the side of the ear. Make contact with the object through the viewslide on the otoscope, and hold for 15 seconds. Then simply remove.
2. If the object in the ear is metal, use metal forceps and place a magnet on the end outside the ear. Simply touch the forceps, now magnetized, to the object and remove.

Robert Bessler, fourth-year medical student
Cleveland Heights, Ohio

Double-decker suturing

My experience with suturing an apprehensive toddler has taught me an innovative approach. Have the mother lie down on the examination table with her child secure in her arms on top of her. Encourage the mother to close her eyes and whisper or sing to the baby during the procedure, allowing little or no movement. This often makes the child more cooperative, although the short but painful stage of anesthetic infiltration may still require help from an assistant.

Sody Naimer
Hof Gaza, Israel

Double glove for speedier exams

Before starting pelvic and rectal exams, I double-glove my right hand. After I finish the Pap smear and pelvic exam, I simply discard the top glove. Below it I have a fresh, clean glove not contaminated by any vaginal contents. This has proved to be a quicker and less messy way to do subsequent digital and occult blood testing.

Reeta Bhargava, MD
Cumberland, Indiana

Helping baby burp

When it is difficult to get air out of a baby's stomach, try this approach. I have used it with my own children and have taught it to countless mothers.

1. Hold the calm (not crying) baby upright, with legs extended and head supported.
2. Lean the baby 30° to 45° to the left. A spontaneous burp often comes up immediately.
3. If step 2 did not trigger a burp, maintain the left lean and try leaning the child forward or backward up to about 30°.

Once you have found the position that works, it should be effective again and again. Anatomically, I believe that swallowed air trapped in the fundus can reach the esophagus when the child is leaned to the left. This passive positioning is less likely to bring up formula than some of the more active maneuvers.

Ron Reynolds, MD
New Richmond, Ohio

Persistent hiccups

When a patient has had hiccups for several hours or days and has tried all pharmacologic options as well as the Valsalva maneuver unsuccessfully, I have found that the following procedure may resolve the problem.

Insert a nasogastric tube as far as the stomach and immediately remove. The hiccups should stop at once. If not, try a second time. The mechanism is irritation of the posterior nasal mucous membrane and lower esophageal sphincter.

Waddah Allaf, MD
Montgomery, Alabama

Extend that leg

To save time when examining a patient, I find it useful to demonstrate the seated straight-leg-raising test by enthusiastically extending my own leg. Similarly, I have the patient mimic my dorsiflexion and plantar flexion of the foot. This quick and easy screening routine alerts me to patients who need more formal testing.

Chris Connelly, DO
Carson City, Nevada

Stained contact lenses

When rifampin is being used in combination therapy for group A streptococcal tonsillopharyngeal infections, patients should be advised that the drug produces orange discoloration of urine and tears. This is a harmless side effect, but it may cause permanent staining of contact lenses.

Michael E. Pichichero, MD
Rochester, New York

Relaxing, reliable rectal

In my work in the military, I have found that patients, particularly men, appreciate and tolerate well this technique for rectal examination--a procedure that is miserable at worst, uncomfortable at best. Ask the patient, who is standing and disrobed from the waist down, to place his forehead on the examination table, feet wide apart. Then have him use both hands to spread the buttocks. This allows the patient some control over the rectal sphincter. The examination then proceeds as usual.

Capt Keith Raymond, MD, USAF
Eulenbis, Germany

Positive fecal occult blood tests in patients taking NSAIDs

The US Preventive Services Task Force (1), along with numerous other medical and surgical societies, has recommended that persons aged 50 and older be screened for colorectal cancer with annual fecal occult blood tests (eg, Hemoccult). Large screening trials have shown that 1% to 6% of these tests are positive, and about 6% of patients with positive tests have colorectal cancer (2).

Nonsteroidal anti-inflammatory drugs (NSAIDs) are ingested by millions of Americans daily (3,4). Because the drugs can cause bleeding secondary to a variety of gastrointestinal lesions, positive fecal occult blood tests may be found in these patients (3-5).

The dilemma then is whether to begin diagnostic evaluation or to stop the NSAID and repeat the occult blood test at a later date. Two studies (6,7) related to this matter have been published. Results of evaluation with such procedures as sigmoidoscopy, colonoscopy, and barium enema showed that the incidence of colon cancer or large polyps in patients taking NSAIDs was comparable to that in patients not taking the drugs.

Because of these results and the fact that colorectal cancer is the second most common cause of cancer deaths in the United States (8), I recommend appropriate diagnostic tests in patients using NSAIDs who have positive fecal occult blood tests.

Some may find this advice meddlesome and not cost-effective. I invite their comments.

Richard R. Babb, MD, Palo Alto, California

References

1. Levin B, Bond JH. Colorectal cancer screening: recommendations of the US Preventive Services Task Force. American Gastroenterological Association. Gastroenterology 1996;111(5):1381-4
2. Van Dam J, Bond JH, Sivak MV Jr. Fecal occult blood screening for colorectal cancer. Arch Intern Med 1995;155(22):2389-402
3. Babb RR. Gastrointestinal complications of nonsteroidal anti-inflammatory drugs. West J Med 1992;157(4):444-7
4. Kwo PY, Tremaine WJ. Nonsteroidal anti-inflammatory drug-induced enteropathy: case discussion and review of the literature. Mayo Clin Proc 1995;70(1):55-61
5. Loebl DH, Craig RM, Culic DD, et al. Gastrointestinal blood loss: effect of aspirin, fenoprofen, and acetaminophen in rheumatoid arthritis as determined by sequential gastroscopy and radioactive fecal markers. JAMA 1977;237(10):976-81
6. Bahrt KM, Korman LY, Nashel DJ. Significance of a positive test for occult blood in stools of patients taking anti-inflammatory drugs. Arch Intern Med 1984;144(11):2165-6
7. Pye G, Ballantyne KC, Armitage NC, et al. Influence of non-steroidal anti-inflammatory drugs on the outcome of faecal occult blood tests in screening for colorectal cancer. Br Med J (Clin Res Ed) 1987;294(6586):1510-1
8. Toribara NW, Sleisenger MH. Screening for colorectal cancer. N Engl J Med 1995;332(13):861-7

The jaws that bite

If you are performing an oral examination on a combative child or adult, it helps to fold the lower or upper lip over the incisal edge of the teeth. If an attempt is made to bite you, the patient will bite his or her own lip first and your fingers will be spared injury.

Kurt R. Hulse, DDS
LaCrosse, Wisconsin

Relief of cough

An unremitting cough may be associated with hyperirritability of the airways caused by upper respiratory infection, toxic inhalation, or allergens. The cough is uncomfortable for the patient and may worsen bronchospasm.

In these cases, we add 0.5 mg/kg of lidocaine to 0.3 mL of albuterol solution in 3 mL of normal saline solution and administer the combination by aerosol nebulization. Lidocaine suppresses the cough reflex while the sympathomimetic agent relieves the bronchospasm.

We have given this therapy to many adult patients, including those with chloramine exposure, asthma, and cough associated with use of angiotensin-converting enzyme (ACE) inhibitors. Results have been excellent, and no complications have occurred.

Raymond J. Roberge, MD, Thomas P. Martin, MD
Pittsburgh

Support for walking

When patients with peripheral neuropathy have suboptimal visual input (eg, from poor lighting or lack of acuity), they should use another person, a cane, or both for physical support, especially when walking on irregular, soft, or unfamiliar terrain. If a cane is used, the patient should have sufficient upper extremity strength to bear 20% to 25% of body weight on the cane; this can be checked with a bathroom spring scale in the office.

The physician often needs to emphasize that the cane is not a sign of infirmity but simply a way to compensate for an impaired special sense. Compliance is improved if the cane is presented as being analogous to a hearing aid or pair of glasses and, as such, only to be used when needed.

James K. Richardson, MD, James A. Ashton-Miller, PhD
Ann Arbor, Michigan

Remedy for paronychia

Paronychial infection can be a stubborn and unsightly problem. In addition to use of topical, local, or systemic treatments, keeping the hand and nail bed dry is crucial in reducing risk of chronic infection.

I have found that spraying the nail bed three or four times a day with New-Skin Antiseptic, an over-the-counter liquid bandage, greatly speeds the elimination of infection and decreases the likelihood of recurrence.

Cheryl E. Heidelberger, MD
Dallas

False PT, PTT values

When a patient's hematocrit is greater than 50% or less than 20%, the prothrombin time (PT) and partial thromboplastin time (PTT) may be falsely increased and decreased, respectively. The excess sodium citrate binds calcium and causes an artificial prolongation of the coagulation test. Therefore, if the physician ordering the tests is aware that the patient's hematocrit is unusually elevated (as in polycythemia) or unusually low (as in severe anemia), it is advisable to inform the laboratory.

The reason for this potential error is that a fixed amount of sodium citrate anticoagulant is being added to the blood by the Vacutainer tube. If the hematocrit is increased, the plasma volume is decreased, and an excess of sodium citrate is added to the small amount of plasma present.

Mehdi Oloomi, PGY-II, Internal Medicine
Brooklyn

Urinary anion gap

In the evaluation of patients with hyperchloremic metabolic acidosis, calculation of the urinary anion gap, which estimates urinary ammonia secretion, is helpful in elucidating its cause.

Urinary anion gap = Urine (Na + K) - Cl

A negative value indicates a normal renal response in the setting of hyperchloremic acidosis and points to a nonrenal cause for the condition (most likely gastrointestinal losses). Conversely, a positive value indicates dysfunction of the renal tubules and points to one of the renal tubular acidoses as a cause of the hyperchloremic metabolic acidosis.

Kelly J. Ahn, MD
Atlanta

Magnesium for steroid-dependent asthma

Having trouble getting an asthmatic patient off (or at least down to the minimal effective dose) of systemic corticosteroids?

Consider a negative magnesium balance as the reason. Magnesium is a known bronchodilator. If the patient's renal function is normal, try the following: magnesium gluconate (eg, Magonate, 27 mg/tablet or 54 mg/5 mL liquid) three times a day. Adjust the dose according to clinical response. Stool softness occurs but is acceptable; reduce the dose if stools become loose.

This protocol has resulted in gratifying subjective as well as objective improvement (gauged by increased expiratory air flow) and significantly spares the use of systemic corticosteroids.

Joseph E. Giletto, DO
Aldan, Pennsylvania

Reviewer comment: There is some controversy regarding the use of magnesium for asthma, but in my experience it works.

ADHD or white-coat phenomenon?

During a clinical interview, the excess motor activity of adults who have attention-deficit hyperactivity disorder (ADHD) may be difficult to differentiate from the fidgety behavior of persons with anxiety caused by the medical setting (ie, the white-coat phenomenon).

One clue is helpful. In the case of ADHD, motor activity increases as the stimulating novelty of the interview diminishes and the patient struggles with impulses to move. With white-coat phenomenon, however, motor activity tends to decrease as the interview proceeds and the patient becomes more comfortable.

David Feifel, MD, PhD
La Jolla, California

Difficult venipuncture

When venipuncture of small veins of the extremities is difficult, apply a blood pressure cuff and manometer and then pump the pressure above diastolic but not near or over systolic levels. Because the blood escapes through the arteries but is inhibited through the veins, the latter become distended, more prominent, and accessible.

Donald D. Lehocz, MD
Athens, Ohio

Teaching children to take pills

I have had very good results over the years with the following method of teaching children to take pills. I have the parents use plain M&M's for practice. These are about the size of pills, and children are less anxious about using them. They know that if they can't swallow one, they can chew it up.

Matt Loewen, DO
Arlington, Texas

Reviewer comment: This method may not be appropriate for use in very young children.

Help with nasogastric tube placement

Placing a nasogastric tube requires patient cooperation, especially in initiating swallowing at the correct moment when the tube has to advance beyond the pharynx. Problems arise when a patient has an altered sensorium or totally refuses to accept the idea of swallowing the tube.

Instead of asking the patient to swallow, wait until the tube has reached a point beyond the nasopharynx. Then place a finger at the patient's larynx. When the next natural swallowing reflex is initiated for accumulated salivary secretions, the larynx will move cephalad and the tube can be gently negotiated in the correct direction.

Gopesh Kumar Modi, Senior Resident
New Delhi, India

Remedy for proctalgia fugax

I read Dr Richard R. Babb's article on proctalgia fugax (April 1996, page 263) with interest because I've had the problem for years but never knew what to call it.

I discovered by trial and error that I could break the spasm with an enema of a few ounces of warm water. The spasm subsides within 10 or 20 seconds as the water is being expelled.

It sure beats putting up with the rather severe pain.

R. L. Soholt, MD
Riverside, California

Basting the ear

When I advise patients to irrigate their ears at home, I have them use a turkey baster instead of a smaller bulb syringe. The baster provides a greater volume of flow at lower velocity and thus causes less pain.

Christopher White, MD
Norwalk, Iowa

Silly photos and the well-baby exam

Sometimes, during a well-baby examination, a child becomes upset and difficult to manage. I carry a silly photograph of my small children that I give to the child to hold during the examination. In the photo, one daughter is making a funny face and the other is wearing a pair of swimming goggles and holding a pet rat.

Children love to look at photos of other children, and I have found that they are so amazed and distracted by this photo that I can breeze through the tough part of the examination.

Ricci Silberman, PA-C
Tucson

Convincing patients to use intranasal steroids

To improve compliance with the use of intranasal steroids for rhinitis, three important issues need to be discussed with the patient:

1. Intranasal steroids are not like over-the-counter nose sprays that people can get "hooked on."
2. They are not the kind of steroids (anabolic) that some athletes and bodybuilders take. Users do not "bulk up," nor do their noses get larger!
3. Improvement is not noticed for 3 to 7 days. The patient should use the medication for a period of 1 to 2 weeks before deciding whether it is effective.

If this information is not given, the patient may not use the medication long enough or may never even try it.

David F. Graft, MD
Minneapolis

Warts and calluses

Often a plantar callus is difficult to distinguish clinically from a plantar verruca. Both may look like hyperkeratotic lesions and are painful on ambulation.

It is possible to tell the two apart by palpation. A plantar callus is painful on direct palpation, while a verruca is usually painful on lateral (side-to-side) palpation. Treatment is more likely to be successful if the lesions are differentiated.

Sherwin Tucker, DPM
Rocky Hill, Connecticut

Easing the rectal exam

Often, the most uncomfortable portion of a rectal examination is the actual insertion of the finger. I place the examining finger at the anal orifice and instruct the patient to cough forcefully. The contraction and subsequent relaxation of the anal sphincter draws the finger into the rectum with minimal discomfort. In addition, the cough maneuver removes the patient's focus from the insertion procedure.

I have used this technique for both rectal and vaginal examinations over many years and found it to be quite useful in minimizing discomfort.

Raymond Roberge, MD
Pittsburgh

Tips for examining infants and toddlers

When examining infants and toddlers, I find that it is comforting to the child if he or she remains on the parent's lap. I delay transferring the child to the examination table until it is absolutely necessary. Some children associate the table with past injections.

Examination of the oral cavity in this age-group is most difficult. One tactic is to have the parent tickle the child; when he or she laughs, you have an opportunity to look into the mouth.

Shakoora Cena Rashada, MD
Douglasville, Georgia

New-onset insomnia and BPH

Whenever an elderly man comes in complaining of new-onset insomnia, I inquire about nocturia. Men with benign prostatic hypertrophy (BPH) often present first with insomnia. The latter resolves when BPH is treated.

Edeane Matsumoto, MD
Oakland, California

Insulin safety net

When diabetic patients who need insulin at home are hospitalized, it is common practice to have them follow a regimen of regular insulin on a sliding scale alone, and insulin is taken only when the blood glucose level is high. I believe that it is much more "physiologic" to have patients take regular insulin plus a reduced dose of NPH insulin (once or twice a day) so that blood glucose levels don't reach high readings in the first place. With this regimen, the sliding scale is used only as a "safety net," in case additional insulin is required.

Mitchell W. Hecht, MD
Atlanta

He who hesitates . . .

During my internship, a worried mother brought her young son to the emergency department because the child had swallowed an open safety pin. I used a tongue depressor and an examination light and observed the open pin lodged in the posterior pharynx. Because I did not have a forceps to grasp the pin, I quietly told the child to close his mouth.

After obtaining a forceps, I once again had him open his mouth. This time, however, the pin was not visible. As a result, a major procedure was necessary to remove it.

The lesson I learned from this experience is that one should always have the proper instrument available at the initial examination for a foreign body.

Nicholas C. Scaccia, DO
Sanford, Maine

Bubbling ear

Sometimes, a patient can be the best teacher. In my case, a patient came to the emergency department because he suspected that he had a ruptured tympanic membrane. When I asked him how he knew it was ruptured, he said, "I hear bubbling in that ear when I blow my nose." Sure enough, the bubbling created by the hole in the drum was visible as the air passed through the pus and fluid that were present.

It must be remembered, however, that although this test is very specific, it may not be sensitive. Fluid must be present for the air to bubble through.

Paul Tayoun, MD
New York City

Should kids sleep with parents?

When parents ask about a child who insists on sleeping with them, simply tell them they have two choices: let the disruptive behavior continue--or stop it.

After a busy day, parents deserve a good night's rest without being disturbed by a tossing and turning child. Parents also deserve privacy for talk and marital intimacies that should not be postponed or missed because a child wants to sleep with them.

Make bedtime fun with stories and lots of listening. But--other than on camping trips when the whole family crams into a tent together or on a weekend morning when children can be allowed to crawl into their parents' bed to visit--kids definitely belong in their own beds.

Glen C. Griffin, MD
Springville, Utah

Iced saline lavage for acute epistaxis

In cases of acute epistaxis, iced saline lavage of each nostril with the patient leaning forward may help decrease or stop bleeding and allow better assessment of bleeding sites. The patient must be seated during examination and therapeutic procedures to lower blood pressure.

Nasal manipulation may cause vasovagal syncope in some patients, so smelling salts may be helpful and an assistant should be available.

Aijaz Alvi, MD
Nedra Joyner-Triplett, MD
Chicago

No apparent cause for crying

It is not uncommon to see an infant or toddler who is irritable even though no physical finding is apparent. I saw an infant who had gone to bed well but awakened at 3 AM crying. The child had no fever and otherwise seemed well.

A thorough examination showed no obvious physical abnormality. However, closer examination of the cornea revealed a small defect. After I administered 1 drop of proparacaine hydrochloride, the child's crying turned into an almost instant smile. Corneal abrasion was confirmed with fluorescein.

John M. Hardges, MD
Chalmette, Louisiana

Warts--an easy freeze

Many practitioners use liquid nitrogen in their offices to treat warts. However, it is often difficult to achieve an adequate freeze, because cotton-tipped applicators do not provide a large enough reservoir for the liquid nitrogen. Although we have been taught to wrap cotton around the applicator tip to increase the size of the reservoir, this is time consuming, unwieldy, and not consistently effective.

I suggest using the cotton-tipped applicator as an obturator in a 4-mm disposable otoscope speculum (see illustration). When held upright, this device can be dipped into the liquid nitrogen and directed much more accurately, thus producing a considerably better freeze. The rate of flow through the tip can be adjusted by varying the amount of pressure used to push the applicator into the speculum.

William K. Faber, MD
Hinsdale, Illinois

Look at the belly button

A child may not cooperate when asked to flex the neck forward so that the cardinal symptom of meningitis, neck stiffness, can be ruled out. If such is the case, ask the child to look down at his or her belly button.

A mom taught me this not long ago, and I believe other physicians will find this technique helpful.

Paul Brigel, MD
Victoria, British Columbia

Occult wheezing

When evaluating a cough, I ask the patient to perform a forced expiration, which often reveals occult end-expiratory wheezing. (This type of cough may respond well to an albuterol inhaler.)

Small children may not be able to do this manuever, even when I ask them to blow as if they are trying to extinguish the candles on their birthday cake. In these cases and with the parent's approval, I gently compress the child's chest. This technique also elicits occult wheezing.

Arnold Goldberg, MD
Pawtucket, Rhode Island

Getting a youngster to swallow a pill

When it is an advantage to give medication in tablet form to a youngster, even a toddler, instead of making a big production of it, simply put the tablet in the palm of the child's hand and, without saying anything, stand by with his or her favorite juice. This method doesn't always work, but it is surprising how often the child will pop the pill into the mouth and swallow it.

Glen C. Griffin, MD
Mapleton, Utah

Is it somatization?

After I have examined a patient in my office with such multiple complaints as palpitation, headache, stomach pains, muscle aches, and anxiety with shortness of breath, I ask him or her to complete a Prime-MD questionnaire, a guide for primary care evaluation of mental disorders. The results allow me to confirm my findings in persons who have somatization problems.

The questionnaire's protocol module can be filled out by the physician, with the help of the patient, in about 8 minutes. A good relationship is thereby established with the patient, and unnecessary and expensive testing is avoided if a diagnosis of somatoform disease is confirmed.

John J. Shigo, MD
Gaithersburg, Maryland

Speedy suturing in children

When only two