Current Issue
Volume: 37
Number: 4
Index: December 2009
Clinical Focus: THE INJURED ATHLETE
Editorial Calendar
April 2010
Clinical Focus: Hypertension
  • Hypertension in athletes
    • Antihypertension medication and its effects on athletes
  • Risk of CVD in professional athletes
  • NSAIDs in sports medicine
  • Arterial and venous injuries in athletes
  • Family history and exercise-induced cardiac remodeling (eg, left ventricular hypertrophy)
  • Physical activity for non-athletes with hypertension
    • Exercise programs for patients with hypertension
  • Sleep changes related to hypertension
  • Resuming exercise after rhabdomyolysis
  • Gender differences in hypertension and treatment options
  • Dietary approaches to prevention and treatment hypertension
  • Exercise and the vascular wall
  • Effects of exercise on aging
  • Association between exercise and atherosclerosis
  • Sodium ingestion and hypertension
  • Arrhythmia and "holiday heart"
  • Increased arterial stiffness in children, patients with type 2 diabetes
  • COPD
View More
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The Physician and Sportsmedicine's online Practice Pearls are exclusive to our Web site. As an online feature, they provide users with practical, easy-to-apply information about patient care. Please note that online feature Practice Pearls are different from Practice Pearls published in the print journal. Printed Practice Pearls summarize and provide commentary on published articles. Online Practice Pearls provide helpful hints to use in daily clinical practice. We encourage authors to read other Practice Pearls to get an idea of the type of information that we publish. All Pearls are pre-screened for relevance upon receipt and then reviewed by the editor-in-chief for acceptance or rejection. Authors will be notified of acceptance within 1 month. We are unable to publish all Practice Pearl submissions.

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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



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



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



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



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



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



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



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


References
  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



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



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



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



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



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



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



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



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



AVOID TRAUMA WHILE REMOVING NASAL FOREIGN BODIES
Here's a trick I use in the emergency department to help remove a foreign body from the nose of a child. First I administer 4 or 5 drops of adult-strength xylometazoline hydrochloride (Otrivin) to the affected nostril and allow 5 minutes for vasoconstriction of the inferior turbinate and nasal mucosa. Then I ask the child to take a deep breath through the mouth and exhale through the affected nostril while I occlude the contralateral nostril. This removes the foreign body about 30% of the time and at least moves it more anteriorly--for easier removal with bayonet forceps--in about half of cases.
J. Madison Clark, MD
Portland, Oregon



AVOIDING PITFALLS OF FECAL OCCULT BLOOD TESTING
Fecal occult blood testing is designed for screening asymptomatic persons over age 50 for colorectal neoplasms. To minimize the incidence of false-positive and false-negative results, the following steps are necessary:
  • For 3 days before and during testing, patients should avoid eating red meat, fruits such as cantaloupe, and vegetables such as broccoli, turnips, radishes, and cauliflower. Vitamin C, aspirin, and nonsteroidal anti-inflammatory drugs should also be avoided.
  • Two samples of each of three consecutive stools should be tested within 4 to 6 days. Obtaining specimens by digital rectal examination in hospitalized patients has a high false-positive rate and should not be done.

Aslam Godil, MD
Fouzia Godil, MD
Loma Linda, California



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



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