Things Specialists Wish Family Docs Would Stop (or Start) Doing

Compiled by Dr Alicia Adams during her PGY-2 rotations:
Opthalmology
  • If the eye doesn’t hurt and there is no photophobia, the zoster/HSV is not affecting their eye
Cardiology
  • there should be no such thing as an outpatient troponin — if you are worried enough to check it, they stay in office until you have the result or you send them to the ER for workup/observation admission
  • if the ER checked a troponin for a non-cardiac reason, don’t trend it. tons of things can cause an elevation (sepsis, renal injury, severe HTN/hypotension  etc.) and unless you think they have ACS, we will not do anything about it. try to anticipate cardiology response and test accordingly.
    • even minor troponin elevations (in an appropriately tested patient) can be handled as an outpatient after maximal medical therapy most times
    • Don’t check in afib until rate controlled.  Reassess cardiac pain after that,  only check if worse or unchanged
    • Think before you trop – even if elevated,  if they are septic or bleeding or have something else acute going on,  need to wait for that to resolve before treating them (cath,  anticoagulants,  etc) .  Likely need to wait for resolution of acute episode and then get outpatient follow up
  • don’t get a stress test if they are low or high risk
    • low risk = false positive that we are stuck dealing with and is now in the chart when all you wanted was reassurance
    • high risk = false negative — they should probably go to cath anyway due to risk factors; it added nothing and just cost everyone time and money
    • stress tests are for the intermediate risk people and can usually be done outpatient as well
    • If history of CAD and concerning symptoms  consider inpatient stress testing to make sure no acute change.  Almost everyone else is appropriate for outpatient.
      • Takes a max of 3 days to get outpatient stress w cards,  just call office at discharge to set up.  They then read nuclear scans as well instead of radiology while inpatient (more accurate)
  • Eliquis is as effective as warfarin and has lower bleeding risk – preferred by cardiology
    • Xarelto = warfarin without monitoring,  1x/day
    • Pradaxa has reversal
  • Use amiodarone or beta Blocker for afib with RVR unless you know their EF is normal because contraction caused by Ca and if EF is 20% and you drop contractility more can cause acute failure
  • Get a BNP for CHF (not the pro-BNP which needs to be adjusted for age) — keeps things more straightforward
  • Afib: try to get them back to normal rhythm to see if they feel better — even if not aware of symptoms, may have much more energy with cardioversion
    • default to anticoagulating everyone
    • AFFIRM trial (rate vs rhythm control) was done in asymptomatic patients
    • if average HR is >120 for 3 weeks, can show up ni acute heart failure
  • amiodarone is better in elderly because of toxin buildup is more significant in younger people (more years to build up)
    • digoxin ok if you have an elderly person who has no room for BP change but needs to be rate controlled (but still not great)
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