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Tools & Resources

Evaluation

Procedures

Additional Resources

Guidelines, Reference Documents, Etc.

General Information

General Medicine/Evidence-Based Medicine

Other

Membership Required: American Family Physician, BMJ Best Practice

Landmark Studies

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Navigating Insurance

Patient Handouts

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Evidence Based Medicine Calculations

EBM Calculations Table.PNG

Relative Risk (RR) = EER/CER = (% disease in untreated patients)/(% disease in treated patients) = 0.58

  • For every 100 untreated patients, 58 will experience MI

  • For every 100 treated patients, only 33 will experience MI

  • Therefore, the risk of MI in a treated patient is only 57% of the risk for an untreated patient

Absolute risk reduction = |CER - EER| = |(% disease in untreated patients) - (% disease in treated patients)| = |0.57 - 0.33| = 0.24

  • ARR = difference between event rates in the control and treatment groups

  • If there were 100 people in the treatment group and 100 people in the control group, there would be 24 fewer MIs in the treatment group as compared to the control

Number needed to treat = 1/ARR = 1/0.24 = 4.16

  • NNT: For every 4 patients who receive the treatment, one MI will be prevented

  • If the treatment is found to increase disease rate, this calculation becomes the “number needed to harm”

Pedigree Assessment Tool

For every family member with a breast or ovarian cancer diagnosis, including second or third-degree relatives:

PAT.png

A score of ≥8 is the threshold for referral to genetic counseling

Wet Mount Preparation

Vaginal Wet Mount

  • Materials

    • Pelvic exam: Speculum, speculum lubricant, speculum light, cotton swab

    • Wet mount: Saline solution, KOH solution, two microscope slides, one slide cover slip

  • Procedure

    • Perform pelvic exam and swab cervix

    • Place swab in test tube with 0.5 cc saline and stir to create a suspension

    • Using cotton swab, smear dime-sized amount of the suspension on each microscope slide

      • Add 1-2 drops KOH solution to the first slide and perform whiff test

      • Add cover slip to the second slide and observe under microscope on 40x magnification

Potential Microscopy Findings - Saline Preparation

  • Normal

    • Squamous epithelial cells

    • Erythrocytes

    • PMNs (polymorphonuclear leukocytes): May be abnormal if present in excessive numbers

    • Sperm cells

  • Abnormal

    • Yeast (sometimes seen more easily on KOH prep as the solution lyses other cellular components)

    • Clue cells: Squamous epithelial cells with > 75% of border covered with bacteria that may indicate bacterial vaginosis

    • Trichomonads: Approximately the size of PMNs and identified by characteristic jerking movement

Nexplanon Insertion

  • Verify

    • No history of

      • Ischemic heart disease, liver tumors/cirrhosis, systemic lupus erythematosus, cerebrovascular disease

      • Breast cancer within the previous 5 years

    • No active AUB, cervical/endometrial cancer

    • Pregnancy test negative

    • Arm desired for insertion (generally non-dominant)

  • Obtain consent

    • Procedure: Pain, bleeding, infection, injury at insertion site

    • Contraceptive method: Irregular uterine bleeding, potential for Nexplanon to dislodge, failure of contraceptive method

  • Site preparation

    • Position patient with shoulder and elbow at 90 degrees

    • Mark insertion site located

      • 8 cm medial to medial epicondyle of humeral head

      • 4 cm inferior to bicep/tricep sulcus

    • Mark a second (terminal) point 4 cm proximal to insertion site to act as a guide

    • Place sterile drape over insertion site

    • Clean insertion site with betadine and let dry

    • Do NOT insert any needles through ink mark to avoid tattooing skin

  • Local anesthetic

    • Wipe injection site with alcohol pad

    • Using a 5 mL syringe with 1.5 inch, 25 gauge needle, inject 2 cc of 1% lidocaine without epinephrine just distal to first mark

    • Advance the syringe along the planned insertion path and raise a wheel

  • Nexplanon insertion

    • Remove plastic cover from Nexplanon injector

    • Place Nexplanon injector needle just distal to first mark and aim toward second

    • Advance along full length of the needle

    • Apply downward pressure to slider and retract fully backward

    • Lift Nexplanon away from skin

  • Post-procedure

    • Stop any local bleeding with gauze

    • Palpate Nexplanon to ensure appropriate insertion

    • Remove sterile drape and place under patient's arm

    • Place adhesive bandage over insertion site

    • Have patient palpate Nexplanon

    • Wrap insertion site with elastic pressure bandage

IUD Setup.png


IUD

IUD insertion -Contraindications for copper IUD -Additional contraindications for levonorgestrel IUD

  • Instruments IUD

    • Sterile cup with betadine

    • Syringe with lidocaine

    • Speculum

    • Ring forceps

    • Tenaculum

    • Sound

    • String scissors

  • Procedure

    • Insert speculum

    • Visualize the cervix

    • Betadine solution on exterior cervix

    • Consider lidocaine with tenaculum

    • Sound the uterus to depth of at least 6 cm

    • Mirena - up, advance, center, back, remove

    • Cut the string (don't pull string when cutting)

  • Post-procedure

    • Give pad to patient

    • Discuss follow-up pregnancy testing

  • Billing

    • Insertion procedure 58300

    • Device

      • Skyla J7301

      • Paraguard J7300

      • Mirena J7302



Biophysical Profile

Theory: Assesses function of regulatory centers in the brain that may be affected by ischemia, hypoxemia, and/or acidemia.


Two points for each of the following during a 30 minute observation period:

  • Reassuring non-stress test, i.e. two accelerations and no late or variable decelerations

  • Deepest vertical amniotic fluid pocket measuring 2 cm or greater (measured in all 4 quadrants)

  • Fetal breathing movements for 30 seconds or longer (timed movement is cumulative, not continuous)

  • Fetal tone, i.e. extension of the spine or an extremity with return to flexion

  • Three or more discrete limb movements

Scoring interpretation

  • 10: Reassuring; continue routine prenatal care

  • 8: Interpretation depends on fluid status

    • No oligohydramnios: Reassuring with risk of stillbirth <1/1000 within 1 week

    • Oligohydramnios present: Deliver at 36-37 WGA

  • 6: Non-predictive

    • 37 WGA or greater: Deliver

    • <37 WGA: Repeat test in 24 hours

  • <6/10: Concerning with risk for fetal asphyxia ~90/1000 within 1 week

    • 32 WGA or greater: Consult maternal fetal medicine and deliver

    • <32 WGA: Consult maternal fetal medicine; individualize treatment plan

Note: Oligohydramnios is defined as no amniotic fluid pocket measuring >2cm


Skin Tag Removal

  • Review the patient’s chart for potential complicating factors, e.g. keloid scars, bleeding disorders (e.g. von Willebrand), previous surgical complications, allergies to betadine/latex, current antiplatelet/anticoagulant medications, etc.

  • Set-up the procedure room by ensuring all necessary materials are present and easily accessible. Prepare for both cryosurgery and electrocautery.

  • Materials: Consent form, gloves, skin marker, six inch cotton swabs, container with liquid nitrogen, betadine, alcohol swab, lidocaine 2% with epinephrine, 3 mL syringe, 16 gauge needle (gray), 20 gauge needle (pink), blunt dermal Bovie tip, Bovie electrosurgery device, flat forceps, specimen container with formalin, 4x4 gauze, aluminum chloride 10% solution, bacitracin, adhesive bandage.

  • Identify the lesion(s) to be removed and appropriate surgical method:

    • Multiple lesions: Place a mark beside each target lesion with a skin marker. Measure and record each lesions’ size and location. Do not remove more than 15 lesions for safety and billing purposes (see notes).

    • ONLY use cryosurgery for unequivocally benign lesions. Do NOT use cryosurgery for lesions with asymmetry, uneven borders, pigmentation, diameter ≥ 6 mm, and/or recent change in appearance.

    • Any lesions with concerning characteristics (see italics above) should be removed with electrocautery and sent for biopsy. Label specimen container(s) and place tissue biopsy order(s) before proceeding.

  • Consent the patient for the procedure. Discuss risk for pain, bleeding, infection, injury to surrounding tissue, temporary swelling, permanent scarring. Inform patient that reactive scaring may may produce a lesion larger than the one removed. Inform the patient that multiple rounds of cryotherapy may be required to remove a lesion.

Cryosurgery Method

  • Submerse the cotton swabs in liquid nitrogen.

  • Place the cotton swabs on either side to of the lesion peduncle and compress until it frosts. Repeat 2-3 times.

  • Complete a procedure note and bill the procedure (see notes).

Electrocautery Method

  • Identify the lesion to be removed.

  • Clean area with betadine. Do NOT use alcohol swabs as alcohol can ignite and burn the patient.

  • Prepare anesthetic (lidocaine 2% with epinephrine): Clean bottle top with alcohol swab. Insert 3 mL syringe with 16 gauge needle and fill syringe. Remove the 16 gauge needle (discard in sharp bin) and attach a 25 gauge needle. Insert the syringe bevel-deep at the lesion edge. Draw back and insure no blood enters the needle before injecting to form a wheel under the lesion. Wait 7 minutes for lidocaine and epinephrine to take effect.

  • Affix a blunt dermal tip to the Bovie pencil. Turn on the electrosurgery generator and set the device to 3.0.

  • Pinch the skin tag with forceps to ensure appropriate anesthesia. Use the forceps to lift the lesion away from the skin. Use the Bovie pencil to remove the lesion.

  • Place the lesion in a formalin specimen container.

  • Have 4x4 gauze and aluminum chloride 10% solution available for hemostasis if necessary. Alternatively, increase the Bovie to 6.0 to use it as electrocautery.

  • Cover the surgical site with bacitracin and an adhesive bandage.

  • Verify the tissue biopsy is labeled and give it to the appropriate staff member.

  • Complete a procedure note, log the biopsy, and bill the procedure (see notes).

  • Call the patient once biopsy results are received and document the conversation.

Notes

  • Local anesthesia

    • Do NOT apply lidocaine with epinephrine to peripheral appendages, e.g. fingers, toes, penis.

    • Conservatively, the maximum recommended topical lidocaine dose is 4.5 mg/kg per session, not to exceed 300 mg. (The 300 mg limit applies to patients ≥ 67 kg.) For 2% lidocaine (20 mg lidocaine per mL), 15 mL solution contains 300 mg lidocaine. Reserving up to 1 mL topical anesthetic per lesion, this results in a maximum of 15 lesions removed per session. Fifteen is also the maximum number of lesions that can be billed under CPT 11200 (see below).

  • Bill each skin tag removed (up to 15 lesions) as 11200. For example, removal of 5 skin tags will be billed as 11200, 11200, 11200, 11200, 11200.

Local Resources

Nutrition and Weight Loss

  • Monroe Aquatics & Fitness Center: Nutrition counseling through Novant Health

  • Atrium Health Weight Management (Ballantyne): Programs for adults and teens

    • Non-surgical weight loss: Nutrition education (including grocery store visits with dietician), meal replacement options, personalized exercise plans

    • Bariatric surgery program

      • Includes nutrition education, personalized diet plans, exercise training, support groups

      • Procedures: Roux-en-Y gastric bypass, laparoscopic adjustable gastric band, sleeve gastrectomy, duodenal switch

Fitness and Adjunctive Therapies