Each article is prefaced with an “evidence cookie”; an evidence based summary that can be absorbed in a glance.  A more detailed summary follows for those whose appetite for knowledge has been whetted.

The first evidence based morsel will be published next week on 5th January 2011, and further articles will be published on Mondays, Wednesdays, and Fridays.

Morsels of Evidence: http://evidencebasedmedicine.com.au

Resources Asthma Management Handbook 2006 (National Asthma Council Australia) [1.1 Mb]

The management of asthma is clearly and in excruciating detail described by the National Asthma Council of Australia. Last year, the NAC published the 2006 update to the Asthma Management Handbook (1) which for all intents and purposes, should be considered the “gospel” of asthma management. Nevertheless, I have a number of criticisms against the publication. According to its own introduction, it is designed as an evidence-based guideline of asthma management aimed at general practitioners. However, I question whether more than a handful of GPs would actually read the entire 157 pages of the handbook! The lack of summary pages on management is unhelpful.

This article was written to address some of the deficiencies by distilling the management of asthma in adults into digestible chunks.

Treatment of acute asthma in adults

Initial assessment

Treatment of an acute episode in a nutshell

Mild:

• Oxygen – SaO2 > 90%
• salbutamol via spacer or neb
• oral prednisone (0.5-1 mg/kg) up to 60 mg
• regular obs

Moderate:

• Oxygen – SaO2 > 90%
• salbutamol via spacer or neb every 1-4 hours
• consider ipratropium bromide neb (500 mcg)
• oral prednisone (0.5-1 mg/kg) or hydrocortisone 250 mg IV
• continuous obs

Severe:

• Oxygen – SaO2 > 90%
• salbutamol via spacer or neb every 15-30 min
  • If no response, salbutamol IV bolus (250 mcg) + infusion (5-10 mcg/kg/hr)
• ipratropium bromide neb 500 mcg q2h (with salbutamol)
• oral prednisone (0.5-1 mg/kg)
• IV hydrocortisone 250 mg q6h x 24h then review
• CXR if focal signs or not responding
• continuous obs
• treat hypokalaemia if present

Treatment of ongoing stable asthma in adults

Diagnosis

• Variable symptoms (especially cough, chest tightness, wheeze and shortness of breath) and;
• spirometry shows significant reversible airway limitation.

Spirometry

• Is the lung function test of choice for diagnosing and assessing asthma.
• Bronchodilator dose for spirometry is salbutamol MDI 4 puffs via a spacer.
• Airflow limitation is “reversible” if:
  • Post-bronchodilator increase of FEV1 greater than or equal to 12% of baseline (where baseline FEV1 > 1.7 L), or;
  • Post-bronchodilator increase of FEV1 greater than or equal to 200 mL (where baseline FEV1 < 1.7 L).

Classification of asthma in adults

Intermittent asthma (all of the following apply in the untreated person):

• Daytime symptoms < 1 per week
• Night time symptoms < 2 per month
• Exacerbations are infrequent and brief
• FEV1 greater than or equal to 80% predicted and varies by < 20%

Mild persistent asthma (where one or more apply and more severe signs are not present):

• Daytime symptoms > 1 per week, but not daily
• Night time symptoms > 2 per month, but not weekly
• Exacerbations occur occasionally and may affect activity or sleep
• FEV greater than or equal to 80% predicted and varies 20-30%

Moderate persistent asthma (where one or more apply and no severe signs):

• Daytime symptoms daily but does not usually restrict activities.
• Night time symptoms at least weekly.
• Exacerbations occur occasionally and may affect activity or sleep
• FEV 60-80% predicted and varies > 30%

Severe persistent asthma (where one or more the following apply):

• Daytime symptoms daily and restricts physical activities
• Night time symptoms every night
• Exacerbations are frequent
• FEV < 60% predicted and varies > 30%

Treatment in a nutshell

• SABA = short-acting beta agonist (e.g., salbutamol MDI)
• ICS = inhaled corticosteroids (e.g., fluticasone propionate)
• LABA = long-acting beta agonist (e.g., salmeterol xinafoate)

Treatment with a preventer medication is indicated for patients with asthma symptoms > 3 times a week or who use a SABA > 3 times a week.

In patients whose asthma control is not achieved despite low-dose ICS, a LABA should be the first choice for add-on therapy.

Hints and tips

Unfortunately, inhaled medications for asthma often comes in incompatible inhalation devices that you will have to get used to. This is especially true with the inhaled corticosteroids.

For this reason, I recommend initially prescribing the use of inhalers that come in the form of metered dose inhalers and encouraging the use of spacers. Much of the “problems” that automated delivery devices are designed to address simply don’t occur if the patient uses a spacer.

Warning about long-acting beta-agonists and controversies

There is good quality evidence that when used alone, LABAs increase the risk of severe asthma exacerbations, hospitalisations and asthma death (2). This is with both the LABAs available in Australia, salmeterol (Serevent) and eformoterol (Foradile, Oxis). There is evidence that fenoterol (a powerful LABA not available in Australia) was the “major cause for the secondary epidemic of asthma deaths in New Zealand” before it was effectively withdrawn from the market (3).

More worryingly, it does not appear that inhaled corticosteroids completely protect against this risk and the conclusion of the meta-analysis by Salpeter, et al in 2006 suggested that LABAs should be reassessed on “whether these agents should be withdrawn from the market”.

This is in contradiction to the Asthma Management Handbook 2006 which recommends adding a LABA to a low-dose ICS in preference to a dose increase. There is clear evidence that this strategy improves symptomatic control but the question of whether this results in an increase in severe episodes and death remains.

As such, LABAs should only be used in conjunction with an inhaled corticosteroid and never alone. Both available agents in Australia come in combination with an inhaled corticosteroid; fluticasone/salmeterol (Seretide) and budesonide/eformoterol (Symbicort). My personal opinion is that LABAs should be never prescribed out of combination with an ICS.

There is no evidence for the use of LABAs in children.

There is some evidence that budesonide/eformoterol (Symbicort) can be used as a reliever (given the relatively quick onset of action of eformoterol) and the Asthma Management Handbook 2006 suggests that a separate reliever may not be necessary. Certainly, that is the line of the AstraZeneca representatives (who try their hardest to differentiate eformoterol from their rival salmeterol). However, given that the Salpeter meta-analysis revealed that eformoterol had a negative mortality profile compared to placebo (just like, and in fact, worse than salmeterol) and that the device (Turbihaler) cannot be attatched to a spacer (in the event of a severe attack), I hold Symbicort (possibly unfairly) in suspicion.

References

(1) National Asthma Council Australia. Asthma Management Handbook 2006. Melbourne, 2006. [Link :: PDF 1.1 Mb]

(2) Salpeter S., Buckley N., Ormiston T., Salpeter E. Meta-analysis: effect of long-acting beta-agonists on severe asthma exacerbations and asthma-related deaths. Ann Intern Med. 2006 Jun 20;144(12):904-12. [Link :: PDF 342 Kb]

(3) Beasley R. Pearce N. Crane J. Burgess C. Withdrawal of fenoterol and the end of the New Zealand asthma mortality epidemic. International Archives of Allergy & Immunology. 107(1-3):325-7, 1995 May-Jun.

Please read the disclaimer

Whether you are seeing a patient in an outpatient clinic, the emergency department or in general practice, the ability to engage in a medical consultation is vital to clinical practice.

Throughout all modern Australian medical schools, the idea and skills of being a good communicator is drummed into students so I won’t necessarily repeat skills that are obvious or self-evident. Rather, the following are some tricks and suggestions that may make you a better communicator.

A good way to think about the goals of a medical consultation is that it has three functions (1):

1. Build the doctor-patient relationship
2. Collection of data
3. To agree on a management plan

The introduction

This step starts with calling the patient from the waiting room, to having them seated in your room. As the aphorism goes, “first impressions are the most important” – and this is true for both you and the patient.

If the patient perceives you as rushed, tired, stressed, or unhappy, it sets off the consultation on the wrong footing. At one end of the spectrum, some people may respond by not telling you all of their worries or symptoms so not to “burden” you any further. At the other end, some people may respond with anger or irritation as they perceive that your distress diminishes their own problems. Either way, it impairs the doctor-patient relationship and the collection of data.

As a corollary, you should try to be mindful of your own emotional responses when you lay eyes on the patient. What prejudicial or otherwise illogical assumptions have you made already?

When introducing yourself, call the patient by name. If you read around the popular media about these introductions, there is often an interesting quandary. Some people seem offended by being referred to by their first name (2). Others chaff that the formalism of being called by their salutation and surname to be anachronistic. Indeed a study in general practice seems to suggest that the majority of patients either prefer or do not mind being called by their first name (3).

A way around this is to use both: e.g., “Good morning John, Mr Bloggs, I am …” and the patient can choose what they prefer.

Physical examination begins with observation and inspection, and both begin the moment you meet the patient. During the introduction, you can observe the patient’s gait and mobility as they ambulate from the waiting room, whether they came with any family members, their body habitus, their “unobserved” behaviour and current emotional state, etc. With the handshake, you can observe the patient’s upper limb co-ordination, hand strength and peripheral perfusion. If you are mindful and observant with your inspection, you will have gained much objective data before the patient has even passed through your door.

Starting the interview – taking the history

Many doctors, junior or otherwise, fall into the trap of interrupting their patients during their opening statements. The first issue that a patient brings up is often not the most important. Furthermore, this interruption can give the patient the impression that they are being hurried or worse, that you are not listening.

My suggestion is, and certainly the research has demonstrated, that the opening statements should be listened to without interruptions. Not only will you pick up many clues, but you will have also develop a small general overview of the problem. For example, the patient may be coming in today with an upper respiratory tract infection for 3 days duration, but their real worry is that they haven’t been well for 2 months.

Furthermore, most patients if left uninterrupted will “run out of puff” within 30 seconds (4). That time, however often seems much longer to the patient (analogous to how time seems to stretch when making an impromptu speech). I would propose that the doctors of patients who claim that “they didn’t listen to me” probably interrupted the patient’s opening statements early.

Contrary to the urge of impatience, interrupting the opening statement doesn’t save much (if any) time and results in a poorer quality consultation and less satisfaction on the part on the patient.

Active listening skills are crucial and take time to develop. Many of the above may seem “obvious” but after having seen many doctors consult, I do not believe that these skills come naturally to everyone. You need to practice these skills and try to be actively mindful of what you are doing.

The question, “is there anything else that I can help you with today”, should be asked early and often. If you only ask this at the end of your consultation, you may unleash a can of worms that you may not have time to deal with adequately (e.g., it is surprising how often a patient leaves a request for a Pap smear or an STI screen until the very end, especially if you didn’t ask earlier). Having a general idea of the patient’s agenda will help you plan your consultation, and furthermore, negotiate with the patient on issues of lesser priority that are perhaps best dealt with at a later date.

Further history and examination

Given that communication is of utmost importance, try to avoid whenever possible using a family member to translate. More often than not, you will be wasting your time; you will be unsure of the history and you will be unsure whether the patient actually understands your questions. You must make an attempt to secure a clinical translator. The phone translator services are usually quite good.

I mentioned previously that observation and inspection begins the moment you meet the patient. This process should continue throughout the interview. The way that I conceptualise this is that you should be able to mostly complete a mental state examination by the end of the consultation. Where a psychological issue was not one of the main focuses of the consultation, you should still be able to comment on:

• Appearance and behaviour: e.g., dishevelled, garrulous, psychomotor agitation or retardation, fidgeting, aggressive, hostile
• Speech: e.g., rapid, slow, monotonous
• Mood and affect: e.g., anxious, depressed, high
• Cognition: including, level of consciousness, orientation, attention/concentration, memory.

With physical examination, do not be embarrassed to request that the patient sufficiently disrobes so that they can be examined properly. At the same time, preserve modesty by giving them sufficient privacy when changing.

Management and the conclusion

Agreement to a management plan is a negotiation between the doctor and the patient. You may have prescribed a medication of exercise regimen that evidence shows will “fix” the patient’s problem but if they do not follow your management advice, it is not going to work. You need to “fit the evidence to the patient”, and not the other way around.

Education, exploration of preconceptions, discussion of alternatives and at times, motivational techniques are all required.

Remember that at the end of the day, it is the patient’s choice; though, you shouldn’t be a nihilist either.

References

(1) Gask L., Usherwood T. ABC of psychological medicine – The consultation. BMJ. 2002;324:1567-9. [Link :: PDF 225 Kb]

(2) Benton T. Don’t call me Thomas. The Chronicle of Higher Education. 16 January 2006. [Link]

(3) McKinstry B. Should general practitioners call patients by their first names? BMJ. 1990 October 6; 301(6755): 795–796. [Link :: PDF 337 Kb]

(4) Rabinowitz I., Luzzatti R., Tamir A., Reis S. Length of patient’s monologue, rate of completion, and relation to other components of the clinical encounter: observational intervention study in primary care. BMJ. 2004 February 28; 328(7438): 501–502. [Link :: PDF 102 Kb]

Please read the disclaimer

Vacutainer system

This short article is relevant for those people or institutions that use vacuumed tubes for venepunction and does not apply to using a needle and syringe.

One of the disadvantages of using a vacuumed tube system for directly withdrawing blood is that there is always a possibility that the needle dislodges or that the vein collapses before all the necessary tubes are filled.

For a long time, this would involve an apology from myself to my patient and a second venepuncture to collect the necessary blood. This is actually a reason that to this day, I still prefer using a plain needle and syringe (despite the increased needlestick risk) for patients with either difficult access or who require blood in many tubes.

However, this is a trick that I learnt from experience:

The reason for this is simple: there are no additives in the serum tube and you can withdraw blood out of it to redistribute if necessary.

Despite the serum tube being usually quite large, only a couple of mililitres of blood are necessary for most simple tests (e.g., UEC, LFTs, Ca, Mg, PO4). If you have already collected 5-6 mL of blood and the vein collapses, you can easily (but carefully) redistribute this blood from the serum tube into any other necessary tubes (e.g., EDTA tube for FBC).

You must be quick, however, as once the blood as coagulated (usually 1-2 minutes), this trick is no longer feasible.

Please read the disclaimer

Warning: This article is as much tongue-in-cheek as useful advise.

As much as we aspire to EBM (evidence-based medicine) I suspect that many of us perform “GBM” (or Google-based medicine)!

Google has become an invaluable tool as part of my day to day practice. Indeed, I find certain aspects of practice irritating without access to the internet (e.g., the current general practice I’m working in as well as the occasional hospital ED that is restricted by a firewall).

I use Google on a day to day clinical basis in a number of settings:

• Searching for patient handouts;
• Looking up clinical information on uncommon and rare diagnoses (e.g., something unexpected on a discharge summary or after a specialist visit);
• Looking up highly specialised medical terminology (i.e., when the radiologist decides to be clever in a report);
• Units conversion (e.g., imperial to metric);
• Information on herbal “medications” that aren’t on the PBS;
• Information on medications with different international trade names (e.g., the international visitor who has run out of medications);
• Anticipating “worried” patients by keeping an eye out on the latest “health scare” misinformation touted in the “mainstream media”;
• Looking for contact details of specialists when the Yellow Pages and White Pages fail.

I do not use Google for diagnostic purposes simply as it’s somewhat of a mixed bag. Interestingly enough, a couple of Queenslanders, Tang and Ng, published a study looking at the diagnostic value of plugging symptoms into Google to see if the correct diagnosis would arise. Impressively, it did so over 50% of the time (admittedly, for the more common diagnoses) (1). My “gut” feeling, however, is that it is still a bad idea to rely on Google for diagnosis though it may be useful for reviewing for possible differentials that you may not have thought about.

Google is also not particularly good for management guidelines. For that, it is still preferable to access known high quality sources (e.g., the “Therapeutic Guideline” series through CIAP).

Reference articles

(1) Tang H., Ng J. Googling for a diagnosis – use of Google as a diagnostic aid: internet based study. BMJ 2006;333;1143-1145 [Link :: PDF 258 Kb]

(2) Tam M., Su M. 2006, “The world according to Google”, Creation of The Medicine Box, Lulu.

The fingertip unit

This article was inspired by a comment from Dr Ewen McPhee (a rural GP) who mentioned the use of the “fingertip unit” in the article on topical corticosteroids.

The “fingertip unit” was original described by Long and Finlay in 1991 and is a handy guide for both doctors and patients to describe quantities of corticosteroid cream (1).

In essence, one “fingertip unit” is equivalent to 20-25 mm of cream or ointment squeezed onto the “fingertip”. One “fingertip unit” is approximately 0.5 g of cream or ointment is is enough to cover the front and back of a single hand.

Fingertip units for body surfaces

The following diagram was liberated from a dosing handout by Schering-Plough Pty Ltd for mometasone furoate 0.1% cream (Elocon):

Note: “hand” refers to the entire hand (i.e., palmar and dorsal surfaces)

For example:

An adult patient has atopic dermatitis over the trunk and back with an area equivalent in size to approximately 4 hand (palm) surfaces. The is equivalent to 2 fingertip units or 1 g of cream

If the cream is applied once a day and the tube contains 30 g of corticosteroid cream, then we would expect that the tube should last approximately 30 days.

Reference article

(1) Long C., Finlay A. The finger tip unit… a new practical measure. Clin Exp Dermatol 1991;16:444-7. [Link]

Please read the disclaimer

Diplococci of Neisseria gonorrhoeae

Sexually transmitted infections (STIs) are common. Many can be treated easily. Some may be asymptomatic but may lead to significant longer term problems if left untreated (e.g., chronic pelvic inflammatory disease from chlamydia increases the risk of ectopic pregnancies and infertility) (1).

It is a reality that people have sex, and some people have many sexual partners. As such, taking a sexual history and offering screening is an important part of preventative health care.

Note: the following guidelines are specifically for the broader Australian population. It may be appropriate to perform additional tests in specific cultural or regional groups (e.g., screening for HIV and syphilis is certain indigenous communities). These guidelines have been adapted the article by Ooi in the February 2007 edition of Australian Prescriber (2).

Who should be screened?

Obviously, someone who has never had sexual intercourse do not require STI screening. Otherwise, as a baseline an annual screen should be considered for people who have changed sexual partners.

Multiple sexual partners, unprotected sex (i.e., without a condom), intravenous drug use (especially the sharing of needles) increase risk of STI transmission.

• Heterosexual men and women:
  • consider annual screening if there has been a change in sexual partners;
  • more frequently depending on risk.
• Men who have sex with men:
  • annual screening if asymptomatic;
  • more frequently depending on risk – up to every 3 months.
• People under the age of 25 years:
  • annual screening if there has been a change in partner;
  • more frequently depending on risk.
• Sex workers:
  • every 3-6 months.
• People who inject drugs:
  • annual screening if asymptomatic;
  • more frequently depending on risk – up to every 3 months.

Asymptomatic heterosexual men

Routine tests:

• Hepatitis B serology (i.e., blood test);
• chlamydia PCR (polymerase chain reaction) from first void urine.

Consider:

• Baseline HIV serology;
• gonorrhoea PCR from first void urine.

Although the guidelines do not recommend routine screening for gonorrhoea, you should consider it. Most men with gonorrhoea will be symptomatic it can uncommonly be asymptomatic (about 10%) (3). I commonly do offer performing gonorrhoea PCR on the urine as well.

You should consider and offer a baseline serology for HIV – though be aware, you must perform adequate pre-test counselling and though it is an anachronism, even a negative test may affect the patient’s future assessment of risk for life insurance.

Symptomatic heterosexual men

Depending on the specific symptoms, you may elect to perform specific tests – e.g., a swab of urethral discharge for microscopy, culture and sensitivity (MC&S) (specifically to culture gonorrhoea), or swab for HSV (herpes simplex virus) PCR in genital herpes. In addition, you should consider screening for:

• Hepatitis B serology;
• HIV serology;
• chlamydia PCR from first void urine;
• gonorrhoea PCR from first void urine.

Asymptomatic heterosexual women

Routine tests:

• Hepatitis B serology;
• chlamydia PCR (first void urine).

Consider:

• Baseline HIV serology;
• gonorrhoea PCR from first void urine;
• high vaginal swab for MC&S (looking or gonorrhoea and trichomonas) (if already performing a Pap smear);
• cervical swab for chlamydia PCR and gonorrhoea PCR (if already performing a Pap smear).

Like men, consider performing a gonorrhoea PCR on urine and baseline HIV serology as well. Unlike men, women present for Pap smears and while this is performed, an opportunistic STI screen by way of cervical and high vaginal swabs for PCR and MC&S can be done.

Symptomatic heterosexual women

Again, you may choose to perform some specific tests depending on symptoms. In addition, you should consider:

• Hepatitis B serology;
• HIV serology;
• chlamydia PCR (first void urine);
• chlamydia PCR (anal and throat swab – depending on sexual practice);
• gonorrhoea PCR (first void urine);
• gonorrhoea MC&S +/- PCR (anal and throat swab – depending on sexual practice).

Be aware that although you can order PCR tests for chlamydia and gonorrhoea in extra-genital sites, these tests may not have been validated.

Men who have sex with men (MSM)

It is important when taking your history to ask a man specifically whether his sexual partners include men as some MSM do not consider themselves “gay” or “homosexual”. It is furthermore important to ask what type of sexual practices they engage in. For example, a MSM who has never had receptive anal sex does not require anal tests.

Routine tests:

• Hepatitis A serology;
• hepatitis B serology;
• HIV serology;
• syphilis serology;
• gonorrhoea MC&S +/- PCR (anal and throat swab);
• chlamydia PCR (first void urine and anal swab).

Consider:

• Gonorrhoea PCR (first void urine).

Indications for anal swabs:

• any anal sex with casual partners;
• any unprotected anal sex;
• any anal symptoms;
• HIV positive;
• past history of gonorrhoea;
• contact with any STI;
• request.

You can perform chlamydia PCR for throat swabs, especially in the presence of symptoms (4). However, pharyngeal Chlamydia tracomatis infection is firstly uncommon and usually symptomatic. In the absence of symptoms, a sole positive chlamydia PCR from a throat swab may well be a false positive.

Homosexual and bisexual women

For the most part women who have sex with women should have the same screening as heterosexual women. Be aware though that some lesbian women may still have sex with men (including MSM) and you should try to elucidate this in the sexual history. If this is the case, apart from routine screening, consider:

• HIV serology;
• syphilis serology.

Furthermore, consider the following diagnoses:

• Bacterial vaginosis / Gardnerella;
• trichomonas.

Sex workers

Routine tests:

• Hepatitis B serology;
• HIV serology;
• syphilis serology;
• chlamydia PCR (first void urine and cervical swab);
• gonorrhoea MC&S +/- PCR (cervical swab and throat swab).

Consider:

• gonorrhoea PCR (first void urine);
• gonorrhoea MC&S +/- PCR (anal swab – depending on sexual practice);
• chlamydia PCR (anal swab – depending on sexual practice);
• hepatitis A serology (depending on sexual practice).

People who inject drugs

They should have the same STI tests performed as per above. In addition:

• Hepatitis B serology;
• hepatitis C serology;
• syphilis serology;
• HIV serology.

Consider:

• Hepatitis A serology.

Hints and tips:

• The most important thing is an adequate sexual history.
• Once someone has been fully immunised against hepatitis A and B, further serology is generally unnecessary.
• There is no place for routine HSV serology in sexual health screening.
• Gonorrhoea PCR though convenient, does not allow for antibiotic sensitivity test; MC&S is preferable (though often involves another swab).
• Chlamydia and gonorrhoea PCR swabs of high vaginal, rectal and pharyngeal sites are not validated.
• For the most part, chlamydia and gonorrhoea PCR of first void urine replaces the highly unpleasant urethral swab.
• Some laboratories can perform PCR and MC&S on a single swab; it is worthwhile calling and finding out.
• All results of sexual health tests should be given to the patient in person (as opposed to over the phone). Patients should make a follow up appointment at the time of the test.
• Send complicated patients to a local sexual health unit!

References

(1) Chlamydia: fact sheet. Family Planning Australia Health. April 2003. [Link :: PDF 47 Kb]

(2) Ooi C. Testing for sexually transmitted infections. Australian Prescriber Vol. 30, No. 1. February 2007. [Link :: PDF 118 Kb]

(3) Sherrard J., Barlow D. Gonorrhoea in men: clinical and diagnostic aspects. Genitourinary Medicine, Vol 72, Issue 6 422-426, Copyright © 1996 by Sexually Transmitted Infections [Link]

(4) Ostergaard L., Agner T., Krarup E., et al. PCR for detection of Chlamydia trachomatis in endocervical, urethral, rectal, and pharyngeal swab samples obtained from patients attending an STD clinic. Genitourinary Medicine, Vol 73, Issue 6 493-497, Copyright © 1997 by Sexually Transmitted Infections. [Link]

Please read the disclaimer

All too often for JMOs, physical examination of the hands is forgotten. In situations other than test conditions, most people “go for the money” – jumping immediately to the body system expected to have the problem. This is perhaps understandable in the time poor hospital environment.

Nevertheless, I feel that all physical examination should always begin with the hands. Even if there are no specific physical signs, the hands can tell you much about the patient:

• Are they warm and well perfused?
• Is the patient nervous and sweaty?
• Do the hands tell you something about the patient’s occupation and lifestyle?

If there are signs, the hands will often give you a medical history in itself.

In a study in a Welsh hospital in 2003 where every ward patient’s hands were examined, 44% had an abnormal physical sign that was clearly present (1). To quote the oft-stated phrase:

An example:

This is a photo of the hands of the four-year-old daughter of a patient who came to see me in my rooms:

Cyanotic nail beds and a clear example of clubbing. The child had congenital cyanotic heart disease (note: this diagnoses was known when the mother was questioned). These signs don’t walk through your door every day and if you don’t take the opportunity to look, you will miss them.

Take five seconds and examine the hands of your patients! You may be surprised by what you find.

References

(1) White HA., Alcolado R., Alcolado JC. Examination of the hands: an insight into the health of a Welsh population. Postgraduate Medical Journal 2003;79:588-589 [Link :: PDF 102 Kb]

Resources Application for approval to prescribe medications under the Pharmaceutical Benefits Scheme (by a registered medical practitioner) The is the Medicare Australia application form for a prescriber number [118 Kb]

Writing an R/PBS (repatriation/pharmaceutical benefits scheme) presciption (aka “external” script for hospital based JMOs) is easy and simple when you know how. Incredibly (looking retrospectively), I don’t think that anyone actually went through with me how to write one. I’m sure there were more than a handful of community pharmacists shaking their heads (or their fists) at my dodgey scripts when I was a resident in ED!

This article is aimed mostly at interns and residents on how to write a community R/PBS prescription.

Who can write a PBS or RPBS script?

You must have a prescriber number and general (i.e., unconditional) registration with the state medical board. Interns (PGY1) have neither so they cannot legally write an R/PBS script. Once you’ve satisfactory completed your internship and have obtained general registration, then you can apply to Medicare Australia for a prescriber number. Your training hospital may not necessarily request that you do this since you only need a provider number to function within the public hospital system. The appropriate form can be downloaded at the top of this article.

Change your mindset

The thing to realise is that PBS scripts are very different beasts to an internal hospital medical chart. They are designed for a different purpose. Hospital medication charts are designed for rapidly changing medications / dosages while PBS scripts are for long term dispensing. You must change your way of thinking for a PBS script.

Box sizes

Once a hospital medication chart is filled, any one medication can be continued “ad infinitum” if so needed, though perhaps more realistically, for the exact clinically indicated period. Medications are dispensed on a daily basis.

With PBS scripts, you must consider the total number of tablets/doses as well as box sizes and repeats.

For example, if you want to discharge someone on cephalexin 500 mg, four times a day for a week, simply writing this on a script is not satisfactory. A box of cephalexin comes with 20 capsules; only enough for 5 days. In this case, you must write a script for a box with one repeat.

PBS indications

PBS indications are not the same as RPBS indications and neither are necessarily the same as clinical indications. PBS indications are the conditions that the government (through the PBS) will pay for the medication out of the public purse and are usually only a subset of all possible clinical indications. RPBS indications are usually somewhat more generous (benefits to war veterans and their family). Prescribing through the RPBS is usually cheaper for the patients as well.

Some common examples:

• celecoxib (and all the COX-2 inhibitors) is only PBS subsidised for symptomatic treatment of osteoarthritis or rheumatoid arthritis (i.e., the government won’t pay for it being used for muscular pain).
• gabapentin only has a PBS indication for treatment of epilepsy. Unless the patient has access the the RPBS, then the government won’t subsidise it for use in neuropathic pain.
• rosiglitazone (and all the glitazones) is not PBS subsided for monotherapy.
• olanzapine (and most of the atypical antipsychotics) is only PBS subsided for treatment of schizophrenia maintenance of bipolar affective disorder (Type I).

Some limitations

• You can only write three medications per single script.
• R/PBS medications that require authority must be written on a specific PBS/RPBS authority prescription pad (not covered in this article).
• Schedule (S8) medications (e.g., morphine) must be written individually on their own script (must include words and numbers for the strength and quantity; see below examples).
• Schedule 100 (S100) medications (e.g., etanercept) cannot be written by you (if it is an S100 drug you will know if you can prescribe it as specific training is required).
• Non-PBS items should not be written on the same script with PBS items.

Example of a standard PBS script

1. Contact details at the top;
2. personal prescriber number (where “1234567″ is on the above sample);
3. patient’s name and address;
4. tick either PBS or RPBS boxes;
5. tick the “Brand substitution box not permitted” box if necessary;
6. drug name (generic name preferable) and strength;
7. dosing amount and frequency;
8. quantity of the medication and number of repeats (if applicable);
9. signature and date.

Example of an S8 script

1. Basically the same as the standard script;
2. only one item only per script;
3. medication strength (i.e., 5 mg) and total quantity (i.e., 20 tablets) must be in both words and numbers.

Example of a private script

1. It isn’t actually necessary to write a private script on PBS stationary but most people do;
2. The script must have your name and prescriber number;
3. the patient’s name and address;
4. cross out both the PBS and RPBS boxes and note that it is a “private script”;
5. drug name, dose, frequency and quantity;
6. signature and date.

Tips and Hints

1. Give both copies of the prescription to the patient (one copy is for the pharmacist, the other for Medical Australia/Department of Veteran Affairs).
2. Beware of the irritating box sizes that don’t make sense. A good example is with clindamycin. The antibiotic guidelines(1) suggest clindamycin 450 mg, three times a day for 7-10 days for mild early cellulitis and erysipelas (in immediate penicillin hypersensitivity). As clindamycin comes in 150 mg capsules, that means 9 capsules a day. A box of 25 capsules then lasts less than 3 days! Furthermore, under the PBS, it doesn’t allow for repeats. If you send someone home from the emergency department with a script for clindamycin the result would be an annoyed patient, an annoyed general practitioner or the patient taking only a fraction of the recommended course. Please ensure there are alternative arrangements in place first!

References

(1) Cellulitis and erysipelas. Therapeutic Guidelines, Antibiotic version 13. October 2006.

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List of resources

• Medical eBooks
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