Solve the Problem

If women do not have a prostate why would they be taking Flomax?

2010-10-28T13:48:00.000-04:00

The short answer is Kidney Stones.

A 5 mm stone in the distal ureter has about a 50-60% chance of spontaneous passage, and in the absence of infection, renal failure or unmanageable pain, may be managed conservatively for up to 4 weeks. It should be noted that the average time to passage has been as long as 22 days. Medical Expulsive Therapy (MET)with use of alpha-antagonists (tamsulosin aka Flomax) or calcium channel blokers (nifedipine aka Procardia) have been shown to inhibit the contraction of the smooth muscle responsible for ureteral spasms (while allowing forward stone movement. The common dose is 0.4mg daily for a month. This has shown to reduce expulsion to anywhere from 2-14 days.

References:
Singh, A., Alter, H.J., Littlepage, A. (2007). A systematic review of medical therapy to facilitate passage of ureteral calculi. Ann Emerg Med

Lojanapiwat, B, Kochakaran, W., Suparatchatpan, N., Lertwuttichaikul, K. (2008) Effectiveness of low dose and standard dose tamsulosin in the treatment of distal ureteric stones: A randomized controlled study. J Int Med Res.

This information is not intended to substitute for the clinical judgement of licensed health care provider, and is presented to merely serve as a point of interest for clinicians. Patients should raise any concerns with their primary care provider.

If healthcare professionals want to connect with me on Linked In

or on Face Book

Thanks for reading. Please feel free to share your clinical wisdom or personal patient care experience.

Raymond Zakhari, NP
Metro Medical Direct

Gout, Hypertension, Hypercholesterolemia: Clinical Pearl

2010-10-26T14:17:00.000-04:00

As you may know hyperuricemia and gout often occur in the context of hypertension and hyperlipidemia. Also, often patients are intolerant of allopurinol, and usually do not like adding extra medications for another chronic condition.

According Feher, Hepburn, Hogarth et al (2003) Rehumatology and Wurzner, Gerster, Chiolero et al (2001)Journal of Hypertension fenofibrate has a more potent effect and has been found to decrease serum uric acid levels by 20-30% , even in patients with tophaceous gout who are already taking allopurinol. Furthermore losartan has been shown to decrease serum levels of uric acid by approximately 10-15%, even in patients who are taking fenofibrate. Just as a point of interest the 100mg dose was not shown to be more effective than the 50mg dose.

So in patients with hypertension, gout, and hyperlipidemia internists may want to consider this 3 conditions with 2 medication combination. Assuming there are no other contraindications.

This information is not intended to substitute for the clinical judgement of licensed health care provider, and is presented to merely serve as a point of interest for clinicians. Patients should raise any concerns with their primary care provider.

If healthcare professionals want to connect with me on Linked In

or on Face Book

Thanks for reading. Please feel free to share your clinical wisdom or personal patient care experience.

Raymond Zakhari, NP
Metro Medical Direct

Seen At 11: Concierge Care A Growing Health Care Trend « CBS New York- News, Sports, Weather, Traffic and the Best of NY

2010-10-09T08:57:00.000-04:00

Seen At 11: Concierge Care A Growing Health Care Trend « CBS New York- News, Sports, Weather, Traffic and the Best of NY

Raymond Zakhari, NP Medical House Call, NYC for general primary care.

Ounce of Prevention: Is it really worth a pound of cure?

2010-08-29T16:16:00.000-04:00

Preventive care can be the most cost-effective care provided. Whether its immunizations to prevent infections, physical exam screenings for breast, colon, testicular, prostate cancers, or surveys for depression, anxiety, and coping ability. The annual physical exam does not need to be a rote fruitless ritual that many have gotten used to by their managed care physician.
On an annual basis I recommend and have done myself blood pressure, EKG, height and weight, (unfortunately I weigh more than I should given my height. But I am working on it and am well aware of how difficult it is.) I also have an annual testicular exam to detect cancer, as well as an eye exam to check for early signs of blood pressure damage and glaucoma. I also have blood work done to check for anemia, liver and kidney function as well as cholesterol and diabetes testing. Just because my BP is normal does not mean that it may not be relatively high and unnoticed. So I use the eye exam to corroborate the findings from my physical exam. Also the body can compensate quite well and symptoms of glaucoma can go unnoticed for a long time.
Patients often ask me what I think about body scans. The answer to that question depends on why you want to have the scan done. I really try to avoid body scans (not just because “House hates body scans”) because they usual yield a finding that may not be related to the presenting problem but now present a problem that may need to be investigated. These findings that are not related to a problem are called incidental findings and they may or may not be problematic, but they are always stress provoking. If you think you need a body scan you should speak to your primary care provider (nurse practitioner or physician) and arrive at that conclusion together. There are some imaging studies that can be very helpful without the risk of radiation and have a lower incidence of incidental findings.

Don’t hesitate to contact me directly If would like to have something checked out (MetroMedicalDirert.com)

These are my thoughts on prevention. If you have any questions or comments please feel free to comment here or on the Face Book page for Metro Medical Direct.

Raymond Zakhari, NP
Primary Care Provider
917-484-2709

Virtual Office Visits

2010-07-08T06:06:00.000-04:00

Support for E-Visits – CPT Code 99444 and 98969

Patients love the convenience of e-visits when available. The best demographic for e-visits are patients who live far away from their clinics, have kids, or who don’t want to spend 2-4 hours for a trip to the doctor when all they need is a quick answer or diagnosis for a minor symptom. Some possible symptoms could be common cold, sinus infections, urinary problems, cough, diarrhea and back pain.

Providing a route for patients to take that does not require them to come to the clinic benefits them and your organization. Many organizations find that overall utilization drops when e-visits are implemented, some places by as much as 25%. This makes e-visits a very interesting proposition for insurance companies, although few actually re-imburse for them currently.

E-visits, with the proper functionality, also allow the patient to update their allergies, vital signs, and history information.

E-visits are the way of the future for healthcare since they can help lower costs by decreasing utilization and improving care efficiency. Patients also enjoy the lower co-pays that e-visits provide. As more and more patients look to lower their healthcare costs they will increase usage of alternative options like e-visits and nurse only visits.

Providing e-visits allows the standard healthcare organization to offer a product that can compete on price with the retail clinics that are popping up in strip malls and Walmart.
Requirements

A patient portal offering e-visit functionality needs to provide several tools to make the e-visit flow usable. For starters, most states require that a patient is notified up front that they may be charged for the visit so having a terms and conditions agreement option is critical. The phr should also allow for the entry of history, allergies, vitals and other information collected during a standard office visit.

Since the information is provided by the patient, the data should not immediately sync in with the permanent chart until reviewed by a clinician or physician. Since the CMS code 99444 states that a timely response is required workqueue functionality must exist so that the e-visits are reviewed by physicians quickly.

Code 99444 also states that an e-visit can only occur with an existing patient, once in any given seven-day period.
Metro Medical Direct in NYC offers this services.

Elder Care: Caring For Aging Parents

2010-07-04T16:31:00.000-04:00

Taking Care of Our Parents
With today’s continuing medical advances, people are living much longer than even fifteen years ago. While technology may be able to prolong our lives, the reality is at some point, we will all need assistance. For the most part, we turn to our family for that support. Now that we are living longer, healthier lives however, that responsibility is largely left up to the adult children who are often in the midst of raising their own children. This phenomenon has become so common that it was aptly named the “Sandwich Generation”, referring to these adult children who feel squeezed between the needs of their aging parents or relatives and the needs of their own families and careers.

My Parents are Getting Older:
According to the National Center for Health Statistics (NCHS), since 1950, the number of people seventy-five and older doubled from 3% to 6%. By 2060, NCHC further estimates that one in eight Americans will be seventy-five or older. And today, 22.4 million households already provide care to a family member over fifty, according to the American Association for Retired People (AARP). What does this all mean? Well, if you’re a baby boomer, you will likely be among the many adult children called upon to take care of your aging parents. This can be a daunting responsibility and often both the aging parent and the child caregiver find themselves living with overwhelming resentment, guilt, and anger. If unresolved, or not taken care of through the guidance of a trained counselor, the mounting stress can quickly destroy the relationship and put everyone at risk for emotional and physical illness. While aging is inevitable, our attitudes and reactions to the situation have an enormous effect on how we adapt. Counseling offers us the tools to meet these new challenges in a healthy and loving way so everyone involved feels the dignity and respect they deserve.

ElderCare: What Can I Expect?
For those who are already providing care for an aging parent or relative, the AARP estimates you’re likely spending eighteen hours a week or more taking them to doctor’s appointments, grocery shopping, helping with financial issues, and generally just being there for them. Add to that the fact that about 67% of all adult children caring for their parents also work full time, it can lead to tremendous frustration and unwanted challenges, which invariably lead to overwhelming stress.
Emotionally, as children we expect our parents to always look after our needs. Somehow it just doesn’t seem right or comfortable for anyone involved to watch as our parents descend into old age and illness. Often we prefer to live in denial rather than face the unavoidable fact that our parents will someday die, essentially leaving us alone to fend for ourselves. No matter how old you are, your parent is still your parent and the child/parent dynamic still subconsciously dominates your thinking. So, when it comes to the point where our parents are no longer independent, it is very hard to accept. As hard as it is for us to face, our aging parents feel as much or more despair, depression, and anger over their own declining ability to care for themselves as we do. Ultimately, they can feel completely vulnerable and at the mercy of everyone around them. So, when you add it all up, the result is two and sometimes three generations of unresolved hurt, scared, and often angry and resentful feelings in one household. And while stress is to be expected, it doesn’t have to become overwhelming.
Do I need Help to Care for My Parents?
According to Social Gerontology, a leading book on the effects of aging, the average American household today includes more parents than children. In fact, a woman can generally expect to care for an older family member for eighteen years. The magnitude of this situation is realized when you consider that a mother normally only raises for her own children for an average of seventeen years. When you factor in things like depression and other serious mental disorders that are so common among aging adults, it is simply a recipe for disaster if everyone involved is not emotionally, socially, financially, or even physically equipped to deal with the inevitable changes this scenario brings. This is a tremendous responsibility that often produces extreme stress and resentment. When these feelings start to affect your everyday life, it is time to get help.
Stress can lead to depression, eating and sleeping problems, anxiety, problems at work, with other family members, and overall exhaustion. Any one of these is a clear sign to get help. Misguided expectations or unresolved family history can often be the cause of conflict in these situations. Counseling allows everyone involved bring their feelings and concerns to the forefront. Emotional support and a new perspective on the situation can help people move on with their lives in a healthy way. While aging may be an inevitable part of life, with help, we can always find ways to accept and deal with the challenges it brings.
The Benefits of Counseling for Help With Aging Parents
Individuals who are faced with the changing roles in their relationship with their parents may be faced with a variety of emotions in terms of what this new relationship will look like. Motivational Interviewing helps provide adult children a neutral perspective when considering the options for how to care for aging parents. Whether it is the decision to move our parents to a retirement home that is better suited to meet their needs, or we open our home and take on their care ourselves, these changes impact how we see our parents and how we see ourselves.
Changing these roles and the relationship to responsibility with our parents presents a challenge as the dynamics of life changes. Our own sense of self in terms of aging may come into question as we see our parents lose some of their independence and vitality. If we are caring for them in our home, routines and family structure are modified. This may include making physical changes to our home to accommodate for the physical limitations for our parents. All these changes affect our current relationships and your counselor will work to address how to integrate these changes into your home and life. This time of change when caring for aging parents is an opportunity to develop your relationship with your parents as they and you enter a new phase of life.

If you need help processing your unique situation with respect to eldercare or would like to arrange eldercare for your loved one log to Metro Medical Direct

Raymond Zakhari, EdM, MS, NP

The Top 5 Reasons to choose private pay in home care in New York City:

2010-06-19T14:37:00.000-04:00

* Maintaining Independence. Private in-home care patients as opposed to those using Medicare are encouraged to be as independent as possible. Patients can enjoy the freedom to move around the comfort of their own home and to their favorite social outings remains possible with private pay in-home medical care.
* Family Involvement. Clients who are cared for at home have the advantage of open visiting hours, decreased medical errors and infections. Family members can stop in and help out as often as necessary without concerns about intruding on the care of others. In times of illness, the presence of family members, friends, and pets can raise a patient's mood and make everyone feel more in-control of the situation.
* Continuity of Care. Private pay medical home care is often provided by the same nurse practitioner (primary care provider) keeps a small panel of patients so that they always know what kind of care has been given or is needed. The patient may also keep their same doctors, and use the medical house calls primary care provider to supplement their health needs when going to the doctor becomes burdensome.
* Increased Safety and Personal Attention. The risks of infection are greatly decreased when a patient uses medical house calls for their primary care needs. The one-on-one care and personal attention also ensures that all your loved one's needs can be met quickly and without the red tape often found in hospitals, nursing homes, or Medicare regulations. Your medical house calls are not hurried unlike the traditional care of the doctor’s office.
* Lower Costs. In-home care private pay providers are far less expensive than nursing homes or assisted living facilities. You are not paying for those unable to pay for their care as institutions attempt to balance their books with your resources. Lower costs also offer peace of mind to those seniors who are concerned about the financial burden their care might put on their family.

Private Pay in-home care clients can still use their Medicare and insurance coverage for diagnostic tests, hospitalizations, procedures, and specialists. Some private pay home care options include:

City Home Companions: Provides non-medical companion care for anywhere from 4 hours to 24 hour live in care. Home companions are able to do light house keeping, shopping, accompany to appointments, remind loved ones to take their medication and serve as a second set of eyes to early changes in condition.

Metro Medical Direct: provides primary care and skilled nursing home visits, medical care coordination and management, facilitates in home tests such as blood work, x-rays, ultrasounds, helps with medical record keeping, and coaching family members to ask the right questions of current health care providers. All services are provided and arranged by a board certified nurse practitioner and or a registered professional nurse. Patients can use this service in lieu of their primary care provider or in addition to their primary care provider when they are not feeling up to going out.

Outreach Physical and Occupational Therapy and Speech Rehabilitation, PLLC brings treatment directly to you. We are the perfect answer for post-surgical patients rehabilitating at home, seniors unable to travel, and busy adults who like the privacy of at-home or in-office treatment. We provide individualized one-to-one rehabilitation, no matter what your age or mobility. Our expertise is the treatment of adults, with a special focus on the specific needs of elders.

By having a primary care provider experienced in Medical House calls you can help keep your loved one in the comfort of their home and avoid admission to the hospital or nursing home.

Post operative chest pain

2010-04-24T22:53:00.001-04:00

Check out this SlideShare Presentation:

Post operative chest pain

View more presentations from Raymond Zakhari.

The Health Care Bill: Has nothing to do with health or care. Discuss.

2010-03-24T16:03:00.000-04:00

This week the health care bill passed and I could not help but wonder why the AMA and Insurance companies would be in support of this? Especially since CMS continues to cut reimbursements.

As I understand it this bill people will be required to purchase health insurance and this will be reported to the IRS in some fashion, those found to not have sufficient insurance or no insurance will be fined, and should this person get sick they will then be covered by a government policy.

Also business will be required to offer health insurance to their employees and if they don't they will be fined; however this fine happens to be less expensive than the cost of an insurance premium because insurance companies cannot exclude people with preexisting conditions. As a result of not being allowed to mitigate the risk of 10 terminal cancer patients signing up tomorrow the premium will have to be adjusted to accommodate worst possible scenarios in order to maintain financial solvency.
I imagine that it is the sum of all these fines that will pay for the care rendered to those non-compliant with the requirement to purchase insurance. In addition to new taxes on investments and income over 200 or 250K. This type of service coverage has been speculated to be similar to medicaid coverage.

In 15 years I've not known a single health care provider to accept medicaid patients in a private practice. In fact the only place I know that takes medicaid benefits are hospital ERs, academic faculty practices were medical residents are trained, and large visiting nurses services. The remainder of private practice health care providers accept commercial insurance, some Medicare, and fee-for-service. Increasingly the latter is becoming the norm.

It has been also been said that there is a shortage of PCPs to render the care that will be needed. So what might this look like in practice as a result of the new health care bill?
Senario:
Patient needs a medical evaluation for a cough. Patient pays the fine for not having purchased his own insurance, and now has this medicaid like coverage. As a result he is unable to get into a doctors office for 4 weeks. So instead he goes to the local ER he get's a basic exam, by the medical resident, and they decide to screen him for TB. Meanwhile he has no where follow up so the patient is referred to the academic faculty practice. The first available appointment happens to be in 8 weeks, the TB test needs to be read in 48-72 hours, so the patient comes back to the ER, but instead of a simple read of negative it happens to be a positive finding. Now the patient needs to register in the ER to be seen and have a chest x-ray. They decide to offer him treatment for latent TB through the faculty practice that does not have opening for 8 weeks, in the ER baseline labs are drawn the first prescription is given (in 4 weeks he will need blood work again to make sure his liver is not failing from the medication) so the patient will return to the ER, and since it will not be the same doctor, he will need to register again, be re-evaluated and labs will be drawn. The new resident will take into account that the patient had smoked in the past and combine this with the incidental finding that is bound to occur on 40 year olds chest xray and insist that he need a pulmonary consult as opposed to a general medicine consult. That specialty clinic happens to have a 3 month waiting list. Pulmonary will probably want to order a CT scan and Pulmonary function test which will take anywhere from 4-12 weeks to accomplish and the next follow up will be in 6 months to discuss results and possible follow up care.
Meanwhile he can get into the general medicine medicaid practice as the 8th week has finally arrived. The faculty practice typically has a limited number of attending physicians who will be supervising/ training the medical residents therefore the patient will continue to wait. So far for this "diagnosis and preventative treatment" 3 visits to the ER were made. Eventually these doctors will get tired of the decreased reimbursement as the government tries to contain the cost.
The Health Care Provider slack will then be picked up by Nurse Practitioners. This is a win for NPs as they will have to have expanded scopes of practice in order to be allowed to meet the needs of the patients coming for care.

Doctors that like the practice of medicine but also like making a living will opt for a fee-for service (direct access, concierge, retainer etc.). This will empower patients that can pay for care to be more active in their health (asking questions etc.) Doctors will enjoy the reduced overhead of not dealing with 3rd party payers and smaller patient panels. The quality of service will also have to increase as there will be increasing competition for these types of paying patients.

Insurance companies will enjoy a short term financial gain of the mandate of insurance purchase.

Nurse practitioner practice rules will become more consistent and similar to states like Alaska, Arizona, Washington. Patients will have more choices in health care providers.

Hospitals should be careful as a result of the increased waiting times in the ER that is only going to get longer because now everyone has insurance. The triage area liability is about to go way up. I suspect there will be far more malpractice suits filed. (In countries with single payer insurance the incidence of medical malpractice is surprisingly much lower than the US).

With all of this waiting in waiting rooms for care employers are going to need find a way to make due with the high rate of absenteeism. They may need to add another week of vacation/ sick time so that they do not penalize their workers for getting the health care they deserve. Also if they do penalize they may be in violation of the FMLA.
As a result the new health care bill will then stimulate job growth because temp workers will be needed to cover the absent workers.

In a further effort to contain cost I suspect the phrase medical futility will become a part of the standard health care discussion. Do not Resuscitate may become an opt out instead of an opt in feature.

With the new health care bill Doctors get paid more, people become more in tune with the cost of health care if they use the fee for service, insurance companies get paid in new policies.
My Predictions for the new health care laws:

And all taxes will continue to go up, bio tech and pharma progress will take a hit in the US (job loss will continue), FDA approvals will take longer in an effort to contain cost, more innovative health care delivery systems will be devised to get around the entanglements of government regulation, and life expectancy will slowly improve because most patients get better despite of the health care system.

Oh one other thing: apparently all preventative services are supposed to be covered like colonoscopies, and mammograms what are we going to do with all the false positives that arise. Oh further testing and surgery (because there was no tort reform in the bill). That will certainly contain cost.

We don't really have to deliver the care, just let people feel that it can be delivered. Wasn't it the justice on a Canadian Supreme court that said "access to a waiting list is not the same as access to care"
Raymond Zakhari, NP
New York City

How to choose a Primary Care Provider?

2010-03-09T21:15:00.000-05:00

How to choose a Primary Care Provider in New York City?

A primary care provider (PCP) is a health care practitioner who renders health care services to people with medical problems. A primary care provider can be a doctor (MD or DO), physician assistant (PA) or a nurse practitioner (NP). Having the right PCP can often make a world of difference in the quality of care you receive, the specialists you are able to see, how fast your health care needs get met. For example there may be a really great dermatologist or GYN that you are trying to get in to see, but that practice may not be accepting new patients. If you have a primary care provider that knows you he or she can usually get you in to the practice that is not accepting new patients or at least have your case reviewed and start treatment while you wait to get in. If you do not have a primary care provider you may be left dialing through the directory that came with your insurance plan or resorting to the long wait of an emergency room.

A PCP is your main health care provider in non-emergency situations. Your PCP's role is to:

Provide preventive care and teach healthy lifestyle choices
Identify and treat common medical conditions
Assess the urgency of your medical problems and direct you to the best place for that care
Make referrals to medical specialists when necessary

Primary care is usually provided in an outpatient setting office or medical house call. However, if you are admitted to the hospital, your PCP may assist in or direct your care.

Having a primary care provider can give you a trusting, ongoing relationship with a known medical professional over time.

When choosing a PCP, also consider the following:

Is the office staff friendly and helpful? Is the office good about returning calls?
Are the office hours convenient to your schedule?
How easy is it to reach the primary care provider? Does the PCP use email?
Do you prefer a provider whose communication style is friendly and warm, or more formal?
Does the provider have a conservative or aggressive approach to treatment?
Does the provider order a lot of tests?
Does the provider refer to other specialists frequently or infrequently?
What do patients say about the primary care provider?
Does the provider invite you to be involved in your care?

Get some referrals from:

Friends, neighbors, or relatives
Your dentist, pharmacist, optometrist, previous provider, or other health professional
Advocacy groups -- especially to help you find the best provider for a specific chronic condition or disability
Read on-line reviews

Before you book the first appointment and while you are feeling well request an appointment to "interview" a potential provider. Now with the use of internet technology you can do web camera interview. There should be no cost to do this. Some practices, particularly pediatric practice groups, may have an open house where you have an opportunity to meet several of the providers in that particular group.

If you do not currently have a primary health care provider, and you happen to get sick, seek non-emergency care from an urgent care center or a medical house calls service rather than a hospital emergency room. This will save you time and money. Some medical house call’s practices can do many of the same services of the traditional doctors office or urgent care center including x-rays, blood work, ultrasounds and EKGs. The other advantage to having your primary care and urgent care delivered by a medical house calls practice is that you are not exposed to all the germs of a traditional health care practice. Keep your options open and consider your primary care provider like one of your expert advisors like your lawyer, accountant, etc. Your PCP can advise you on and help you navigate the health care arena.

Raymond Zakhri

MetroMedicalDirect.com

Convenience in New York City

2010-02-25T21:45:00.000-05:00

In the City were everything delivers health care can as well:
www.MetroMedicalDirect.com metromedicaldirect.com

Email/ Virtual Office visits
Web-Camera appointments
On line forms and bill pay

It's the convenient retail clinic alternative that spares you the waiting room.

If you've not tried Seamlessweb.com:

stores your order preferences
allows you to order from anywhere to anywhere without having to carry your wallet

Groceries:
www. FreshDirect.com

Avoid the schlep and hassles of the grocery store

These are 3 convenient services in NYC that make life a little easier especially when the weather will not let up.

Why you should visit your primary care provider when you are healthy?

2010-01-30T19:14:00.001-05:00

The purpose of a well patient physical exam by a primary care provider is to help establish a base line of what would be considered normal for you as an individual. Some other benefits of an annual physical exam include primary screening for disease, assess risk for development of future diseases and conditions, and to establish and maintain a therapeutic relationship with a primary care provider (doctor or nurse practitioner) in the event of an illness.

Why people don’t go to doctors?

The most common reason cited for men not going to doctors is it takes to long. That is to say the appointment never seems to start on time, and they often have to take off an entire day of work. Another reason men don’t go to doctors is they may feel fine, and have adopted a mentality of if it is not broken I don’t have to fix it. Despite these 2 very good reasons it is still important to see your primary care provider regularly to check for potential problems.

Did you know that most people who have high blood pressure never have any symptoms? In fact this is the reason hypertension is known as the silent killer. High blood pressure is also the leading cause of erectile dysfunction (ED), and is treatable and preventable. The only way to find out if you have high blood pressure is to have your blood pressure checked regularly, and if you get an abnormally high reading, you should have it rechecked at least 3 times with in 2-3 weeks to make sure the one reading was a fluke. Two other problems can often go undetected and without signs and symptoms for many years is high blood sugar and high cholesterol. These 3 conditions can exist individually or together for 10-15 years without producing a single symptom until the disease becomes advanced. When these three conditions come together the help comprise the 3 out of the 5 criteria that make up Syndrome X. In addition to an annual physical exam by a primary care provider to screen for high blood pressure, high blood sugar, and high cholesterol below I will outline some age specific exams that should be done during your annual physical exam.

By the way anyone that says an annual physical exam is useless is doing it wrong. And anyone that thinks an annual exam is done in less than 10 minutes is leaving many important things out. If this describes your past experience with primary care providers it may be time to get a new primary care provider.

Now that you’re an adult >18 years old:

Have your blood pressure checked at your annual physical exam and each time you see your primary care provider. Normal blood pressure should be <120/ <80. Both numbers are important.

If the top number (systolic number) is greater than 130 or the bottom number (diastolic number) is greater than 85, call your primary care provider.

Another way to get your blood pressure checked regularly is to watch for screenings in your area. You can also have your blood pressure monitored using the automated machines at local pharmacies.
If you have diabetes, heart disease, kidney problems, in your or your parents or siblings you should pay closer attention. There is probably a genetic predisposition in your family
Considering the western diet everyone should have their cholesterol (fasting lipids) checked at their annual physical exam by their primary care provider.
Again, if you have diabetes, heart disease, kidney problems, in you or your parents or siblings you should not let this go unchecked.

Immunizations:

Discuss with your PCP having a tetanus-diphtheria booster every 10 years. Especially if you engage in any contact sports or high adventure travel.
Your primary care provider may recommend other immunizations if you are at high risk for certain conditions such as pneumonia.

Men: Testicular exam: Between ages 15-35 and greater than age 50 is the highest risk groups for testicular cancer. This cancer is highly curable if caught early. A good primary care provider should teach you how to do this and review it every year at your annual physical exam.

Men should do a monthly testicular self-exam so that any lumps can be detected early.

Annual Physical exam:

You should have your first physical exam when you turn 21.
The first physical exam should included comprehensive blood work, and a lifestyle survey, and review of high-risk health situations.
Most experts would say that this can be done less often than an annual physical exam, but I would argue that you are not a statistic you are an individual.

Women: Have your breasts examined at your annual physical exam or your GYN appointment.

In addition do a monthly breast self-exam.
Women should contact their primary care provider or women’s health care professional immediately if they notice a change in their breasts, whether or not they do breast self exams
Women between the ages 20-40 should request a breast ultrasound if anything abnormal is noted. Breasts of this age are usually too dense and generate false positive results on a mammogram leading to unnecessary testing. If the ultrasound reveals something then discuss with your primary care provider an MRI. This discussion is essential so that you have a very specific plan for how you will proceed with results of incidental findings.

Women: Pelvic exam and Pap smear:

Screening should start within 3 years after first having vaginal intercourse or by age 21.
Beginning at age 21, women should have a pelvic exam and Pap smear every year to check for cervical cancer.
If you are over age 30 or your Pap smears have been negative for 3 times in a row, your primary care provider may tell you that you only need a Pap smear every 3 years.
Women who have had a total hysterectomy (uterus and cervix removed) probably do not need a Pap smear, but should consult with the GYN that performed the surgery.
Women who are sexually active should be screened for Chlamydia infection, because there may not always be symptoms with this STD. This can be done during a pelvic exam.

Beginning at age 40

Colon cancer screening should be added to the annual physical exam
A stool test can be simply done every year with the rectal exam to check the prostate.
People with risk factors for colon cancer like long-standing ulcerative colitis, personal or family history (parents or siblings) of colorectal cancer may need a colonoscopy more often.

Men: Prostate exam:

Most men age 50 and some men as young as 30 should discuss screening for prostate cancer with their primary care provider.
Screening tests may include the PSA blood test but should at least included a digital rectal examination.

Women: Mammograms:

Women over the age of 40 should have a mammogram done every 1-2 years depending on risk factors to check for breast cancer.

Osteoporosis screening: Depending on age and certain medications and other risk factors. Speak to your primary care provider.

All postmenopausal women with fractures should have a bone density test (DEXA scan).
Women under 65 who have risk factors for osteoporosis should be screened.

Men: Osteoporosis screening:

All men older than age 50 should discuss screening with their primary care provider.

If you are over 60 or have Risk Factors (high blood pressure, diabetes, cholesterol)

Discuss with your primary care provider an Abdominal aortic aneurysm screening:

Usually men between ages 65 - 75 who have smoked should have an ultrasound done once to screen for abdominal aortic aneurysms.

Some other ultrasounds to discuss with your primary care provider if you have diabetes, heart disease, kidney problems, include cardiac echo, renal ultrasound, and carotid Doppler studies.

Now you are probably thinking that you don’t have time for all of this testing and would like to just take your chances. Well if you live in Manhattan consider yourself fortunate. There is a primary care provider medical house calls practice that will see you in your home, office or hotel, and can arrange to have these tests done also at your home office or hotel. The primary care medical house calls practice is called Metro Medical Direct. It is owned an operated by a board certified primary care provider. This service takes the hassles out of going to the doctor.

Patients can request appointments online at www.MetroMedicalDirect.com. They can complete all their health forms online for further efficiency. The typical visit length is approximately 50 minutes all of which is face time with a primary care provider.

Now there are no more excuses to avoiding your annual physical exam.

Ipad missed the boat for health care

2010-01-29T19:10:00.000-05:00

The problem was not having a light portable computer to take with you everywhere i.e. a lap top or the Air. The problem was having it seem like your not working on a computer when dealing with clients and of course avoiding all the problems usually associated with Windows products.

Unfortunately the ipad is based on the same OS as the iphone. That means that there is no ability for an adobe flash player. That means no streaming net flix or hulu. And even worse I can't use my EMR (electronic medical record).

I use Practice Fusion because it does everything an EMR should do, but it requires the adobe flash player. It's great because everything syncs and is stored off site and allows for secure messaging among office staff.

It would also have been great if Apple didn't do another exclusive with At&T. This thing basicly looks like a big Ipod-itouch.

The iPad 2nd generation will hopefully fix this problem.

Metro Medical Direct is a web-based primary care medical house call and urgent care service in Manhattan that functions as truly a paperless practice.
Metro Medical Direct takes the hassles out of going to the doctor. I just wish apple would take the hassles out of portable electronic charting.
MetroMedicalDirect.com

Executive Physical Exam in Your Apartment

2009-11-10T00:05:00.002-05:00

There has been much debate over primary care for everyone raising the cost of health care. The main reason is because in the traditional medical model testing begets more testing. This is the reason executive physicals are so expensive and often times inconclusive.

The problem with many of these tests is there has not been a clinical utility demonstrated with many of the findings. Also, many of the tests reveal things that have no treatment. The idea of testing for something without having a workable plan in mind from the outset is bad medicine. Often findings on these extensive and expensive tests reveal things that may never progress to a disease state. These tests also allow the doctor to give up on critically thinking about you as an individual and often times sets off a cascade of red herrings.

The hype in the media of course does nothing to help this rush for massive testing. The Bio-Physical 250 or the latest manufacturer of CT scanners hyping the benefits of a total body scan as the gold standard in disease prevention is does nothing to decrease mortality. There is a rhetorical comment in medicine that refers to CT scanners as the diagnosis machine. This comment is made tongue-in-cheek. Just because something abnormal appears on the scan does not mean that it is what is causing the current problem. Another problem with unwarranted scanning and testing is the fear that becomes inspired in many patients.

Is there any benefit to the advances of modern science and medical testing? The plus side of testing is that sometimes these findings may motivate patients to do major healthy lifestyle changes. This assumes those changes will have an effect on the abnormal finding.

Is there an executive physical that can actually motivate behavior change and not cost thousands of dollars? Yes. The way this is done would be by a health care provider that takes the time to get to know you. One whom you establish a relationship with. It is very important for your primary care provider to get to know you in the context of your daily life. This yields a far better picture of your health rather than a one time snap shot that leaves us all guessing at how you got to this point. The best executive physical should focus on current lifestyle habits and state of health. Patients should complete a detailed history which includes a screening for alcohol abuse, domestic violence and sexual history. Also included should be a depression screening, anxiety screening, and quality of sleep screening. Finally no health review would be complete without an extensive nutritional and diet review. Ideally a 3 day diet recall/ journal should be kept in advance of the actual meeting with the health care provider.

Another important component of an executive physical which is often overlooked is a health education session in which patients learn how to navigate the health care system with respect to their current and future health problems. Patients should be taught how to speak to health care providers to get the answers and the care they need.
In an effort to perform a better physical exam and health survey a new trend has started emerging in the New York City area. Patients are being seen in their homes. The comprehensive physical exam consists of the health surveys previously discussed. This is becoming particularly attractive to men who state the main reason they do not go to the doctor is because of time wasted. Another advantage to being seen in your own home is the less likely chance of catching a infection in a standard medical office or hospital. How many times have you gone in for a physical and then three days later gotten sick?

Conducting a physical exam in the patients home consists of the following measures that yield the most informative data:

waist measurement
height on a door jam
blood pressure in both arms in 3 positions
screening men for testicular cancer (and teaching them how to do this on their own)
as well as digital rectal exam for prostate cancer.

These test combined with a through skin exam and review of the major systems can yield far more useful data than a whole body CT Scan that picks up obscure findings that have no clinical correlation. The home based executive physical exam also allows for a look in the refrigerator, bathroom, and common living area for quality of food, hygiene, and potential hazards.

What about testing?
Blood tests should be done with a plan of what you hope to do with the results in mind. Random and massive testing can have some very serious and expensive consequences.
This is a list of tests that will yield the most useful data that can actually be addressed without causing further harm or alarm:

* complete blood count (CBC)
* comprehensive metabolic panel (CMP)
* Lipids
* cardio-CRP
* homocystine
* HgbA1C
* Serum Insulin
* thyroid profile
* urine analysis and micro albumin
* Hep A and B antibodies
* Varicella and MMR titers
* Syphilis titer (RPR), Herpes titers and HIV

These test give insight to the major body organs and systems as well as highlighting risk of infectious diseases. The results can be greatly improved with lifestyle modifications. Other tests can be added on if clinically indicated.

What about imaging?

In an effort to spare patients needless radiation and to maintain biggest bang for the buck much of the imaging should done by ultrasound. This adds no radiation and allows for a sufficient evaluation of blood flow. Insufficient blood flow is typically what kills most people.

* Carotid dopplers (for stroke risk)
* 2-D Echo (heart function)
* Renal Ultrasound (kidney function and early high blood pressure)
* Abdominal including hepato-billiary (aneurysms, liver size and function)
* PA/Lat chest X-ray and 12 lead EKG (shape of lungs, sub-clinical chronic diseases, and electrical function)

This exam including the tests can be done in a patients home. Insurance sometimes picks up the cost of the tests, if something is revealed during the non-invasive portion of the exam that would have warranted the test. E.g. High Blood pressure or a heart murmur would probably justify many of the tests listed above.

What should patients do once they get all theses results?

Since the primary motivation in conducting an executive physical was to motivate a health behavior change patients are encouraged to follow-up with the provider for health behavior counseling at least a year. Meeting quarterly to discuss goals and ways to achieve them helps provide the needed psycho-educational support along the way. Some practices conduct these sessions by web-cam to ease the burden of traveling to the doctors office for frequent appointments. The focus of these meetings is to see what modifications are working and what is not, and why?

The reason these tests and screening tools are recommended is because the patient can actually do something with the results. Depending on the type of health care provider you see your annual physical exam can be futile. Many physicians have said the annual physical is really not worth a whole lot in the way of catching and treating illness. If you happen to see a Nurse Practitioner the annual physical exam is an opportunity to spend time teaching patients about their individual health. This is the time to ask all your questions and review any concerns you may have had through out the year.

Are executive physicals cost effective? No, not as they are currently being done, but if they are done by your primary care provider, and it is used as a spring board to motivating a healthy lifestyle change; then without a doubt they can be very cost effective and beneficial.

Raymond Zakhari, MS, NP http://MetroMedicalDirect.com Board Certified

Metro Medical Direct The first web-based primary care medical house calls practice in NYC that takes the hassles out of going to the doctor. Care is provided by a board certified nurse practitioner who examines you at your home, office or hotel.

Secure patient portal offering the home-based executive physical exam, email consultations, web-cam appointments, texting and secure messaging, access to your test results.

Back Pain: Alternative Treatments

2009-11-10T00:00:00.000-05:00

One of the most common chronic pain conditions is low back pain. This condition affects almost 35 million people in the United States. Treatment of this condition can be very challenging. In order to effectively treat the pain it is essential to uncover what is causing the back pain in order to treat the underlying cause.

Causes of back pain can fall into one of three categories. The most common cause of back pain is muscle and ligament strain or weakness. The difficulty in diagnosing these conditions is often times no objective test findings are able to identify an organic cause. The reason imaging studies like x-rays and MRIs are often ordered for these conditions is to rule out the most serious conditions. The diagnosis Musculoskeletal back pain with out a visible cause is made by excluding other potential causative factors. Some common findings on x-rays and MRIs include scoliosis, and subluxations (joints out of place).

Another common cause of back pain includes improper body mechanics. Working at awkward angles, lifting things and twisting, working on surfaces and inappropriate heights can all be environmental factors that cause musculoskeletal back pain. These environmental factors that can cause back pain are also called ergonomic related injuries. Uneven hip heights, or shoulder heights, no wrist or arm rests in your work area or desk chair, sitting on a wallet in your back pocket all can be modifiable environmental factors that can alleviate or cure back pain.

The third condition that can cause back pain is disc disease. This is the most commonly sought after medical diagnosis for back pain in western medicine. This condition often causes weakness and or a decrease or loss of function in the foot or hand. The severity of pain and the degree of functional loss often times are the determining factor in deciding the course of treatment. Disc disease can also be caused by arthritis but the same principles apply toward treatment. Beginning from conservative to most aggressive depending on pain, function and the other conditions the patient may have that make various treatments more risky than others.

Treatment
In most cases of back pain multiple factors are responsible for the symptoms that are occurring. Usually a combination of treatments can be very effective.As with any treatment Lifestyle modification must be addressed. This is especially true if lifestyle was the primary cause of the problem.

Some basic guidelines to keep in mind with respect to lifestyle modification in treating back pain symptoms include:
• If it hurts do not do it.
• Lift with the legs (never bend at the waist, squat with the knees like you are sitting in a chair and hug the object as close to your body as possible).
• Consider using warm most heat and massage.
• Consider getting a medium firmness mattress, and sleeping with a pillow between your thighs when sleeping on your side or placing a pillow under your knees while sleeping on your back.
• Core strengthening exercises and stretches are also very effective in building up supporting muscles.

Other treatment measures include:
Physical therapy combined use of electrical stimulation, ultrasound, soft tissue massage, myofacial release, acupressure, acupuncture and osteopathic manipulative treatments may all help to reduce or eliminate back pain. In addition some over the counter and prescription anti-inflammatory medications and topical applications may also be effective in the short term use to break the initial pain cycle and to allow you to do the therapeutic exercises. On rare occasion narcotics and muscle relaxers may be used for very short-term use. Prolonged use of narcotics and muscle relaxers can lead to dependence and addiction and may become ineffective over time in treating any other pain conditions. For this reason they should be used with the utmost caution and supervision.

Another lesser-known treatment option that is available only through a health care provider is an intravenous nutrient infusion (sometimes called the Myer's Cocktail) that contains magnesium. Magnesium serves as a muscle relaxer and B complex vitamins can help with neuropathic nerve pain. No official studies have been done to test the effectiveness of this infusion, but some patients have reported significant pain relief. This therapy would be classified as not harmful and possibly helpful in patients without any contraindications. A weekly infusion for 6 weeks can provide lasting pain relief in combination with some above listed therapies.

Back pain is a common problem that affects many people at one time or another. It is important that the underlying cause be determined before an appropriate treatment can be utilized. For this reason patients are advised to seek the advise of a qualified healthcare provider to ensure that a more serious condition is not being missed.

Raymond Zakhari, MS, NP http://MetroMedicalDirect.com
Board Certified

Who’s who in health care « The Informed Patient

2009-08-13T23:50:00.001-04:00

Who’s who in health care « The Informed Patient

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Attention Deficit Disorder (ADD), Attention Deficit Hyperactivity Disorder (ADHD) « The Informed Patient

2009-07-20T23:26:00.002-04:00

Attention Deficit Disorder (ADD), Attention Deficit Hyperactivity Disorder (ADHD) « The Informed Patient

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Basic EKG

2009-05-12T06:56:00.001-04:00

EKGs seem to cause stress. Let this help solve the problem

Basic EKG

View more presentations from RZakhariNP.

2009-04-21T07:04:00.000-04:00

Einstein once said, 'The definition of insanity is doing the same thing over and over again and expecting different results.'

"You cannot help the poor by destroying the rich. You cannot strengthen the weak by weakening the strong. You cannot bring about prosperity by discouraging thrift. You cannot lift the wage earner up by pulling the wage payer down. You cannot further the brotherhood of man by inciting class hatred. You cannot build character and courage by taking away people ' s initiative and independence. You cannot help people permanently by doing for them, what they could and should do for themselves."

Abraham Lincoln

What the problem. Now let us solve it.

2009-04-04T11:09:00.000-04:00

Did you ever have a great idea or come up with a way to make an existing product or service better. These ideas seem to strike at the most inopportune time in the shower, just while you were about to drift off to sleep etc. Of course there is no pen or paper handy to write it down, or you assume someone else has thought of it.

I feel like I have a ton of great ideas and often times I don't have the time, money or know-how to run with it. So I generally forget about them and life goes on with the way things are.

I've created this blog that can serve as a place to make your great idea or gripe (which in turn may generate the great idea)known. Perhaps an inventor, entrepreneur or venture capitalist will come by and share your vision or be inspired by your idea and run with it. They may want to provide you with the resources to make the idea a reality or they may take your idea without attribution and run with it. (Which I have no problem with, because let's face it if you can't execute the idea, or invest the sweat equity to make it a reality this should not stop the idea from becoming a reality).

Who knows the idea may already exist and perhaps needs a better marketing strategy, perhaps a repackaging, or a new target group a minor modification.

I was going to launch a site ThatSucks.com, but I don't want to pay for hosting, and my ADD won't let me sit still long enough to build a web site.

But if anyone knows of a way to post audio clips to this site easily that would be great (hint: google create clicky thing like the video button) or if anyone knows of an audio equivalent to YouTube that could some how be linked in.
Also if someone knows how to add a Twitter connection so the gripes can be expressed in a 140 characters of less and link back to this blog that would be nice too. And by all means if someone knows how to create a FaceBook, MySpace, LinkedIn etc fan pages cross linking so that you can gripe and post from anywhere at anytime have at it.
Thanks for reading, and coming on this journey with me. The ideas here might make you the next big deal or solve a big problem.