Clinica Del Valle

General Physical Exams

A physical examination, medical examination, or clinical examination is the process by which a medical professional investigates the body of a patient for signs of disease.  It generally follows taking of the medical history—an account of the symptoms as experienced by the patient.  Together with the medical history, the physical examination aids in determining the correct diagnosis and devising the treatment plan. This data then becomes part of the medical record.

• Here’s how often you should have a complete physical by your doctor.

Preventive Healthcare

• Preventive care lets your doctor find potential health problems BEFORE you feel sick. It includes all measures to ensure wellbeing and prevent long term consequences from family history and/or disease.
• Preventive care can include immunizations, lab tests and other diagnostic testing, physical exams and prescriptions. All of these services help your doctor understand your symptoms or diagnose your illness. These visits focus on prevention and allow our physicians to work closely with you to plan for your future health.
• Below are the recommended vaccines with their recommended timings/frequency:

• Here are some of the recommended screenings for adults:

Immunizations, Vaccinations, & Flu Clinic

Whether you need a flu shot, school vaccinations, or other inoculations, we are able to provide you and your family with the necessary immunizations necessary to maintain your health.

• Availability: We stock a wide range of vaccinations (from booster shots to tetanus shots to school shots).
• Quality of service: We administer vaccines according to the best practices established by both the CDC and the general medical field.
• Convenience: We have several locations for your convenience to get your immunizations and flu shots.

Flu Clinic

Our practice prides itself in providing you and your family members with the influenza vaccine. Influenza is a contagious disease that spreads itself amongst people throughout the United States. It is commonly spread by coughing, sneezing and close contact to individuals of all ages. Statistics have shown, though, that the risk of getting the flu is the highest in children. Symptoms of the flu include:

• Fever/chills
• Sore throat
• Fatigue
• Coughing
• Headaches
• Stuffy and runny nose
• Getting a flu vaccine in the form of an injection will not contain any live influenza virus, but is instead an “inactivated or recombinant” vaccine. A live attenuated influenza vaccine is actually given as a spray into the nose. It is recommended to get a flu vaccine every year, with the flu season generally occurring between October and May.
• You should not get an influenza vaccine if:
• You have any severe, life-threatening allergies
• You have ever had Guillain-Barre Syndrome

Chronic Care Management

Medicare and Comprehensive Primary Care are committed to improving your healthcare within our practice and improving the coordination of your care with other healthcare providers. To reach that goal we encourage all our Medicare patients to schedule an Annual Wellness Visit and enroll in our Chronic Care Management Services¬ (CCM) — both covered benefits for Part B recipients! As always, we are dedicating to working with you and thank you for trusting us with your healthcare needs!

Annual Wellness Visits are good for your health, help ensure more of your health needs are met, and are highly encouraged by Medicare for all Part B recipients.

• Aligned with national quality measurement guidelines!
• No cost to Part B recipients – no copay, coinsurance or deductible!
• Allowed every 12 months – Comprehensive visit allowed during the first 12 months following Part B enrollment. Subsequent visits allowed every 12 months thereafter.
• Focus on illness prevention, detecting potential risks:
• Review past health status
• Illness prevention assessment
• Identifies your Circle of Care (healthcare providers, family members, and others involved in your care). You always retain the ability to direct us about what information may be shared!
• Current medications and medication management options
• Risk Assessments — fall prevention, behavioral health, home safety, nutrition, and more
• Not a traditional head-to-toe physical. Physicals are never covered by Medicare.
• Helps your CPC providers since Medicare now grades providers and reports grades nationally. Grades represent how well we care for your overall health, reach out to you, provide preventive services, and coordinate care with your specialists and family. Help us get an “A” and schedule your wellness visits each year!

Chronic Care Management Services (CCM) are provided to improve the management of chronic conditions and pays your provider’s office when we provide and document 20 or more minutes of additional care outside of a traditional office visit in a given month. This is good for you because we can do more than ever to help manage your chronic conditions, and hopefully prevent hospital and ER visits. And for the first time, our office can be compensated for providing these premium services. Here are some facts about the Medicare CCM service benefit:

• Services are designed to improve your overall healthcare and prevent illness.
• Available only to Part B Medicare recipients
• Must have two or more chronic conditions to qualify.
• Must elect to sign up to participate.
• Cost to you is only about per month (co-insurance) when at least 20 minutes of additional services are rendered and documented. No cost to you for months when less than 20 minutes of additional service is rendered.
• You may cancel at any time, if you change your mind or feel the service is not beneficial.
• Additional CCM services include, but are not limited to:
• Comprehensive yearly care planning
• Coordinating care with specialists, family and community resources (e.g. help arranging appointments, referrals, transportation, and more
• Telemedicine family conferences to help with advanced directives, review hospital and ER discharge instructions, and more.

If you have two or more chronic conditions and you are interested in receiving these premium services to help improve your overall health and prevent illness, talk with your provider or one of the clinical staff today.

Treatment for Acute Conditions

All our providers are well-trained, experienced, and motivated in providing excellent care for acute conditions like cough, cold, flu, sore throat, cuts & rashes, broken bones, sprains & strains, headaches, urinary tract & upper respiratory infections, ear & eye infections, etc.  Your doctor will consider any chronic condition management you may be on while creating a treatment plan for your acute condition.  Medication reconciliation is done at each visit to make sure you get the most effective and best-suited treatment for your condition and symptoms.

Guidance and medical treatment for weight management and smoking cessation

Weight Management: 

Obesity is one of the greatest public health challenges worldwide.  It is not only a medical but also a philosophical, ecological, economic, sociocultural, and psychological problem.  The primary goal of weight management in primary care is to reduce the morbidity and mortality of overweight or obese patients and to improve psychological well-being and social function.  To achieve this reduction in morbidity or mortality, the risks inducing these have to be decreased.  In general, obesity interventions are used for patients with an increased risk of morbidity or mortality.  Many medical complications associated with obesity can be improved by intentional weight loss.  The treatment should be tailored to the patient's individual needs and risk profile. 

Smoking Cessation:  

Cigarette smoking harms nearly every organ of the body, causes many diseases, and reduces the health of smokers in general.  Quitting smoking lowers your risk for smoking-related diseases and can add years to your life.  Primary care providers who offer counseling and arrange follow-up sessions for patients can help increase the chances of smoking cessation after lung screenings, according to research from the National Lung Screening Trial (NLSN).  Our providers take a keen interest in promoting smoking cessation and guide their patients with current smoking status ways to quit smoking.

Adolescent Care

Providing care to adolescents can be challenging because teenagers are often struggling to make decisions on their own. They are in the transition between being children and adults and often do not want advice. Our providers work to speak in terms that adolescents can understand about acute or chronic issues as well as education regarding preventive medicine. We provide comprehensive, primary care for adolescents ages 12 to 21. Some 10 and 11 year olds are treated if developmentally mature.

Services available include:

• Comprehensive physical exams and immunizations
• Urgent medical care
• Treatment for asthma
• Allergy shots
• Nutritional support and counseling for eating disorders
• Screening for complications associated with obesity
• Contraception counseling
• Pregnancy testing and referral
• HIV antibody counseling and testing
• Behavioral problems
• Learning disorders
• Attention deficit hyperactivity disorder (ADHD)
• Gynecological problems, including sexually transmitted diseases

We respect the privacy of your adolescent/teenager, so all discussion of care especially those on topics of STD’s, drug use, and birth control remain confidential. We do know, though, that it is very important to talk honestly about any risks associated with such behaviors.

Women’s Health

Women have unique health issues.  These unique issues include pregnancy, menopause, and conditions of the female organs.  Also, some of the health issues that affect both men and women can affect women differently.  Our providers are qualified to care for these unique health issues that affect women.

There is so much to know about the woman’s body.  And as your body changes with time, you are bound to have questions you never thought of before.  You can come here to explore a range of women’s health issues.
Get help with decisions and common concerns on topics such as:

• Pap Smear
• Premenstrual Syndrome
• Headaches

Pap Smear

A pap smear is a diagnostic test for cervical screening that can detect potentially pre-cancerous and cancerous processes in the endocervical canal. This test is performed by opening the vaginal canal with a speculum during a physical exam, and collecting cells from the outer opening of the cervix of the uterus and the endocervix with a swab. The cells are examined under a microscope to look for any abnormalities. It is very important for each women to have a pap smear annually as part of their women’s routine visit.

What Causes an Abnormal Pap Smear

Abnormal cell changes in the cervix and endocervical canal can be caused by certain types of human papillomavirus (HPV), other types of bacterial or yeast infections, smoking, an impaired immune system, or menopause. These cell changes may go away on their own or can be successfully treated.

But, certain types of HPV have been linked to cervical cancer. It has been reported that with regular screenings and appropriate follow up care, death from cervical cancer can be reduced by 80%.

Premenstrual Syndrome

Premenstrual syndrome (PMS) refers to a varied collection of physical and emotional symptoms during part of a woman’s menstrual cycle. There are more than 200 reported symptoms of PMS including stress, anxiety, difficulty in falling asleep (insomnia), headache, fatigue, mood swings, increased emotional sensitivity, changes in libido, bloating, lower back pain, abdominal cramps, constipation/diarrhea, swelling or tenderness in the breasts, cyclic acne, joint or muscle pain, and food cravings.

The American College of Obstetricians and Gynecologists estimates that at least 85 percent of menstruating women have at least one PMS symptom as part of their monthly cycle. Most of these women have fairly mild symptoms that do not need treatment. Others (about 3 to 8 percent) have a more severe form of PMS, called premenstrual dysphoric disorder (PMDD).

The causes of PMS are not clear, but changes in hormones during the menstrual cycle seem to be an important cause. Some other possible causes include:

• Low levels of vitamins and minerals
• Eating a lot of salty foods, which may cause you to retain (keep) fluid
• Drinking alcohol and caffeine, which may alter your mood and energy level

Headaches

The menstrual cycle has a definite impact on the development of migraine headaches for some women. Approximately 50% of women have reported migraines associated with their menstrual cycle. A woman’s body has many biological changes that produce a widespread effect on their body. Some women are more sensitive to the fluctuations within the menstrual cycle. Studies suggest that migraine can be triggered by a drop in estrogen levels, such as those which naturally occur in the time just before your period. Often the migraine will occur anywhere between two days just prior to menstrual period onset through the first three days of menstruation.

There are no tests available to confirm the diagnosis, so the only accurate way to tell if you have menstrual migraine is to keep a diary for at least three months recording both your migraine attacks and the days you menstruate.

This will also help you to identify non-hormonal triggers that you can try to avoid during the most vulnerable times of your menstrual cycle.

Evaluation for anxiety and depression

Anxiety and depression are psychiatric disorders frequently seen in family practice.  It is advisable that primary care providers should evaluate the patients to look for any signs or symptoms of anxiety and/or depression.  Catching these conditions and treat early on with medications and/or counseling can help improve the quality of life of the patients.  Depression/anxiety if not treated can lead to far more serious health issues and can even result in death due to suicide.  Our providers evaluate their patients using the NCBI recommended screening tool PHQ9 (health questionnaire) for criteria-based diagnosis of depressive disorders and measure the level of severity.

Post-Hospital Discharge Follow-ups

Post-Hospital Discharge follow-up visit presents a critical opportunity for the primary care provider to address the conditions that precipitated the hospitalization and to prepare the patient and family caregiver for self-care activities.  This visit includes a variety of services from reviewing the complete documentation from the hospital records to creating a plan for the patient and the caregiver to follow-through with the Discharge Instructions.   Following checklist explains the typical workflow for these kinds of visits:

Travel counseling and vaccinations

Planning to travel abroad?  We know it can be overwhelming, but we’re here to help you with your travel vaccinations and offer travel health advice.   We offer pre-travel counseling and immunizations.

Travel Health Services

• Pre-travel counseling
• Review of previous vaccinations and immunizations
• Malaria prevention advice and prescriptions
• Info about travel health topics including traveler’s diarrhea

While vaccination is the primary focus of the travel medicine department, your provider can also provide advice on consuming potable water and food.  Travel consultations are based on the recommendations of the CDC.

Common Travel Vaccinations and Immunizations

Below are a list of common travel vaccinations and immunizations.  Please note that this list is not conclusive.  Please visit the CDC's Travel Health page for complete information.

• Tdap (Tetanus, Diphtheria and Pertusis)
• Hepatitis A and B
• Influenza
• Pneumovax®
• Meningitis
• Shingles
• Japanese encephalitis
• Typhoid
• Yellow fever
• Rabies
• Polio

Resources for Travelers

For more info, please visit the CDC website https://wwwnc.cdc.gov/travel 

Minor Surgeries and Procedures

Minor surgery in primary care has long been held to be cost-effective and popular with patients.  Minor surgery procedures in primary care include the following:

• Cryoth
• Electrocautery.
• Curettage.
• Therapeutic injections used in a variety of conditions – e.g.:
  • Injections into joints (steroids but also perhaps viscosupplementation).
  • Aspiration of joints.
  • Injection of tennis and golfer's elbow, or carpal tunnel injection.
  • Injection of varicose veins and piles.
• Excisions.
• Incisions.
• Other procedures which the practice is deemed competent to carry out - eg, skin biopsy (punch and shave), endometrial sampling, removal of toenails, removal of contraceptive implants, evacuation of perianal hematomas and removal of skin lesions where clinically indicated (see local guidance).

Equipment and accommodation

• Most surgeries have a dedicated treatment room in which such procedures are performed; however, cryotherapy, electrocautery and curettage can be performed in a normal consultation room, provided that there is adequate lighting and space.
• A clean area is not as important as for 'cutting' surgery but it is desirable and creates a favorable impression of a professional service.
• Equipment should be appropriate to the job and of adequate specification: c
• A curette can be sharp or blunt. A sharp curette is more frequently employed, although it can cause more damage if used without skill. A range of sizes adds versatility. Disposable instruments are now recommended. A hot water boiler is inadequate and even pressurized autoclaves can no longer be recommended. If there is any uncertainty about the adequacy of equipment, the Clinical Governance team of the local Clinical Commissioning Group (CCG) should be able to give advice.
• Appropriate infection control measures should be in place. National Institute for Health and Clinical Excellence (NICE) guidance is available.
• Electrocautery is provided by a hot wire. This apparatus usually works on about 12 volts. This may be provided by a battery, but a transformer plugged into the mains is more usual. There is a button on the handle to switch the current on and off. There may be a number of heads of various shapes and sizes for various jobs. They can be removed to be cleaned and sterilized but letting them glow red will provide a much higher temperature than any autoclave, although not for so long.
• Cryosurgery requires a cold source and the most common is liquid nitrogen. It can usually be bought by special arrangement from a local hospital or directly from a supplier if a storage vessel is purchased. It is essential to remember that it is exceptionally cold with a boiling point of −196°C and so requires appropriate precautions for use and storage. Thick gloves and goggles must be worn when decanting or transferring liquid nitrogen.

Organizational issues

These procedures can be carried out:

• In normal consultations. Most people do not perform minor surgery during the course of normal consultations, except perhaps the injection or aspiration of joints and such techniques.
• At a dedicated session. It can be better to ask the patient to return to a dedicated session in a specific room with the equipment set up and, in the case of liquid nitrogen, with a fresh supply of the material to hand.

Consent

Informed consent requires full information on the proposed treatment, alternatives and possible complications including, for example, a measured opinion about the cosmetic result. Standardized information sheets can be useful.

Techniques

The following techniques form the basis of minor surgery provision under additional services:

Local anesthesia

• Sometimes lesions are so superficial that they can be removed without any need for local anesthetic. It is required for cautery but should not be used with cryotherapy.
• Lidocaine 1% is the most commonly used local anesthetic and it can be used for these procedures. It is most conveniently administered using a dental syringe with a fine dental needle and cartridges made for the syringe.
• A lidocaine/adrenaline (epinephrine) mixture is often used. This prolongs the duration of action and increases the total dose that can be used; however, its greatest asset is that it induces vasoconstriction and so reduces bleeding. It must not be used on fingers, toes or the penis.
• If analgesia is required on a mucous membrane it is possible to apply lidocaine directly via a piece of gauze and this numbs the surface so that injection is less painful. It does not cross the horny barrier of keratinized epithelium in the skin and so is of no use to numb skin. For topical use, a 2% or 4% solution is acceptable but otherwise a maximum of 1% is recommended.
• Remember that after injection of local anesthetic it is necessary to allow a few minutes for the injection to have its effect.
• Another way to obtain superficial topical analgesia is to 'freeze' the skin with an ethyl chloride spray. This is a highly volatile liquid that comes in a large ampoule with a spring-loaded rubber stopper. It is inverted over the lesion and vapor pressure of the liquid ensures that when the cap is opened a fine spray of ethyl chloride is directed at the lesion. Usually it takes about 15 to 40 seconds for the area to turn white before beginning the procedure. Although it is a convenient method, it is not very effective and the duration of action is very limited. It may be necessary to stop and spray again a number of times. It is used by some for superficial curettage but use is probably not widespread. NB: ethyl chloride is highly inflammable and must not be used in association with electrocautery. It should not be used close to the eyes, nose, ears or other orifices.

Curettage

• Curettage is reserved for superficial lesions like seborrheic keratosis and solar (actinic) keratosis, which are usually so superficial that removal does not leave a scar.
• Keratoacanthomas can also be removed by curettage but it tends to be deeper and often leaves a scar.
• Ethyl chloride can be used for analgesia but if the lesion is thick and horny it may not penetrate and so infiltration under the lesion with lidocaine is preferable.
• Hold the neighboring skin firmly with the non-dominant hand and, with the curette in the dominant hand, use a firm motion to get under and elevate the lesion. Sometimes a rather raw area below the lesion oozes blood. Firm pressure with a piece of gauze for several minutes should stop this. Alternatively a superficial electrocautery can seal the vessels (but not if ethyl chloride has been used).
• Removal of a keratosis often just produces a cornified lesion that is of no value for histology but, wherever possible, excised tissue should be sent for histology (to confirm the clinical diagnosis and to exclude malignancy).

Electrocautery

• Electrocautery can be a useful technique, especially when a lesion is vascular.
• The equipment used usually has a range of settings, typically from 1 to 10 (for example, coagulation between 3 and 4, cutting between 6 and 10).
• Its main disadvantage is that it often burns the tissue beyond recognition so that it is impossible to obtain histological confirmation of the lesion. Patients sometimes find the smell of burning tissue rather distressing.
• It is useful for removal of skin tags when the diagnosis is usually clear. In obese patients these are often multiple. A little bleb of local anesthetic is injected into the base of each.
• Remember that ethyl chloride is contra-indicated.
• After giving a few minutes for the local anesthetic to work, grasp the lesion with a pair of forceps and press the button on the handle so that the tip glows bright red. This usually takes 5 to 10 seconds. Then touch the base of the lesion with the glowing coil and it will cut swiftly though it. The lesion comes away in the forceps and there is usually no bleeding. If there is a little bleeding then touching the area with the glowing tip should seal it.
• A few hours later, when the local anesthetic has worn off, the patient may feel discomfort in the burned area and this may need simple analgesia.

Cryotherapy

• Local anesthesia should not be used and is not necessary.
• Cryotherapy works by rapidly freezing tissue cells which then thaw, causing lysis of cells.
• Cryospray, cryoprobes or cotton-tipped applicators can be used.
• The art of this technique is to apply enough cooling to destroy the lesion without applying too much and causing collateral tissue damage. If in doubt, undertreat, as it is possible to treat again but overtreatment will destroy healthy tissue.
• The contact with the tip produces a rim of blanching. It may then freeze the lesion to the tip and it can be pulled away but more often it falls away some time later. This means that there is often no tissue for histology.
• It is recommended that the technique be learned by attending a course or from an experienced and appropriately trained practitioner.
• Knowing what to treat and what not to treat with cryotherapy is most important. Cryotherapy can be used very successfully for a variety of lesions. The list below of lesions treatable with cryotherapy is not exhaustive and does not imply that the technique is appropriate for all such lesions. An important part of learning the technique is getting familiar with what can be treated successfully and what lesions require other techniques and possibly referral.
  • Actinic keratoses.
  • Seborrheic keratoses.
  • Warts and verrucae.
  • Lentigines.
  • Skin tags.
  • Superficial spreading basal cell carcinoma.
  • Basal cell carcinoma.
• It is worth avoiding:
  • Lesions on the pinna (can cause necrosis of cartilage).
  • Lesions close to the eye.
  • Treatment of lesions on the hands and feet in Raynaud's phenomenon.
• Complications can arise after treatment and patients should be warned of these. Blistering and pain occur frequently.

Cardiac Risk Analysis

As per CDC, heart disease is the leading cause of death for people of most ethnicities in the United States, including African Americans, Hispanics, and whites.  For American Indians or Alaska Natives and Asians or Pacific Islanders, heart disease is second only to cancer.  Based on your signs or symptoms, your doctor may recommend diagnostic testing to calculate any cardiac risk you may be at and create a plan based on the results.  The following diagnostic tests may be used to calculate the cardiac risk:

Echocardiogram

An echocardiogram (also called an echo) is a type of ultrasound test that uses high-pitched sound waves that are sent through a device called a transducer. The device picks up echoes of the sound waves as they bounce off the different parts of your heart. An echocardiogram allows doctors to see the heart beating. It also shows the heart valves and other structures. This test may be ordered by your provider to help to diagnosis one of the following:

• Abnormal heart valves
• Abnormal heart rhythms
• Congenital heart disease
• Damage to the heart muscle from a heart attack
• Heart murmurs
• Inflammation (pericarditis) or fluid in the sac around the heart (pericardial effusion)
• Infection on or around the heart valves (infectious endocarditis)
• Pulmonary hypertension
• Ability of the heart to pump (for people with heart failure)
• Source of a blood clot after a stroke or TIA

Electrocardiogram (EKG)

An electrocardiogram (EKG or ECG) is a test that checks for problems with the electrical activity of your heart. An EKG shows spikes and dips in a line tracing that reflects the heart’s electrical activity. An EKG may be ordered by your provider:

• To check the heart’s electrical activity.
• To help find the cause of unexplained chest pain, which could be caused by a heart attack, angina or pericarditis.
• To help to find the cause of symptoms such as shortness of breath, dizziness, fainting, or rapid, irregular heartbeats (palpitations) that may be signs of heart disease.
• To find out if the walls of the heart chambers are too thick (hypertrophied).
• To check how well medicines are working and whether they are causing side effects that affect the heart.
• To check how well mechanical devices that are implanted in the heart, such as pacemakers, are working to control a normal heartbeat.

Stress Test

A stress test, also called an exercise stress test, shows how your heart works during physical activity. Because exercise makes your heart pump harder and faster, an exercise stress test can reveal problems with blood flow within your heart.

A stress test usually involves walking on a treadmill or riding a stationary bike your heart rhythm, blood pressure and breathing are monitored. Or you'll receive a drug that mimics the effects of exercise.
Your doctor may recommend a stress test if you have signs or symptoms of coronary artery disease or an irregular heart rhythm (arrhythmia). The test may also guide treatment decisions, measure the effectiveness of treatment or determine the severity if you've already been diagnosed with a heart condition.

Why it's done

Your doctor may recommend a stress test to:

• Diagnose coronary artery disease. Your coronary arteries are the major blood vessels that supply your heart with blood, oxygen and nutrients. Coronary artery disease develops when these arteries become damaged or diseased — usually due to a buildup of deposits containing cholesterol and other substances (plaques).
• Diagnose heart rhythm problems (arrhythmias). Heart arrhythmias occur when the electrical impulses that coordinate your heart rhythm don't function properly, causing your heart to beat too fast, too slowly or irregularly.
• Guide treatment of heart disorders. If you've already been diagnosed with a heart condition, an exercise stress test can help your doctor find out how well treatment is working. It may also be used to help establish the treatment plan for you by showing how much exercise your heart can handle.

Your doctor may use a stress test to help determine the timing of cardiac surgery, such as valve replacement. In some people with heart failure, stress test results may help the doctor determine whether you need a heart transplant or other advanced therapies.

Your doctor may recommend a test with imaging, such as a nuclear stress test or echocardiographic stress test, if an exercise stress test doesn't pinpoint the cause of your symptoms.