Sunday, December 27, 2015

A Congenital Heart Valve

I picked up the medical chart outside the patient exam room and walked into introduce myself. 
“Hi, I’m Sharon, I’m a PA and am working in this clinic temporarily covering for another PA who is on maternity leave.  How can I help you?”
The male Hispanic patient was leaning forward on the exam table obviously short of breath as well as showing facial grimaces from pain.  He was only 24, way too young to be having chest pain from a MI. 
“I’m having chest pain and can hardly catch my breath.  I was here being seen about a month ago with almost the same symptoms but the PA who saw me didn’t think anything about it.  Now my symptoms are worse and I can hardly breathe.  I’m also very tired, I have no energy.”
“Okay, well do you have any history of asthma, breathing diseases, heart disease, for instance?”
“No, I’ve never been sick.  I’ve had the flu a few times but that’s it.  I rarely saw a doctor when I was younger.  I think I only went in when I needed a vaccination for school.”
“Does anyone in your family have any lung problems such as asthma, or COPD for instance?”
“No, not that I know of.”
“How about any cardiac history, anyone in your family with a history of heart attacks, or the like?”
“No.  Not in my mother’s relatives.  I don’t know anything about my dad’s side of the family, seeing that he left when I was a toddler.”
As he answered my questions he continued to give me facial grimaces from his chest discomfort. 
“Okay, well let me check you over quickly.”  After checking his vital signs which showed a somewhat high blood pressure as well as a pulse oximetry (blood oxygen levels) which showed his oxygen level at 90% (a little low) I started doing my physical exam. 
I quickly went over the head and neck exam, and moved my stethoscope over his lungs to listen to them.  His lung fields were clear, he didn’t have any wheezes or abnormal sounds.  I then listened to his heart sounds.  I put my stethoscope over his anterior chest wall to find out he had a very loud systolic murmur.  The murmur was over his aortic valve.  It was at least a 4/6, possible a 5/6 in intensity.  He didn’t have a thrill.  The remaining three areas that we clinicians listen to for heart sounds were normal. 
I felt his radial pulses bilaterally and they were equal.  The murmur radiated up to his carotid pulses in his neck.  I could also hear the murmur over his posterior back.  I had the patient lay down and finished doing my abdominal exam as well as feeling his pedal pulses (pulses in the feet). 

When working up a patient who has chest pain you have to acquire a full medical history on them.  This will then guide you on what potential medical diagnosis’  the patient maybe having.  This patient was 24, he was too young to be having a heart attack (these generally occur in men > 40 years of age).  He denied having any problems with asthma or other lung conditions.  So I am left with a cardiac (heart) problem. 
After I listened to his chest I heard the typical sound of a stenotic (hardened) aortic valve.  When we listen to the heart we grade heart murmurs from 1 to 6.  A one means that most people even with a stethoscope listening to the chest wall will not be able to hear it.  A murmur graded as a two is a soft murmur, barely perceptible, you have to really listen to hear these.  A murmur graded as a three is louder, definitely there.  A four is quite loud.  A five is louder yet, it sometimes has a thrill associated with it, meaning that you can feel with your hand on the chest wall the vibration of the underlying cardiac murmur.  A six is very loud, sometimes it can even be heard without your stethoscope even on the chest wall.  Thrills are always felt with a murmur determined to be a six. 
Then there are systolic murmurs vs diastolic murmurs.  This just means at what point in the cardiac (heart) cycle is the murmur heard.  Is it during systole (when the heart is pumping) or in diastole (when the heart is at rest)?
Heart murmurs can also radiate their sounds to other areas of the body.  Many of them will radiate to the back or neck for instance. 

I advised the patient, “I want you to stay laying down, I’m going to send the medical assistant back in here to do an EKG on you and then I’ll come back in and explain what needs to be done, okay?”
I left the exam room and advised my medical assistant to get an EKG on him.  While she was in doing this, I picked up the phone and called the local cardiologist’s office.  When his office receptionist picked up the phone I advised her that I had a patient who needed an urgent echocardiogram and an appointment to be seen by the cardiologist within the next few days. 
The receptionist made the necessary appointments and I wrote them down on a piece of paper which I would give to the patient when I went back into see him. 
By that time the medical assistant came out of the patient’s room with the EKG in her hands which she gave to me.  The EKG showed he had an enlarged left atrium, a slightly enlarged left ventricle, with no tall R waves or ST changes. 

An EKG (electrocardiogram) is useful in patients who have a cardiac diagnosis.  It can tell you whether any of the chambers are enlarged, whether the nerve conduction from the upper to the lower chambers has been affected, or slowed down due to damage, such as in a patient who has a history of having a heart attack. 
In a patient who has aortic valve involvement you are looking for changes on the left side of the heart, strain on the left ventricle (ST changes) as well as changes in the R wave. 

I went back into to see the patient and began explaining everything I had found out.  He was still laying down. 
“You can sit up if you’d like,” I advised him.
“No, it’s more comfortable for me if I lay instead.”
“Okay, well then let me explain to you what I found out and what needs to be done.  You have a defective heart valve, with you it’s your aortic valve.  The heart has four chambers from which it pushes blood into your lungs and then into your whole system.  Between each of these chambers is a heart valve which helps to keep the blood from back flowing when the heart muscle contracts.  In your case one of your valves which we call the aortic valve has decided it doesn’t want to work anymore and hence it has become hardened and probably almost unmoving.  The aortic valve is the valve that blood flows through when it is leaving the heart and going to the rest of the body.”
“When I listened to your chest just a few minutes ago I heard a very loud heart murmur which told me that your aortic valve was damaged.  Each part of your chest wall represents a certain location where heart sounds are referred to.  The aortic valve sounds are referred to your upper chest on the left side.” 
“Do you understand everything I’ve said so far?”
“I think so.”
“Okay, well when a heart valve decides to begin not working like it should, it gives you a lot of symptoms, such as your chest pain and your having a hard time breathing.  You also mentioned you were tired and had no tolerance for walking for any long distances.  Your elevated blood pressure is also a symptom of your aortic valve not working the way it should.”
“Do you understand what I just said?”
“Yeah, I was going to ask you about my chest pain and not being able to breath, but you just explained it.”

Patients who have heart problems can have a myriad of signs and/or symptoms.  These can include:  (not a complete list, just some of the more common ones)
--high blood pressure
--fatigue, low exercise tolerance
--chest pain
--shortness of breath
--passing out (syncope)
--palpitations (a feeling or knowledge that your heart is beating)

“Okay, well I have written down on this paper a referral for you to get an echocardiogram, which is a study of your heart where they bounce sound waves off of your chest wall to ascertain your heart function and the function of your valves.  It won’t hurt at all.  Below your echocardiogram appointment is your appointment to see the cardiologist whose office you’ll be visiting to get your echocardiogram done at.  Your appointment for both of these is in two days.  Keep these appointments, it’s very important.  The cardiologist will get a lot of information off of the echocardiogram.  You can expect him to see you and then immediately refer you over to the cardiovascular surgeon to have your valve replaced.  Due to your age the valve replacement will be a pig valve, this will be used so that you don’t have to be on blood thinners, which you would have to be on, if they put in a St. Jude metallic valve for instance.  Once your valve is replaced all of your symptoms should disappear.  You can expect the cardiologist to tell you he has to see you every 6 to 12 months and that you will have to have an echocardiogram done every year to assess the valve replacement’s function.  Any questions will this information?”
“No, I think you covered it.  So I just have to deal with this chest discomfort and feeling as though I can’t catch my breath until I see the cardiologist?  
“That’s right.  Because I think you’re going to be in the operating table before the week is out, I don’t want to be giving you anything for your blood pressure or pain because that will mask your symptoms, and the cardiologist needs to see how symptomatic you are.  He will use this information when he talks to the surgeon and this will be a deciding factor in how soon you get your valve replacement.”
“Do you understand?”
“Yeah, I think so.”
“Okay, well I wish you well.  You can let your employer know to expect you out of work for at least six weeks, if you need me to sign the paperwork for this, please bring it in.  Otherwise the cardiologist can do it.”

A few days later I received the echocardiogram results with the cardiologist’s encounter note.  The echocardiogram showed a bicuspid aortic valve (people have a tricuspid, or 3 leaflet aortic valve normally).  His mean pressure across the valve was 45, with an aortic valve area of 1 cm2.  His left atrium was mildly enlarged, his left ventricle was slightly enlarged but his ejection fraction was 60%. 

The cardiologist note showed the same physical exam findings as I found and his plan was to have the patient seen by the cardiac surgeon within 2 days to be scheduled for an urgent aortic valve replacement.

There are accepted guidelines put out by the American Heart Association/American College of Cardiology regarding when to replace a heart valve.  The latest guidelines were put together in 2014.  This patient was symptomatic, had little exercise tolerance, his echocardiogram showed severe aortic stenosis, he was determined to be a D1 (based on the guidelines) which necessitated his having his valve replaced. 

Due to his age (24) he will be facing several valve replacements over his lifetime.  With this in mind they don’t like having to put in a metallic valve replacement, they would rather use a pig valve initially so that the patient doesn’t have to be on daily blood thinners. 

Bicuspid valves are acquired while in utero, they are generally associated with a genetic mutation on chromosome 9.  They can be associated with other medical conditions such as Turner Syndrome, coarctation of the aorta, etc.  Patients typically are told to have their family members screened for the presence of their having a bicuspid valve.  Patients are also given instructions on prevention of endocarditis (infected heart valve). 

I didn’t hear anything else until two months later when the patient showed up on my clinic schedule.  I was happy to see him back. 

I knocked on the door and went in. 
“How do you feel?” I asked excitedly. 
“Oh, you don’t know how great it feels to be back to normal again.  I can do anything I want, all of my symptoms are gone.  The cardiologist doesn’t want to see me back for a year he said.  I went back to work two weeks ago.  I now have this ‘zipper’ as they say on my chest to remind me of what happened.” 
“Well, yeah for you.  I’m so glad you’re back to normal.”
“I just need you to check this on my surgical scar, I get just a speck of yellow drainage every day or so on the band aid I have over it.  It doesn’t hurt, it doesn’t bother me otherwise.”
“Well, these are generally called a ‘seroma’ which just means yellow colored fluid drainage.   Let me put some exam gloves on and I’ll look at it.”
After inspecting the very minimal ¼” opening over his surgical scar and ascertaining that the fluid was coming from just below the skin epidermis and didn’t extend down to his sternal wires as well as there not being any skin erythema (redness), nor any increased heat to the area, I knew it would continue to heal just fine. 
“What you have is what we call a seroma.  It’s not infected, it will continue to close up on its own.  Just keep it clean with soap and water every day when you take a shower and if you want to keep a band aid on it to absorb the one or two drops of yellow fluid it expresses daily that’s fine.  Just come back into clinic if it starts getting larger, or you start having a fever, or the skin around it starts becoming red and/or painful.  Otherwise you’re doing great.  I’m so happy for you.  Can I listen to your new valve?”
“Sure, go ahead.”
I put my stethoscope up to his anterior chest wall and listened.  His heart sounds were all totally normal, as if he had never had an abnormal congenitally acquired bicuspid valve. 


Tuesday, December 15, 2015

A Mother's Heart

You leave your doctor’s office with a heavy heart.  The news was not what you wanted, you were hoping you were finally pregnant, but no, it wasn’t to be this month.  When are you finally going to be able to hold your newborn in your arms? 
You dream about it.   Although your friends are supportive, they have toddlers and newborns of their own.  On the other hand, your arms remain empty.   Your heart yearns for what never seems to happen.  How much more can you take emotionally?  Then there are also the financial worries which you have to think about.
Your cellphone rings.  It’s your spouse, Ted.  He  is asking what happened.  You can hardly get it out that yet again, you’re not pregnant.  The procedure didn’t work, another chance at IVF down the drain.  Ted tries to calm you down, but your heart is almost inconsolable.   After a few minutes, time spent mostly with you in tears, you tell Ted you’ll talk to him that night when he gets home from work.
You get into your car to drive back to your work.  Before going in, you clean the makeup off your face which has become so tear stained that your mascara is smeared.  You put a ‘fake smile’ on your face and walk back into the office.  Telephone calls from sales people need your attention.  You pick up the phone receiver to get busy, at least your heart can be distracted temporarily. 
That night, Ted just holds you on the couch, and lets you cry until you’re out of tears.  The decision as to whether to try IVF for a third time, can wait until another day. 
That night, yet again, you dream about your newborn son plagues your sleep.  Sometimes you’re comforted by the dream, but tonight you’re not.  You awake the next morning with a wet pillow, you’ve been silently crying.
Ted is in the shower, you get up, put a robe on and walk into the kitchen to start the coffee maker.  Another day, maybe, just maybe, that magical day will come when you’re told by your doctor you are indeed pregnant.  You have to hold onto hope, hope in the process eventually working.  Hope that your arms won’t stay empty forever.  For the time being the door to the nursery will stay closed.  Its neutral colors, ready-made crib, infant blankets and neatly folded newborn clothes will just have to wait a little while longer. 
After his shower, Ted walks into the kitchen.  He gives you a tender hug and a kiss on your cheek.  He then reaches for his coffee mug and turns to face you.  “So, when do you want to try again, honey?  You decide, I’ll leave it up to you.”
“I’m scheduled to attend a conference next month.  So how about trying two months from now?”
“Fine, just tell me when to show up at your doctor’s office to do my donation.  I’ll leave it up to you to make the appointment.  I best get going, otherwise I’m going to be late for work.  Talk to you tonight.”


Thursday, January 2, 2014

A Hispanic Mother

A Hispanic Mother

I was working at a rural health clinic in the Eastern hills of Texas when one day a Hispanic female came into be seen.  She was in her 20s, and I found out that she was trying to help support her family of two young kids who’s husband was usually gone being a long haul truck driver.
I knocked on the exam room door and went into introduce myself to a new patient named Maria. 
“Hi, I’m Sharon, I’m the PA who works at this clinic.  How can I help you?”
Through her sister that she used as a Spanish translator, Maria responded, “I’ve got pain and numbness in both of my hands, it comes and goes and I need help.”
“Ok, what do you do day to day?”
“Well I take care of my two young children who are not in school yet, try to keep my house clean, feed my kids and then I work 40 hours a week over at the slaughter house which processes fresh chicken for our grocery stores.”
“What exactly do you do at the slaughter house?”
“I work the line, I take the sliced chicken and make the final cuts into it so that it ends up in nine pieces, which is then packaged and sent out.  So I use my hands all the time.”
“What about at home?”
“My hands are usually numb when I get home, so I end up trying to shake them awake several times every night, which doesn’t work.  By the time I go to bed I usually have pain in one or both of my hands and have to take some Tylenol so as to be able to sleep.”

Risk Factors for Carpel Tunnel Syndrome:
--repetitive actions of the hand or wrist
--sustained hand or arm positions

Usual Symptoms:
--dull, aching discomfort in the hand, wrist or forearm
--numbness in the hand, usually in the first three fingers, sometimes involves the fourth finger (which is the area that the median nerve serves)
--weakness in the hand, clumsiness with grasping objects
--sometimes it helps when the patient shakes their hands, this can sometimes decrease the tingling or pain temporarily

“Is there a spouse in the picture?”
“Yes, but he’s gone the majority of the time.  He works as a long haul truck driver.  He’s only home every few days every other week.”
“Hmm, okay.”
“So let me ask you do you take any medications on a regular basis or are you allergic to any medications?”
Through her translating sister, Maria responded, “No, to both of your questions.”
“Alright, have you had any prior surgeries?”
“Okay, well then let me take a look at your hands and we’ll go from there.”  With that I approached her sitting on the exam table and picked up her left hand and started to palpate it to assess whether she had any abnormal growths or potential hand fractures.  Then I asked her, “where exactly is your numbness and/or pain in your hands when it shows up?”
She pointed to her first three fingers on both hands and then the medial side (inside edge) of her wrists.
"Do you have any tingling or numbness above your wrists?”
“Every once in a while, I’ll get some tingling up my forearms that doesn’t last very long.”
“Ok. Let me see your other hand for a moment.”  Maria handed me her right hand and I palpated it to make sure there wasn’t any abnormality with it.  Once I had determined that she didn’t have any obvious problem with her hands I asked her to put her hands in a totally flexed position (do an internet search for Phalen's test to see pictures of this) that put pressure on her wrists.  I asked her to hold that position for 60 seconds.  Maria was only able to hold the position for 20 seconds before she said her hands had gone numb again. 
Then I asked Maria to hold out her hands and I tapped on her wrist (do an internet search for Tinel test, carpel tunnel syndrome to see how to do this maneuver).  Maria had tingling pain referred down into her hands when I did this, which is a positive test. 
So I knew that Maria had what is called ‘carpel tunnel syndrome’ in both of her hands. 
“Maria, you have what is called ‘carpel tunnel syndrome.  This means that you have tendon swelling in the carpel tunnel area that is pressing down on the nerve that serves your hand and gives it sensation and motor movement.  Your carpel tunnel is right here in the center of your wrist and it is a small round hole through which many of the tendons that start at your elbow come down into your hand.  This is also where the big nerve to your hand, called the median nerve comes down into your hand.  Your tendon(s) are swollen because of all of the repetitive work you do cutting and packaging chicken.”
“So, what do I do about it?” asked Maria.
“Well, usually we can treat it with some Motrin and your wearing wrist braces which will hold your hands/wrist in the most relaxed position for your hands.  You should notice an improvement in your symptoms after a few days, but definitely by the time you come back to see me in two weeks.”
So where do I get the wrist braces?”
“We’ve got them here in the clinic, I’ll go get them and show you how to wear them.”
With that I left the exam room and quickly found the wrist splints for both of her hands in our supply cabinet and came back in and showed her how to wear the splints.  I explained to her that she needed to wear them at night and take prescriptive dose Motrin three times a day.  I told her to make a return appointment to see me in two weeks, which she did. 
Two weeks later she returned to clinic and her symptoms were almost gone, so I advised her to continue to wear the splints at night and to stop the Motrin. 

When I saw Maria in clinic more than 10 years ago it was common practice to use a non-steroidal medication such as Motrin along with the wrist splints which keep the patient’s hands in the most relaxed position possible so as to allow the swelling of their tendon(s) coming through the carpel tunnel area to normalize in size again.  Nowadays there is evidence that Motrin or other non-steroids don’t work and are not recommended.  Instead what is recommended is to use the wrist splints along with systemic steroids, such as prednisone. 
If the wrist splints/prednisone doesn’t work then patients are referred over to a hand surgeon who goes into the carpel tunnel area surgically and enlarges the area of bone involved so that the median nerve, hand tendons have a larger area to travel through on their way to the patient’s hand. 

Monday, December 2, 2013

An Elderly Patient with a Fainting Spell

I was the primary care provider for an elderly 78 year old man who had been a patient in the clinic I worked in for several years.  Dan was very friendly and always appreciated my help.  He had made an urgent appointment to be seen that morning, so when I walked into see him early during my afternoon shift of patients, I knew something was up. 

“Sharon, I passed out yesterday morning at home.  I don’t remember what happened except I was feeling light-headed and then woke up on the floor of my bedroom.  Thankfully it’s carpeted, so I don’t have any nasty bruises anywhere.”

“Well, how long were you out and what did you do after you came to?”

“I don’t know how long I was out, probably for just a few seconds, I know it wasn’t longer than a minute.  I felt fine after I came to,  so I got up and finished getting ready for church.  My wife wasn’t happy with my not wanting to go to the emergency room, but I didn’t see any reason for it.  I finally told her I would come in here to be seen today, instead.”

“Okay.  Did anything else happen to you yesterday or this morning?”

“No, my wife and I went for our usual morning walk and then I’ve been home reading the newspaper and doing odds and ends.”

“Alright, well when people pass out like that it can mean they are having heart problems or problems with their thyroid for instance.  Is this the first time that you’ve passed out?”


Risk factors for syncope (fainting)

Vasovagal reactions (a episode of simple fainting due to the patient smelling a strange odor for instance, or other similar episodes)
Changes in blood pressure (what is called orthostatic hypotension, there has to be a difference of >20 systolic/10 diastolic) when the patient has his blood pressure taken in the 3 different positions: laying, sitting and standing.
Diurectic medication which can deplete the blood pressure

“Okay, well then let me take a look at your labs for a minute and re-check the medications you’re on.  I seem to recall that you’re not on any water pills.”

“I’m not.  I’m just on my blood pressure meds and a medication for my cholesterol.  That’s it.”

I flipped through his paper chart (the clinic was getting ready to change over to an electronic health records, but we were still using paper charts at that time).  I quickly found the section with his lab results listed.  His thyroid had just been tested within the past six months and it was normal.  I flipped over to his medication list to make sure that he wasn’t on a diurectic which could deplete his blood volume too much and cause him to have a fainting episode.  Dan was right he wasn’t on any diurectics.  He was on a beta blocker and a calcium channel blocker for his blood pressure and cardiac angina.  He was also on a statin drug to keep his cholesterol levels in the normal range, as well as a daily aspirin.  I also knew from having taking care of Dan in the past that he was not one to drink any alcohol, nor smoke.

“Dan, when was the last time that you saw your cardiologist?” 

“I see him every six months for my angina.  I’m supposed to see him again I think in two weeks.  I haven’t had any problems with my angina since he started me on, hmm what’s it called, it starts with an n, umm Norvasc, that’s it.”

“Norvasc is your calcium channel blocker, it’s used for blood pressure and cardiac angina and it works very well for both.”

“Okay, so why did I pass out yesterday morning?”

“Well, I think you passed out because of your heart, I think you might have problems with what’s called atrial fibrillation, which is a common condition in elderly patients like you who have a history of high blood pressure and cardiac angina.  But I’m not sure as of yet.  So let me do a physical exam, then I’ll have the medical assistant come back in and take your vitals signs while you’re laying down, sitting and standing.  That will tell me whether you are having any orthostatic changes that could have caused your fainting spells.  I’ll also have her do a ECG on you to see whether there is any difference in your cardiac rhythm.  If that’s negative, then I’ll have you move your appointment up with your cardiologist and he’ll have to finish up the work-up.  Okay?”

“Whatever.  I just need to be able to tell my wife that I’m being taken care of.” 

Risk Factors for Atrial Fibrillation

Cardiac surgery
Heart Failure
Hyperthyroidism (thyroid gland that is overactive)
Heart Attack
Myocarditis/Pericarditis (infection of the heart muscle or outer lining of the heart, the pericardium)
Acute lung disease
Cardiac arrhythmias (especially Wolff-Parkinson-White syndrome)
Symptoms of Atrial Fibrillation
Syncope (fainting)
Chest palpitations (feeling your heart beating)
Shortness of breath
Chest discomfort

So I proceeded to do his physical exam (which was negative and unchanged from prior visits) and then walked out of the exam room and asked the medical assistant to do his vitals in 3 positions (laying, sitting and standing).  After that I asked her to do a 12 lead electrocardiogram (ECG).  

After she had completed the ECG, she brought me his 3 sets of vitals signs (not enough of a change to classify him as having orthostatic hypotension).  His ECG showed the answer.  He had atrial fibrillation.  Prior to his QRS complex he didn’t have a clear P wave and had lots of waves before his ventricular contraction (QRS) would take place. 

I went in to talk with Dan and advise him that he needed to move up his appointment with his cardiologist. 

“Dan your ECG tells us what’s going on.  You have new onset atrial fibrillation.  As I handed him his ECG I pointed out the waves prior to the QRS complex.  Your cardiologist is going to have to do a 2 weeks study of your heart rhythms, where you will wear a constant monitor and then have you come back in to be seen by him.  From the 2 week study he’ll know how frequent your atrial fibrillation is and then he’ll decide on what to do about it.  He may also do another echocardiogram on you to assess any structural heart changes.  Something else he may also decide to do, is an acute cardioversion where he tries to shock your atrium out of it’s abnormal rhythm.  So with this in mind, I’m going to go call your cardiologist’s office and see whether we can get you into to be seen by him tomorrow.  I’ll be right back.”

I left his exam room to go out and call his cardiologist’s office.  I explained to the front desk person that I had a patient of Dr. Taylor in my office and that Dan needed to see him within the next 48 hours due to new onset atrial fibrillation.  As I expected she put me on hold to go talk to his nurse.  She came back and told me that he could see Dan on Wedsnesday morning at 8:30 am.  So I told her to go ahead and book the appointment and I went back into Dan to inform him of the appointment. 

“Dan, Dr. Taylor can see you on Wednesday morning at 8:30 am.  So make sure to keep this appointment.  Meanwhile I’ll fax over to his office the office note from today, your ECG and your thyroid results.  Any questions?”

“No, don’t think so.”

“Oh, and one more thing.  Seeing that you have an appointment so soon with Dr. Taylor I’m going to let him decide when to start you on Coumadin or Xarelto which will not allow the platelets to clump together.”


“Alright, well I wish you well and I’ll find out what happened with Dr. Taylor when we receive the consultation note back.”

Treatment of Atrial Fibrillation

Beta-blocker medications which decreases the pulse rate
Calcium channel blockers which also decrease the pulse rate
Cardioversion or ablation or maze surgery (which would only be done at the time of open heart surgery)
Anti-coagulation (either Coumadin or Xarelto or a similar agent) – this prevents the platelets from sticking together, forming a clot due to the upper atriums of the heart not beating correctly.  Patients are anti-coagulated based on their CHADS score (CHADS score goes from 0-6, any score above a 2 requires that the patient be anti-coagulated).  Patients receive 1 point for each of the following: hypertension, age > 75, diabetes, heart failure.  Two are given for previous stroke or transient ischemic attacks.
If the patient has sick sinus syndrome (sinus tachycardia followed by sinus bradycardia, i.e. pulse above 100, then pulse below 40) then they can be treated with a pacemaker which paces the heart as well as addresses the atrial fibrillation. 

A few days later via fax, I received the consult note from Dr. Taylor.  He had seen Dan, ordered a follow-up echocardiogram on him and decided against trying to cardiovert him, per patient request.  So instead he had started him on Xarelto and discontinued his aspirin.  Dan was set up to have two weeks of his cardiac rhythms monitored.  He was to return to the clinic in two weeks which had been his originally scheduled appointment time. 

Two weeks later I received another follow-up note from Dr. Taylor.  Dan had completed his two weeks of monitoring, as well as his echocardiogram.  There wasn’t any change in his echocardiogram except the occassional atrial fibrillation.   His two weeks of monitoring showed that Dan was having episodes of atrial fibrillation that lasted for several minutes and then quit, only to re-start again. 

So Dr. Taylor decided to increase his beta blocker in an effort to acquire heart rate control.  Dan was scheduled to return to see him in follow-up in another two weeks.  Eventually, Dan’s atrial fibrillation was controlled with the increase in his beta blocker and he was symptom free.   

Thursday, September 19, 2013

A Patient's View of Multiple Sclerosis

Recently, while working in a rural agricultural town in Colorado, I walked into see a patient, who had been coming to this particular family practice for 20 years.  She had initially been diagnosed with multiple sclerosis 25 years ago, when she and her husband had been living in Denver.  For the first few years she had been seen at the multiple sclerosis center, based out of one of the community hospitals in Denver.  It had a large referral base from six surrounding states. 
Georgia told me that she was very happy with the care she received there from a physician who was very compassionate and willing to work with her.  When he retired, she saw his colleague, but didn’t get along with him, so she quit going, and hence hadn’t received care for her MS since.
Then her husband, a dentist, decided to accept a position in this rural, agricultural town that I was working in. During this time, Georgia had learned to handle her multiple sclerosis relapses through mental determination, rest, tylenol/motrin and lots of physical therapy.  She knew that it would eventually go away, it always had in the past.  But with each episode (thankfully they only came along every few years) she was left with a little more pain and disability to chronically live with. 

Risk Factors:

--genetic predisposition among Northern European Caucasians
--increased risk with increasing latitutde, which implies a potential environmental trigger
--Vitamin D deficiency
1/400,000 people affected, femaile to male ration of 3:1.
--usual presentation between the ages of 20-40.

Signs/Symptoms of Multiple Sclerosis:

optic neuritis (pain in the eye with loss of vision)
myelitis (inflammation of the spinal cord with sensory and/or motor loss below the affected area)
muscle spasticity/pain
electric shock sensation provoked by head/neck movement
changes in bladder and bowel function

Then there was the day that I saw her in clinic.  Georgia was complaining of non-stop diarrhea, low back pain which almost had her immobilized.  She also had generalized abdominal pain with referred pain down both legs.  To say it mildly, she was miserable. 
I ended up working up her diarrhea/abdominal pain and got a MRI of her back.  Her diarrhea was caused by her MS (no surprise there), as was her lower back pain/abdominal pain which the MRI revealed was due to partial myelitis (another sign of active MS).  I gave Georgia some lomotil to control her diarrhea, and Cymbalta to help control her pain.  But that still left her with her MS, in its acute flare-up.

Diagnosing MS:

Done by doing a MRI of the brain which needs to show white matter disease (the brain, typically black on the MRI shows white spots within it)

Over the course of working her up, I ended up seeing her three times in a two weeks.  Each time I saw Georgia I continued to try to counsel her that she needed to return to Denver to be seen by a MS specialist.  Georgia’s memories of the last MS specialist she had seen were still so strong that she would barely even discuss this with me.  I kept trying.  I gave her loads of updated information on MS, the newer treatment modalities available and what she could expect from them.  She brought them home for both her husband and her to read.  She later told me that her husband had devoured the information, and had even looked some additional information up on the internet.

It wasn’t until I kept reiterrating (over the three clinic appointments) my having previously worked alongside Dr. James (pseudonym), a MS specialist who saw patients at the medical school in Denver, how compassionate he was, how willing he was to work with patients, how caring, kind and friendly he was with all of his MS patients, that she finally relented and gave me permission to make her an appointment with him. 

Clinical Course of MS:

MS can take one of three pattersn: relapsing-remitting (my patient), secondary prgoressive or primary progressive. 

Treatments Available:

--interferon based (interferon beta)
--monoclonal antibody (natalizumab)
--anthracycline based (mitoxantrone)
--glatiramer (copolymer of four amino acids)
--fingolimod (phosphate modulator that restricts activated lymphocytes)
I quickly called and made the referral.  I asked the receptionist to make it an urgent appointment due to the patient’s symptoms.  Thankfully, there was a cancellation and my patient was able to take this appointment, two weeks away.  She would have to be in a car for two hours driving back to Denver to see him, but I knew it would be worth it.  The next day she called in to leave me a message.  Her husband was so estactic that she had finally decided to pursue treatment again for her MS, that he had taken the day off from his dental practice and was going to take her up to Denver himself. 
Fortunately I was still working at this clinic when she showed up six weeks later.  She hobbled in, using a cane, but had the biggest grin on her face you would ever see.  She told the clinic secretary that she had to talk to me. 
I was just coming out of one of the exam rooms when I saw her at the front desk.  I motioned for her to come on back into one of the empty exam rooms, which she did. 
“So, tell me I want to know what Dr. James said.”
With tears running down her cheeks, “Sharon, you were so right.  He is the kindest, most compassionate physician I have ever met.  My husband just thought the world of him.  He’s started me on a oral medication, Fingolimod which is working wonders for me.  I saw him two weeks ago for follow-up and I’m supposed to go back in two more weeks for another follow-up.  The medicine is working so well for me that I’m back doing physical therapy and am able to walk short distances again.  I can’t thank you enough.”
“Oh, I’m so glad you went, because he was exactly what you needed!  I’m happy that you finally found someone you can work with.”
“So am I, so am I!”

Friday, July 5, 2013

A Sports Injury

I went into see a teen-ager who had suffered an acute injury at school.  Amanda was a patient I was familiar with, she was very sports orientated, usually ending up playing at least two sports per school year.  She was known as the best volleyball spiker on her team and during the spring season she was involved in cross country running.  I could well imagine her bedroom wall.  It was most likely decorated with all of the local, regional and state awards she had won from her sports endeavors.  She was very smart, tall and lanky.  She was the type of teen-ager that any parent would be proud of, responsible, mature and focused on her school studies. 
“Hey, Amanda, what’s going on?”
“Sharon, I was getting ready to spike the volleyball last night during our tournament when I hit the ball the wrong way and all of the sudden I had this intense pain in my hand and wrist.  I tried to shake it off, but that didn’t work.  So I had my coach take me out of the game for the rest of the period and sat on the sidelines with an ice pack on it.  That helped, I also iced it last night at home.  But it still hurts today and I can’t make a fist with my hand without pain here in my arm.”
“Okay, well let me take a look at your arm.  You’re right handed aren’t you?”
“Okay, well then let’s start with your showing me whether you can rotate your right arm back and forth.”
“I can do that, it hurts a little bit over my lower arm though.”
“Okay, well now can you fully extend your hand and then make a fist out of it?”
“I can extend my fingers, but I can’t make a fist, my third finger doesn’t want to cooperate.  It really hurts over the top part of my hand when I do that and it causes pain down my lower arm up to my elbow when I do it.”
“Okay, then try bending your hand back and forth.  Does that hurt?”
“Yeah, when I try to bend my hand in towards my wrist.  The same areas hurt.”
“Okay, when I tug on your third finger does that hurt?”
“Yeah, that hurts all the way down to my elbow.”
“Okay, well it looks as though you have tendonitis, you have sprained the tendon that serves your third finger.  I think it happened when you went for the ball and the ball forced your thrid finger backwards.  Your tendon to the third finger goes from the tip through your wrist and onto the elbow where it hooks into your radial bone.  It’s going to take about four weeks for your tendon to heal.  So if there is any more tournaments to be played with your volleyball team, I think that’s off the table.  I’m going to put your hand, wrist and lower arm into an ace wrap to help support it.  I want you to keep putting ice on your hand/wrist, 15 minutes on, 15 minutes off until tomorrow.  Then you can start applying heat, 15 minutes on, 15 minutes off.  You’ll find that if you keep your hand/wrist in the ace wrap it will help with the discomfort and prevent you from moving your finger.  I want you to take some motrin every day, try taking two over the counter strength tablets three times a day for the pain.  I also want you to slowly extend and flex your right hand several times a day to help slowly stretch out the tendon, which will help loosen it up.   It should take about four weeks before the tendon is totally healed, afterwhich you should be able to go back to your regular activities.  If it’s not healed by then, please come back in and be seen.  Any questions?”
“No, I don’t think so.   Although, how am I supposed to write in school?”
“Hmm, I think you’ll have to ask your teachers how they want to handle that.  It’s going to be cumbersome at best.   By the way how did your team do last night?”
“We won.  So we’re going onto the district tournament next weekend.”
“Oh, dear , they’re going to be playing next weekend without their best spiker.  Sorry about that.”
“Yeah, I know, bummers!”
“Alright, well there’s always next year, Amanda.  Do well, come back and see me if your arm doesn’t feel totally normal in about a month, okay?”

I didn’t hear back from Amanda again through the rest of her school year.  She came in during the summer for her sports physical and told me that her tendonitis had healed up nicely and she was able to use her arm without any pain after about 3 weeks.  She had just finished school for the year and told me she had won the state cross country championship. 

Thursday, July 4, 2013

An Infection Way Too Common in Women

I walked into the exam room to see a patient I was familiar with.  I had taken care of her kids many times before when they had strep throat, upper respiratory infections and when she had problems with her sinus allergies. 
“Hi, Liz, what brings you in?”
“Oh, Sharon, I think I’ve got one of my bladder infections back again.  I woke up yesterday morning with that initial feeling that I knew something was wrong.  It burned to urinate.  So I started drinking my cranberry juice yesterday and that helped some, but my symptoms are worse today.  I had to get up and go use the restroom several times during the night, even though I had very little urine to get rid of.”
“Well, Liz, I have yet to come across a woman who didn’t know that she had an urinary tract infection.  Women are very good about picking up these types of infections.  So did you give the medical assistant a sample of your urine before you came in this room?”
“Yeah, she had me leave a sample in the lab.”
“Great.  Have you had any back pain, fevers, nausea or vomiting?”
“Well this morning it began to hurt on my left side of my back.  Nothing else.”
“Okay.  What antibiotic do you typically take that works for your urinary tract infection?”
“I think it’s called Cipro, I know it’s a white pill I take twice a day, and it works real well for me.”
“Well, Cipro is one of the antibiotics we use, that’s for sure.  How frequently do you get these infections?”
“Maybe once a year, no more than that.”
“Okay, well then you don’t need a prescription for antibiotics to use at home when you’re symptoms start up.  We usually give patients their own antibiotic prescriptions to use if they have a history of having numerous urinary tract infections  (UTI) during the past year.   I note you don’t have any drug allergies and besides problems with seasonal allergies you don’t have any other problems.  Are you taking your Allegra right now?”
“Yeah, I started taking it about a week ago  when the trees started blooming.”
“Ok, well  then let me take a look at you by listening to your chest, heart and feel your abdomen.  Then I’ll go find out what your urine sample shows.”
Liz’s physical exam was normal except for mild tenderness over  her lower abdomen in the midline (corresponds to where her bladder is located) and she did have some costovertebral tenderness on the left side (back pain which corresponds to urinary tract infections).

Risk factors

female > male
urinary tract malformation
hospitalized patients (especially those who have foley catheters in)
presence of renal stones
immunocompromised patient (kidney transplant)
diabetic patient
sicke cell disease
polycystic kidney disease


lower midline pelvic discomfort/pain (over bladder)
pain over lateral posterior back (either right or left, or both sides)
burning with urination
blood in urine
protein in urine
bacteria +
leucocyte esterase + (on urinalysis), this shows the presence of white blood cells

“Liz, I’ll be right back, I’m going to go see what your urine results are.”
I left the exam room  and walked over to the lab station.  The tech gave me her urinalysis results which showed what I expected a typical UTI to show, she had positive nitrates, leucocyte esterase, bacteria and a small amount of protein.    I walked back into the exam room and advised Liz of her results. 
“Liz, I’m going to give you Cipro to take for the next 7 days twice a day to make sure the infection is totally cleared up.  I’ll send off your urine to have a culture done on it just to make sure that you’re not infected with an unusual  bacteria or that the bacteria is not resistent to the Cipro.  Go ahead and acidify your urine by drinking lots of cranberry juice, and you can pick up some ‘Azo’ over the counter which will help with your urge to urinate and well as address your burning sensation. It will turn your urine orange so don’t be concerned about that. You should only need to take the ‘Azo’ for 2  days or so, then stop it.”
With that I handed her a prescription for her antibiotics. 
“Thanks,  for your help.”
“No problem.  Now I hope you enjoy your weekend.
“I will.”


urinalysis shows bacteria, leucocyte esterase, +nitrates, ? protein, ?blood
Culture (if done) will reveal 80-85% E. coli, a gram negative bacteria
Treatment consists of antibiotics for 3-10 days.  The length of time is decided upon by the clinician and the extent of symptoms the patient has.  Many women can be treated for 3 days if the clinician believes it is an uncomplicated infection (i.e. bladder infection only).  If the clinician believes the bacteria has gone up into the kidneys then the patient needs to be treated for 7-10 days. 
Kidney involvement can be suspected if the patient has positive pain over their back sides on the lateral aspects, nauea/vomiting and/or fevers.
Typical antibiotics can include: Macrobid, Cipro, Bactrim DS, or a Cephalosporin.