Friday, December 30, 2011

A Patient with a Productive Cough

I was working in an urgent care setting when a 40ish African-American normal weight patient came into be seen.  After she was checked in by the medical assistant I went into see her.  I noticed that her vital signs showed she had a normal pulse, her respirations were 20 (within normal range), and a normal blood pressure. 
“Hi, my name is Sharon.  I’m a physician assistant.  How can I help you?”
“Hi.  I’m Carla and I can’t quit coughing, it’s keeping me up at night.”  She was barely able to get that out of her mouth without being interrupted by several hacking coughs.  She used a kleenex to catch her productive green sputum.  Afterwhich she proceeded to catch her breath.
“I see.  How long have you been sick?  And, do you have any fevers?”
“I’ve been sick for the past 4-5 days.  I’ve had chills and sweats, is that what you mean??”
“That will do.  What about sore throat, or sinus drainage?”
“My throat just feels raw from all of the coughing I think.  But my nose won’t stop running, green crude  just drains from it, every time I blow my nose.  I just feel crappy, I’m so tired I just want to sleep.”
“Okay, any other symptoms?”
“No, I think that’s it.”
“No, wait,” said Carla.  “It hurts here when I cough.”  As she spoke these words she pointed to her right front chest wall.
“Any alcohol or smoking use?”
“No, I don’t smoke and I only have an occassional drink of wine around the holidays.”
“Okay, well how about any medications you take on a regular basis?”
“I’m just on a blood pressure medication for my hypertension, that’s it.”
“Anything else in your past medical history, such as asthma, or problems with acid reflux?”
“No, nothing else.”  As she spoke she had another round of hacking coughs. 
“Alright, well let me take a look at you , listen to your chest and all, then I’ll decide if you need a chest x-ray or not.”

Patients typically present with various signs and symptoms that are characteristic of pneumonia.  These can include:
1)      sinus drainage
2)      productive or non-productive cough
3)      fevers or chills/sweats
4)      fatigue
5)      a rapid heart rate
6)      rapid breathing

There are various different host factors which can contribute to a patient coming down with pneumonia.  They include:
1)      smoking
2)      alterations in the level of consciousness
3)      alcohol
4)      low oxygen levels
5)      breathing in toxic chemicals
6)      malnutrition
7)      being immunosuppressed, i.e. on cancer chemotherapy, or taking steroids
8)      elderly > 65 yrears of age
9)      cystic fibrosis patient
10)   having COPD, chronic obstructive pulmonary disease
11)   lung cancer

After looking into Carla’s ears, nose, throat, feeling her neck glands and then listening to her chest and heart sounds, she had some very definitive positive findings.  Her sinus’ were swollen and red, her throat was red, she had some slightly enlarged lymph nodes in her neck, but most striking were the fine crackles I heard at the base of her right lung, on her front and backside.  When I listened over the one place that she said it hurt when she coughed I also heard a characteristic ‘squek’ sound (typical sound of a pleural rub, or pleurisy).
“Okay, well Carla it looks as though you have what is called community acquired pneumonia.  You also have a pleural rub, or what we call pleurisy.  So I’m going to send you next door to have an chest x-ray done and once that’s done, then come back over here to me.  Here’s your radiology request, I’ll see you back in a little while.”
As Carla slid off of the exam table she proceeded to let out several more hacking coughs.  She picked up her purse and slowly walked next door.

It is not unusual for patients with pneumonia to have co-existing pleurisy.  Pleurisy just means that the lining of the lung is inflammed from the local infection.  The best way to address this pain/discomfort is for the patient to take non-steroidal anti-inflammatory medications for two weeks, at which point the pleurisy will be totally resolved.  The use of the non-steroidal will also address their fevers/chills/sweats.

We look at patients with five questions in mind to determine whether they need to be hospitalized for their pneumonia.  These five questions we ask ourselves consists of:
1)      is the patient confused
2)      what is the patient’s urea (a part of the patient’s kidney function).  Given the patient had a normal blood pressure coming into the clinic and was on appropriate blood pressure medication, I would expect her kidney function to be normal.
3)      what is the patient’s respirations, are they higher than normal?
4)      what is the patient’s blood pressure, is it below normal?
5)      are they over the age of 65?
Each question is given 1 point and if the patient has 2 points they need to be admitted to the hospital, and if their total points are 3 or highter they could need to be admitted to an intensive care unit of the hospital.

About thirty minutes later, Carla showed back up with her chest x-ray in her hand.
“Come back on into the exam room, Carla, I’ll take your chest x-ray, and I’ll be right back.”  I walked down the hall and slide the x-ray into the lighted reader.  As I expected Carla had a clouded look to her right lower lung (white opacity) which was characteristic of pneumonia.   I walked back down the hall and walked into the exam room where Carla was sitting. 
“Okay, Carla, you chest x-ray showed what I expected, you have pneumonia of your right lower lung.  So I’m going to start you on Biaxin, which is an antibiotic that I need you to take twice a day.  But before I do this, I need to make sure that you are not allergic to any drugs, are you?”
“No, I’m not allergic to anything.”
“Okay, well then here’s your prescription for the Biaxin.  I want you to take the Biaxin for the next 10 days.  I also want you to take some over the counter Aleve, which also goes by the name of Naprosyn, two tablets twice a day for the next two weeks.  This will help take care of the pleurisy you have, which is caused by the inflammation from your pneumonia.  Does that make sense?”
“Okay, well then for your cough and sinus drainage I want you to take some over the counter Mucinex D for your sinus’ and then some plain robitussin pearls, which is just cough medicine without anything else in it.  You can also take Delsym if you can’t find the robitussin pearls.  Don’t take anything else for your fevers/sweats/chills, the Naprosyn will address these symptoms.  So no Tylenol or Motrin.  Drink plenty of fluids and you should start feeling better in a few days.  I need you to come back in and be seen by us here in the urgent care clinic in 10 days.  We need to make sure that your symptoms are almost gone and your physical exam shows that your pneumonia has resolved.  Any questions?”
“No, I think I have it.”
“Okay, well then I’ll see you back in 10 days.  I wish you well.”

The typical bacteria/virus’ that can cause pneumonia are varied.  They include:
1)      Strep pneumoniae
2)      H. flu
3)      Staph. aureaus
4)      gram negative bacilli
5)      Legionella
6)      Mycoplasma
7)      Chlamydia pneumoniae
8)      various virus, usually flu virus
9)      misc. agents: tularemia, anthrax

With the above pathogens in mind, we treat patients with pneumonia by giving them a broad spectrum antibiotic.  Typically this is a macrolide (of which Biaxin is one, the other one is Zithromax), or we use doxycycline.  If we suspect that they patient may have a resistant Strep pneumoniae then we can combine the macrolide with a beta lactam antibiotic such as Augmentin. 

About 10-11 days later, Carla showed back up at the urgent care clinic.  She was checked in and I went into see her.  She was still a little fatigued, but her cough, sinus drainage and lung findings were all back to normal, which made me happy.  I was glad that her pneumonia had resolved on the antibiotics I had prescribed her.  I dismissed Carla from the clinic with a ‘high five’ hand slap.  

Monday, December 19, 2011

A Patient with Diabetic Neuropathy

I was seeing patients in my hepatitis clinic when I went into see a new patient who had been referred over for possible treatment of his viral hepatitis C infection.  As I was going over his past medical history he mentioned that he had recently noticed some tingling in his feet  with some loss of feeling.  The patient’s name was John, he was in his late 40s, had a slightly balding head, and was probably about 20-30 pounds overweight.  He was a married hispanic, 5’6” in height.   And he was probably anxious, his hands didn’t stop fidgeting the whole time I was seeing him.
“Well, John I see a part of your past medical history is that you have type two diabetes.  How long have you had it?”
“About 5 years.”
“Have you kept your blood sugars in the normal range as well  as your HgbA1c levels around the 7 range?”
“No, not really.  I tried to stay on the diet my primary care physician gave me, but I like my Mexican food too much.  I know it’s not good for you, but it’s what I like to eat.  My primary care physician has told me that he’s going to start me on insulin injections if I don’t start working on getting my extra weight off with exercise and eating right.  If he puts me on insulin, then that will be three medications that I will have to take for my diabetes.  That’s not good, is it?”
“No, it doesn’t sound like it is.  But you’re having tingling in your feet with some numbness is probably related to your diabetes.  But because it can also be related to your hepatitis C infection, I’ll have to send you over to the neurology clinic and have them assess you for the cause of your problem with your feet.  Meanwhile, you do indeed need to work on those ideas that your primary care physician gave you regarding how to control your diabetes.  If this is indeed diabetic neuropathy starting up in your feet, the better your control your diabetes the better your neuropathy can get.  Okay?”
“I’ll try.” 
“Okay, well then let me finish up with your history, I’ll do a quick exam, check the size of your liver, things like that and then I’m going to send you off for blood work and an ultrasound of your liver.”
With that, I finished taking his history and doing his physical exam.  After that I sent him off for all of the blood work that would be needed as well as his ultrasound.  I also handed him the referral form so he could get into to see the neurology service. 

Diabetes can cause nerve damage and it can occur in several different areas.  Patients can have gastric neuropathy, where they have problems with rhythmic passage of food through the GI tract, or they can have nerve problems with their GU tract (kidney, urinary bladder, erectile dysfunction).  They also can have problems with nerve damage to their peripheral nerves (legs, feet, hands). 

Sometimes diabetic neuropathy can just show up as a loss of feeling with no parasthesias (i.e. tingling, burning or pain associated with it).  But if the patient has parasthesias, then they need to be treated medically. 

Both type 1 diabetics (what used to be called juvenile diabetes) and type 2 diabetics (which used to be called adult onset diabetes) can have neuropathy.  In the type 2 patients they can have neuropathy when they are initially diagnosed with diabetes.  With the type 1 diabetic, their neuroapthy problems can begin as soon as five years into their disease. 

I saw John back in the clinic several weeks later after he had gotten all of his lab work done, had his ultrasound and had been seen by the neurology service.  I read the neurology note and even though they were going to see him back in clinic they believed his peripheral neuropathy was due to his diabetes and not his chronic hepatitis C disease.  They wrote he was supposed to get his diabetes under better control and they wanted him seen by his primary care again to address this.  He was also supposed to see the podiatrist to teach him how to do appropriate foot care for his diabetes. 

I knocked on the exam room door and went in.  John was sitting on the exam room table, fidgeting with his hands again.  “Hi, John, how are you?”
“I’m okay, I guess. I’m trying to address my diabetes like the neurology service wants me to do.  But it’s not easy.”
“That’s understandable.  Anything that is worth doing, can sometimes be hard.  But keep it up, don’t give up with your addressing your diabetes every day.  It will pay off.”
“I’ll keep trying.”
“Good, I have your lab results and your ultrasound.  If you come over her to the computer I can show you the results and explain them to you.   So why don’t you sit right here, and I’ll go through them.”
I explained all of John’s test results to him and after answering his questions, I set him up for a liver biopsy. 
He returned after his liver biopsy and I noticed he had seen his primary care regarding his diabetic care and was doing better with his daily blood sugars.  He had also seen neurology for his follow-up appointment and their testing had shown his neuropathy was indeed due to his diabetes.  The neurology service had started him on Elavil to take at night to help with his foot tingling.  He had an appointment to see them in follow-up so as to make sure that the medication was working. 
I knocked on the exam room door and went into see John again.  As usual, he was fidgeting again sitting on the exam room table.  He always reminded me of a person who didn’t like to be seen for any medical needs.  Being a patient probably made him uncomfortable, no doubt.

Treatment for diabetic neuropathy consists of having the patient acquire better control of their diabetes, this means they need to have their daily blood sugars as close to the normal range as possible, they need to have their HgbA1c  levels below 7.0 (which is a test for chronic control of diabetes).  Patients who have neuropathy also need to make sure they are doing appropriate foot care, i.e. they are looking at their feet every day, making sure they don’t have any ulcers, or blisters.  The third part of medical therapy for diabetic neuropathy is controlling the parasthesias.  Patients who are having the tingling, burning or pain with their neuropathy need to be treated with medication.  They can be treated with anti-depressants, anti-seizure medications, or sometimes even pain medications. 

“Hi, John,” I said.  I have your liver biopsy results here.  You don’t have a lot of damage to your liver, you’re a stage two, (liver biopsies go from stage 0-4, 4 being a cirrhotic liver, or end stage liver) so if you want to wait until after you get your diabetic neuropathy under control , you could do it without a problem.  In fact you probably won’t need treatment for your hepatitis C for several years.  By then there will probably be new medications out for it which will work better.  Maybe the new medications coming out will not be interferon based, I don’t know at this point.  But if interferon is not a part of the treatment program, that would be good for you, seeing that one of the possible side effects to interferon is parasthesia, which is very similar to the tingling going on in your feet right now.”
I noticed after I told him he could wait to receive his treatment for his hepatitis C, that his fidgeting hands calmed down. 
“Really, I don’t need to start right now?” John asked.
“That’s what I said, your liver biopsy shows only a limited amount of damage to it, so you don’t have to start right away.  You can wait a few years.  That will give you time to get your diabetes under control and hopefully your diabetic neuropathy will be better with your being on medications for it.  So is that okay with you?”
With this news, John became somewhat animated.  “Yeah, that’s sounds great!  Thanks.”
“Okay, well for those patients who are wanting to wait, I see them once a year just to get their labs re-drawn, viral load re-done and let you know of any changes in the treatment regimens.  Is that okay?”
“Yeah, that’s okay with me.” John said rather excitedly.
“Alright, well then I’ll see you a year from now.” 

Wednesday, December 14, 2011

Those Holiday Blues

The holidays are upon us and for many people this means having to deal with family members with whom they don’t get along, eating too much, not exercising, being stressed out at work, not taking time to relax, and incurring too many bills from buying presents the budget wouldn’t allow. 

So how do we de-stress from the holidays and manage to get through to January in one piece?  Here’s some helpful hints to keep you emotionally healthy:

1)      Recognize your patterns of behavior and if you’ve been tempted before to spend too much, set up a budget plan for your holiday spending, and then stick to it. 
2)      If you’ve previously had a hard time being around certain family members who might be critical or judgmental of you, limit your exposure to them and if you can keep your distance from them. 
3)      If you happen to have problems with SAD during the winter (i.e. seasonal affective disorder) then make sure that you are outside for at least 30 minutes a day soaking up the sunrays.  This will help you increase your mood.  If you have SAD make sure to exercise, at least 30 minutes of walking every day.  Get your sleep, 8 hours a night.  Limit your alcohol intake.
4)      Remember at the holiday dinner, it’s not a competition as to who makes the best pie, or cooks the most delicious turkey.   The holiday dinner is supposed to be fun, filled with great conversation and laughter.  Who’s going to remember who made the best pie or the most delicious turkey years from  now?  But I bet you will remember the cameraderie you shared, the joy you had. 
5)      If you’re going to be at a relative’s house, plan for what the kids are going to do, bring along games for them, or set aside a room for them to play in away from all of the adults.  Hence they won’t be underfoot or in the way. 
6)      Don’t set yourself up for defeat.  If you’re previous holidays have been only so-so, don’t set yourself up with expectations that this holiday season you’re going to go and do so and so and also so and so.  If you think this way and then it doesn’t happen, you’re only setting yourself up for an emotional let down.   Be realistic in your expectations of what is going to happen this holiday season.
7)      Keep up with your exercise, stay on your regular schedule regarding it.  Exercise not only helps to lift your mood, but it also helps to address those extra calories we tend to eat over the holidays. 
8)      If your kids tend to get hyper when they have eaten a lot of sugar, limit their sugar intake. 
9)      Eat balanced meals during the holidays.  You can have a bite of cake or a small piece of pie, but try to eat a balanced diet during the day so that your own blood sugar levels stay level and hence you don’t become moody or overly tired.
10)   Lastly, set yourself a goal for  next year and use this holiday season to begin working at it, whether that is to lose weight, go back to school, learn a new skills, whatever.  You’ll feel good about working towards a goal you want and by the time the New Year rolls around you would have already started working on your New Year’s resolution.  By starting early on it, you’re more likely to follow through to completion with it. 

I hope you enjoy your holidays with your family members. 

Again, thanks for reading, sharon

Tuesday, December 6, 2011

Questions to Ask Prior to Having Cosmetic or Plastic Surgery Done

Okay, I know some of you are thinking of having plastic surgery done, or cosmetic surgery done to enhance your looks, so I came across some information for you, which should be helpful in your decision to have the procedure done. 

Here is a list of ten questions to ask yourself prior to having any cosmetic procedure done:

1)      where is the procedure being done, is is at the provider’s home residence, or  a back alley somewhere?  If so, this should be a ‘red flag’ to not have it done.
2)      is the provider who’s doing the procedure a physician who is board certified in either dermatology or plastic/reconstructive surgery?  Ask to see their board certification, if need be.  If the physician is not in one of these two specialties, don’t have the procedure done.
3)      how many of these procedures has the physician done per year, what is their complication rate?
4)      ask to see pre and post op pictures of other patients they have done
5)      make sure to have the physician explain exactly how they are going to do the surgical procedure and when you can expect to have the final results visible, will it be 6 weeks, 3 months or 6 months?
6)      acquire recommendations from your friends, who did they go to and what were their results?
7)      do your homework, look up the physicians on the internet.  There are now website that will grade a physician, you can also call your state medical board and ask them whether the physician has anything against their license. 
8)      If you come across a webiste that is fancy with lots of videos, or you see a TV ad, or gives a 1-800 number or 2 for 1 procedures, DO NOT go to this facility to have your procedure done.  All of these tactics are ‘red flags’ that they are not reputable or know what they are doing.
9)      make sure the physician is associated with a reputable hospital and they have been credentialed by this hospital to be on staff.  This will tell you that the hospital has already looked into the physician’s credentials and has verified them.  The hospital will also only allow the physician to do procedures that they are qualified to do, which is another factor in your favor.
10)   lastly, listen to your intuition, if your gut says something is wrong, then something is wrong and don’t have it done by the physician you are thinking of doing your procedure.  Start your search again.  Having any cosmetic procedure is not worth having a botched procedure.  You need to make sure it is done correctly the first time around.    

So, for those of you who are thinking of creating a ‘new you’ for the New Year, please remember the 10 questions above prior to having your procedure done.  I wish all of my readers the best!

Thursday, December 1, 2011

Some Personal Reflections

I just finished reading a book by Dr. Jerome Groopman and his wife, Dr. Pamela Hartzband.  The book is titled, Your Medical Mind.  I would recommend the book if you are wanting to understand how and why you (or someone close to you) make the medical decisions you do. 

Dr. Groopman/Hartzband review the various decisions that patients make and what makes them decide on a particular course of action.  They review the four basic options of medical decision making, believers, doubters, minimalist (what they also called the naturalist view) and maximalist.  In the book they interview several patients and delve into what made that patient either a minimalist, maximalist, etc. 

The two physicians also interview patients about what happened after they made their decisions regarding surgical options, taking medications, etc.  They asked them whether they had any regrets, would they have changed their minds? 

This book was an interesting read for me because it showed that for some patients their medical decisions regarding their own healthcare is a fluid one, one day they can say ‘this is what they want,’ another month down the road their decision has changed and they want something else.  Just as patients do not stay stationary in time, nor does medicine. 

Things change with patients, family scenarios change with patients, financial situations change with patients.  As patients change, so does medicine.  Not only are their new treatments available, but patient-physician relationships change (hopefully becoming clearer with the physician acquiring a more focused understanding of what motivates the patient to work towards their own better health).

Medicine will remain an art.  It is an art (using wisdom, understanding, compassion) on the part of the physician or clinician as they see each patient.  Yes, we as clinicians learn the science of medicine (or what is also called ‘evidence based medicine) during our training days going through our PA programs or medical school.    But then we spent the rest of our working days seeing patients and learning how to apply the ‘art of medicine’ to each and every patient we see. 

A part of our applying the ‘art of medicine’ is learning what motivates patients to make the medical decisions they do.  Then it is up to us to help them make the most of that decision and achieve the best healthcare they can. 

I have spent years working alongside numerous physician mentors.  I have learned an incredible amount of wisdom, undersanding and compassion from them.  I remember one physician mentor who had been my opthalmologist as I grew up.  He told me ‘ask, ask, ask again until you understand everything you need to know.  Don’t be afraid to ask.’  And with that sage advice I left to drive south to Texas to begin my PA training.  I’ve never forgotten what he said, as I’ve applied it numerous times during my working in medicine. 

I am honored to work in medicine, honored that patients trust me, confide in me and believe in my capabilities as a medical provider.  I will never stop growing and learning medicine.   I’m challenged by it every day. 

Wednesday, November 30, 2011

Thank you for reading my blog

To all my readers:

Thank you for reading my blog of real patient stories.  I hope you enjoy the stories, that you have learned something from them and can take away from them how to be a better patient advocate (for yourself or for someone else) and be more involved in your own patient care.
Please do leave any comments you have, anything you would like to learn about, or anything you would like to see changed on the blog that would make it more appealing to you or to other readers.

Thanks again for coming alongside and reading and learning (I hope),

A Reluctant Patient

I walked into clinic one day and found out I had a new African-American patient to see, he had been sent by his primary care physician for what they believed was a problem with alcoholism.  But the consult mentioned that his liver enzymes were not in line with that, so they wanted him seen by the hepatology clinic. 
I knocked on the exam door and walked into see my new patient, whom I’ll name, Conrad.  He was a tall male, 6 foot, somewhat obese, wearing worn jeans, work boots, and a t-shirt that had seen better days. 
“Hi, Conrad, I’m Sharon and I’m a physician assistant in the hepatology clinic.  How can I help you today?”
“I don’t know.  My primary care physician sent me here, something to do with my liver.” 
“Well your consult says that they weren’t sure whether your problems with your liver was due to your drinking alcohol or whether it was due to something else.  Does that ring a bell with you?” 
“Yeah, something like that.”
“Alright, well then why don’t we start with how much do you drink on a daily basis?”
“Umm, one or two drinks a day.”
“No more, are you sure?”
“Yeah, I’m sure.  It’s usually just a beer, sometimes two beers a night after work and that’s it.”
“Okay, I’ll take your word for it.  How long have you had problems with your liver?”
“I don’t know.”
“Okay, well then let’s start with your medical history, what medications do you take and for what reasons?”
“I’m a diabetic, so I take glyburide and metformin twice a day.  I also have high blood pressure so I’m on lisinopril and some sort of thiazide, I think.  It’s a water pill.”
“Okay, well that sounds like you’re on hydrochlorothiazide, does that ring a bell for you?”
“Yeah, that’s probably it.”
“Anything else?”
“No, that’s it.”
“I was looking at your previous medical visits and it looks as though you seem to miss coming into be seen as scheduled by your primary care physician.  Why’s that?”
“I have to work.  And my appointments , I sometimes forget about, so I end up rescheduling them.”
“Okay, well then, have you had any surgeries?”
“What about your family history, anything there, such as heart disease, kidney disease, or anything else?”
“My dad died of some sort of heart problem when he was about 70 something, my mom lives here and she has some sort of arthritis.  My brother died in a car wreck, my sister is fine, I think.  She’s younger than I am.”
“And you’re 51, is that right?”
“What are your drug allergies?”
“Drug allergies, what’s that?”
“It means, have you had any problems with any medications in the past such as a drug rash, or swelling of your lips, or anything along that line?”
“Umm, no.”
I finished taking his history and then did his physical exam.  He was somewhat obese, and  had a slightly enlarged liver (the liver edge was slightly below his right rib cage).   I noticed that he had dirt and grim under his fingernails, his hands were coarse, which lead me to believe he was some sort of a  manual laborer.  Other than this, he exam was normal.  I ordered a complete work-up for his elevated liver enzymes as well as an abdominal ultrasound of his liver.  I then gave him a follow-up to come back in and see me in six weeks. 

Patients who have elevated liver enzymes have inflammation of their liver cells (hepatocytes).  It is up to us, the clinician to figure out why the inflammation exists.  It can be caused by alcohol, fat storage, copper storage, viral diseases (hepatitis A, B, or C, epstein-barr, cytomegalovirus, herpes), auto-immune disease (patient’s immune system is attacking itself), liver cancer, metastatic cancer, iron overlaod (what is called hemachromatosis), adverse drug reaction, biliary disease (the bile duct that drains the liver), liver abscess, glycogen storage diseases, alpha-1 anti-trypsin disease, or cirrhosis.  
So we have to do a complete work-up on these patients which includes blood work to assess for auto-immune disease, genetic diseases, iron studies, viral serologies, as well as blood counts (which tells us their platelet counts, their clotting factors, and level of hemoglobin/hematocrit).  Then the ultrasound will show us the size of the liver as well as it’s consistentcy (does it have fatty infiltrates, is it nodular or scarred down, does it have fluid filled cysts). 

Once I had all of his test results back, I waited for him to keep his clinic appointment.  I wasn’t surprised by the fact that he cancelled the first return appointment and finally kept his second one.  I walked into the exam room and greeted Conrad. 
“Hi, Conrad, I’m glad you were able to make it into clinic to be seen.  I hope all is well with you.”
“Yeah, I’m fine, work is just keeping me busy.”
“Well, that’s good.”
“I printed off copies of all of your labs as well as your ultrasound report, so here they are, you can keep them.  Let me explain them to you.”
I went through all of his lab results and explained to him that they showed he had hemachromatosis, or what is also called ‘iron overload.’  His ferritin and transferrin saturation were both quite high, his hemoglobin/hematocrit level was also corresponding high.  Putting all of this together explained why he had elevated liver enzymes.  Once I answered his questions I then advised him that we needed to get the gene studies done for him which would tell us whether he had one or both copies of the abnormal gene.  I also explained that we needed to do weekly blood draws at the blood center until we could get his iron levels down, after that we would be doing blood draws every 2-3 months to keep his iron levels in the normal range.
“Okay, Conrad you also need to let all of your family members know about this so that they can be tested for the gene that causes this disease.  That means your sister and your mom.  The other thing is you need to stay away from red meats, any over the counter iron supplements which typically come in the multi-vitamins and don’t eat any organ meats.  All of these have high iron content in them.  Oh, and no more drinking any alcohol, that tends to make this condition worse.”
“Wow, can you write all of that down for me, so that I can remember it?”

Hemachromatosis is a genetic disease that affects 10% of the population, where it shows up in a heterozygous condition (1 normal gene, 1 abnormal gene).  In .5% of the population it shows up in a homozygous state (two abnormal genes). 
The disease causes patients to have several abnormal results:  a high red blood cell count (hemoglobin and hematocrit), high iron studies (ferritin, iron sat, transferrin), abnormal liver enzymes, and then on physical exam they can h ave: increased skin pigmentation, diabetes, arthritis, impotence, enlarged heart, weakness, fatigue and abnormal cardiac rhythms on their EKG reading.
The long term consequence of this disease (if it is not treated correctly) can be liver cancer, cirrhosis of the liver, enlarged heart (which usually shows up as heart failure), and mortality from their diabetes. 
“Alright, well here is your lab slip to have your gene studies done, I’ve already faxed in your orders to the blood center for them to do your weekly blood draws, so here’s their number to set up your times.  I’ll see you back in six weeks, at which point in time we should be able to figure out how frequently we need to schedule you for your long-term blood draws.  I’ll see you then, do well until then.”
I wasn’t surprised to hear from the blood center a few weeks later that Conrad had missed two of his appointments and they therefore needed new orders faxed over.  He also missed his six week follow-up with me.  Conrad finally showed up almost 3 months after I had seen him. 
“Hi, Conrad, I’m glad your back in clinic.  I have your blood draw from this morning and it shows that your hemoglobin, hematocrit numbers are now down in the low normal range.  Your iron studies show that they are now in the low range.  So I think we can set you up to have your blood drawn at the blood center every 3 months, so that’s good.  Your gene study came back and showed that you have one copy of the abnormal gene, which is what we can a heterozygous state.  I hope you told your sister and mom to be tested.”
“I did.”
“Okay, well then I’ll fax in your new order over to the blood center, you can call and set up your time and then we’ll see you back here in 6 months.  Does that sound okay with you?”
“Yeah, that’s fine.”
“Alright, well then I’m glad to see you again.”

We as clinicians have to work with our patients who are non-compliant with either being seen in the clinic, or non-compliant with their medical regimen.  We have to figure out what it is that is making them non-compliant.  It could be they are unable to make it into clinic or take their medications for an assortment of reasons.  For us, as clinicians we need to figure out the patient’s why so that we can help them increase their overall health.  Many times this involves doing intensive patient education, discussing their concerns to figure out what it is that drives their health choices,and then giving patients positive re-inforcements and/or encouragement. 

Once I had figured out the reason for Conrad’s non-compliance (he needed to keep his job so as to pay his bills) then I was able to understand his being a no-show in the clinic and was willing to re-write his blood center orders for him when needed so that he didn’t suffer any of the long-term consequences of his disease. 

Thursday, November 17, 2011

A High School Wrestler with a Skin Infection

I walked into the urgent care exam room to find a 17 year old teen-ager sitting on the exam table.  He and his dad were there together.
I introduced myself and then asked how could I help.
“Something’s here on my leg I need  taken care of,” the adolescent replied.
“Hmm, okay, let me take a look.”
With that the tall strapping 165 pounder, muscular physique adolescent dressed in a muscle t-shirt and rather loose fitting but long nylon shorts, pulled up one of his legs to his shorts, to show me the skin on the lateral side of his right leg.  He had several abrasions surrounded by erythema (redness).  I felt his skin and it was warm to almost hot to my touch. 
“When did this happen?”
“Two day ago,” Doug replied.  “I had a match after school, I’m a wrestler you see, and it took a while for me to pin my opponent, but I did!  I didn’t notice anything until that night when I was home doing my homework and my leg started to itch right where this redness is.  That’s when I noticed I had probably gotten some, what do you call it, ‘mat burn’ I think on me?” 
“Okay, so what did you do?”
“Nothing, I had already taken my shower at school after my match, so I tried not to itch it, finished my homework and went to bed.”
“And what happened the next morning, which was yesterday?”
“I woke up and saw what I thought was ‘mat burn’ was worse, it still itched somewhat but the whole area was larger.  I washed it off with soap and cool water thinking that would help and went to school.  During school I noticed that it was beginning to bother me, it was tender to touch, so at wrestling practice last night I showed it to my coach.  He sent me home and told me to be seen by a doctor, he thought it was infected.”

This patient is showing typical signs of community acquired methicillin resistant staphylococcus aureus (CA-MRSA).  The skin typically harbors at least two bacteria, both of which are staphylococcus, one is called staphylococcus aureus and the other is called staphylococcus epidermis.  In the past several years the staphylococcus aureus strain has become more and more resistant to antibiotics. 

Due to this resistance, it is now harder to treat staphylococcus aureus infections with the run of the mill antibiotics.  Many of the staphylococcus aureus strains are showing they don’t respond to oxacillin (penicillins) and they are called MRSA.  MRSA infections are then split into two categories, based on whether the MRSA was acquired in the hospital or in the community, hence CA-MRSA or HA-MRSA. 

“Okay, so did you go in and get seen by a physician yesterday after school?”
“No, I waited until after dinner to show it to my dad here and he said,” changing his voice inflection to resonate with a bass tone closer to his father’s voice, ‘first thing in the morning you’re going into be seen, you understand me son?  That’s nothing to fool around with!”  Dropping the bass voice, and returning to his tenor voice, Doug then said, “so that’s why I’m here.”  After he said this, Doug turned his head to look at his dad with a smirk.  His father grinned back at him. 
“Okay, well Doug you have cellulitis of your right lateral thigh, which in English means you have a skin infection.  Seeing that you are a wrestler you most likely have what we call community acquired methicillin resistant staphylococcus aureus or MRSA.  It’s typically now found in locker rooms, athletic clubs, on wrestling mats, soccer players, etc.  Almost any place where there is a chance to acquire a breakage in your skin followed by introduction of skin bacteria.  And that’s what has happened to you.”
“So what do I do about it?”
“I’m going to have to put you on antibiotics, are you allergic to sulfa drugs?”
“What’s that?”
“Sulfa is a substance found in may drugs, such as sulfasalazine, Bactrim, some diurectic medications, etc.  Do you have any allergies to medications?”
Doug looked at his dad, who nodded no. 
“Okay well then seeing that you most likely have MRSA there is one drug that you can take orally which will take care of it and that is Bactrim.  You will have to take it twice a day for 10 days.  Before you leave here I’m going to mark the outside areas of your cellulitis, in other words where you redness stops.  I want you in 24 hours to look at the pen markings and make sure that the redness has not gone beyond them, instead the redness is smaller.  If the redness has gone beyond the pen markings then you have to come back in here and be seen again, we’ll have to switch you to a different antibiotic or a combination of antibiotics, understood?”
“Yeah, I guess so.”

Concerns over CA-MRSA:
There are many risk factors for CA-MRSA which include: 1) skin trauma, 2) crowding, 3) skin to skin contact, 4) sharing personal items such as razors, towels, etc, 5) frequent exposure to antimicrobial agents, 6) challenges in personal hygiene.

Nowadays, 61% of all skin and soft tissue infections are being caused by CA-MRSA.  So now in the out-patient clinics we are dealing with a resistant skin bacteria that if left untreated can continue to cause damage and eventually can invade the system. 

I went ahead and took his past medical history (seasonal allergies), family history (only positive for heart disease in his grandparents), medication history (zyrtec for his allergies).  After that I did his physical exam and besides a low grade fever, the only positive portion of it was the erythema on his right lateral thigh.  It measured about 8 inches in length by 3” in diameter.  The area was mildly swollen, tender to touch, and had increased warmth. 
“Okay, I’m going to mark your thigh here with my pen and remember what I said, if this isn’t better by tomorrow you come right back in, alright?”
With that his dad said emphatically, “I’ll see to it that he comes back in, if it’s worse.”
“Alright then, here’s your prescription for the Bactrim, take it twice a day, no fail.  If you have any nausea from it eat yogurt once a day.  Also make sure to keep this area nice and clean by taking a daily shower and using antibacterial soap.”
“What about my wrestling, I have a match next Thursday night?”
“Thanks for reminding me, that’s off, you’re not going to be able to play in that match.  If this clears up you can go back to playing after you finish your antibiotics, and your skin is back to its normal color.  And that’s another thing, let your coach know that you have this infection, tell him he needs to tell your team mates in case they come down with it from having contact with the wrestling mat.  Tell your coach that he is going to have to apply a bleach solution to the mat and let it dry before anyone else gets on it again.  Can you do that for your team mates?”
“Sure,” Doug replied rather flatly.  “But you don’t underestand,” he said emphatically, “I have to play in the match next Thursday, if I’m going to divisionals.”
Doug’s dad immediately interjected, “Doug, we’ll just have to talk to your coach, there has to be some other players who haven’t been able to play in every match up to divisionals.  I’ll go with you to talk to your coach on Monday, okay?”
“Alright, Dad,” Doug said, not really believing it would work.  Doug turned his attention back to me. 
“Okay, well then take your antibiotics, I wish you well and good luck with the rest of your wrestling season.”
 “Okay Doug, let’s go, we’ll stop by the pharmacy on the way home,” his dad said pleased that the problem wasn’t anything worse.
Doug didn’t appear the following day in clinic, so I assume that the Bactrim was working and he was getting better with each successive day.

 If a patient has methicillin sensitive staphylococcus aureus (MSSA) then they can be treated with penicillins, such as amoxil, augmentin, dicloxacillin, keflex, etc.  But if the patient has MRSA then our choices of antibiotics is smaller with our armormentarium being only Bactrim (a sulfa drug), clindamycin, tetracyclines or fluoroquinolones (Cipro, which we don’t use in a pediatric setting). 

Had Doug come back the following day, I would have added in clindamycin to the Bactrim.  If this had not worked then he probably would have to have been be switched over to an intravenous antibiotic.   I was glad that the Bactrim had worked for him.