Sunday, January 16, 2011

A College Student's Freedom


I was doing some locums work in a college student health center, filling in for one of the other providers who was on maternity leave.  I picked up the next patient chart to see that it was a returning patient who had just had a LEEP procedure 4 weeks before by the visiting gynecologist.   
Her chart said that she needed to be seen for a possible urinary tract infection.  I knocked on the door and then went in and introduced myself.
“Hi, I’m Sharon, I’m one of the physician assistants who works in this clinic, and you’re Beth?”
“Yes.”
“You’re 22, is that correct?”
“That’s right.”
“It says here on your intake sheet that you think you have another urinary tract infection. What are your symptoms?”
“Well my boyfriend and I had sex the other night.  I woke up two days ago and started having a feeling of burning when I urinated.  So I knew what that meant and I started drinking cranberry juice.  That helped a little bit, but by this morning I was having to go to the bathroom a lot and my urine now has a strong smell to it.  So I know this means that I probably have another urinary tract infection and I need antibiotics for it.”

Urinary tract infections in women is quite common.  Women usually come down with them after they have had a sexual encounter, or had a gynecology procedure done with instrumentation.  It also occurs in women who are pregnant, or who have diabetes, are immunocompromised (due to receiving cancer chemotherapy for instance), or who are  using a diaphragm or spermicide for their birth control.  Women are at risk for urinary tract infections due to the short length of their urethra and the tendency of E. coli to be able to adhere to the urethral lining. 

Whereas, in men, a urinary tract infection is quite unusual.  They generally get them if they have an anatomical abnormality, or have just received a urological procedure. 

Usual symptoms include increased need to use the restroom, urgency to use the restroom, strong smell to the urine, burning or pain with urination, midline lower pelvic pain, back pain, fevers, or nausea/vomiting. 

“Okay, I see, are you having any fevers, back pain or pelvic pain?”
“No, I’m not having any fevers.  I do have some discomfort over my lower pelvis though, right here.”  As she stated this, she put her hand over her lower pelvis where her bladder would be. 
“Any other symptoms, such as nausea, vomiting, or diarrhea?”
“No.”
“Are you taking any prescriptive medications?”
“Yes, I’m on birth control pills.”
“Okay, well you probably know the routine.  I need you to sit up here on the exam table and let me listen to your lungs, heart and feel your abdomen.  Then I’ll send you off to the lab for a urinalysis.”
“Alright.”
 I listened to Beth’s heart and lung sounds.  They were normal.  I then palpated both sides of her back to see whether she had any costovertebral tenderness, which she did not. 
“Okay, Beth now I need you to lay down for me so I can do an abdominal exam on you.”
“Alright.”
I listened to her bowel sounds and then palpated her abdomen.  As I was palpating over her bladder, Beth spoke up and said, “that’s uncomfortable.”
“Okay, well I’m done.  You can sit up now.”
I gave her the lap slip to have the urinalysis done and sent her down the clinic hallway.
While she was gone it gave me a few minutes to quickly review her chart.  Her problem list included frequent urinary tract infections, having had four in the past year.  The LEEP procedure was done just 4 weeks ago due to cervical changes consistent with CIN (cervical intra-epithelial lesions).  Her pathology had come back as a high grade CIN stage 3.  Her LEEP procedure had removed the better portion of her cervix, as well as the surrounding tissue.  If and when she ever decided to get pregnant she would have to deal with an incompetent cervix, which would mean her OB/Gyn would have to tie it closed until she was ready to deliver her child. 
She would also require close gynecology follow-up after she graduated this semester, so unless she had a position straight out of school with health insurance she was going to end up falling through the cracks. 

Having acquired their freedom from their parent’s restraint while they lived at home, many students find themselves lost in the maze of possibilities while in college.  Not only do they now have time to explore their own sexuality in an unrestrained manner, they have access to alcohol and other mind altering drugs. 

Many students just don’t know what to do with all of this new found freedom.  There are too many tempting items within their view: parties, staying out all night, boozing up, binge drinking, and having sex. 

Due to their unrestrained behaviors at times, even though many students end up leaving their college days behind them, unfortunately they don’t leave the consequences of their behaviors behind them.  They take with them their sexually transmitted diseases (HIV, gonorrhea, chlaymydia for instance).  They take with them their alcoholic tendencies, and what’s worse is that women can also take with them cervical cancer due to acquiring the human papilloma virus.  Based on how their cervical cancer is treated, the women can have obstetrical problems later on, such as an incompetent cervix. 

There are many ways to treat cervical intraepithelial neoplasia (CIN).  Patient’s are first diagnosed with CIN from their pap smear.  Once the pap smear results are known (which typically shows atypical cells, inflammatory cells) then the patient is brought back to have a cervical cone biopsy done.  This is a procedure where a small amount of cervical tissue is stained with vinegar which then turns the abnormal cells white.  The gynecologist then removes these cells by doing a cone biopsy. 
The cells are sent off for the pathologist to look at them under the microscope.  He determines how atypical the cells are and whether there is the presence of human papilloma virus. 
Based on these results the patient is then seen again to determine treatment.  They can either receive ablative therapy (laser or cryotherapy) or excisional therapy (LEEP: loop electro procedure).  After the patient has their definitive treatment, they are then seen every six months for the next year to determine whether there is any evidence of relapse. 
Within the past few years a vaccine has become available for adolescents to receive.  The vaccine is called Gardisil.  It protects against the patient acquiring human papilloma virus.  It has to be given in multiple injections but its benefit are tremendous.  It will end up sparing many, many women from having to undergo cervical cancer treatment because it will treat the root cause: HPV. 

Just about then, Beth knocked on the exam room door and handed me the completed lab slip with her urinalysis results.  
Her urinalysis showed that she did indeed have a urinary tract infection.  She had 3+ leucocytes on it, positive nitrates, small amount of protein, and a moderate amount of red blood cells. 
“Well, Beth you were correct. You do indeed have a urinary tract infection.  What antibiotic have you been put on in the past which has worked for you?”
“I think I was put on Cipro about 3 months ago when I had my last one.  It worked for me.”
“Okay, well seeing that you have quite a few white blood cells present (leucocytes) I’m going to give you a Cipro script which I need you to take for one full week, twice a day, okay?”
“Okay, not a problem.”
“You can also take some azole which comes over the counter and turns your urine orange.  Most women like it because it helps with the discomfort during the first 24 hours until the antibiotic has had time to do it’s work.  You also need to be drinking lots of fluids to flush out your bladder and continue with the cranberry juice, that will help to acidify your urine which the bacteria don’t like.”
“But you probably already know all of this information seeing that you’ve had several urinary tract infections before.”
“Yeah, I know the routine.”

Typically the causative agent for a urinary tract infection is E. coli (80% of the time).  Most women are able to take one of 3 antibiotics for it.  Ciprofloxacin works very well as does Bactrim and Macrobid.  Based on the extent of the infection patients can be treated for 3 days or 7 days. 
Many patients are given antibiotics as a prophylaxis against their acquiring another infection.  They are given instructions on what to look out for and how to take the antibiotics.  If they are trained correctly, this approach can work very well for them.
    
“I see that you’re going to graduate in 2 months.  What are your plans after your leave school?”
“I’ve just been given a contract to teach junior high science out at the Fairfield School District.” 
“Well that’s nice to hear.  So you’ll be able to do your follow-up exams for your cervical cancer I hope?”
“Yes, Dr. Brown told me that I had to have regular exams every 6 months for at least the next year.   He told me that I had to get a copy of my record though so that I can give it to the OB/Gyn whom I decide to see.  How do I go about doing that?”
“All you have to do is go out to the receptionist desk and ask her for the ‘release of information form.’  Fill it out and then give it back to her.  You can then come in tomorrow and she will have copied what portion of your record you will need to take with you.”
“Oh, great, thanks for the information.”
“You’re welcome and I wish you the best.”

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INTRODUCTION/DISCLAIMER

Hello, welcome to my blog about medicine.  I’ve written it for all of the various laypeople out there who need solid information on how to be the best patient advocate they can be for their family members as well as for themselves. 
At no time do I want you (my reader) to assume that the medical information contained in these real patient encounters are meant for you.  Please take the time to discuss any information contained in these stories with your physician or medical provider.  Only with their help can you determine what the best route is for you to take in addressing your own personal health issues.
Please know that I have never used the patient’s real names or given away the locations of the clinics/hospitals I saw them in.  All of the stories are real patients I’ve seen, real scenarios that happened with real endings.   I’ve written about the most interesting, informative patient encounters I’ve been involved in over more than 20 years and counting of being involved in clinical medicine as a physician assistant.  Hopefully this will also allow you to understand what a physician assistant is and what we are capable of doing.  We are as close to being a physician as we can be, without being one, our typical medical training involves an undergraduate degree with 3 additional years of graduate training. 
I hope you enjoy reading the stories, learn from them and use the information contained herein to help you become a better patient advocate for yourself and/or your family members and friends. 
I wish you the best,
Sharon


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