Tuesday, May 31, 2011

I Think I Have a Sinus Infection, I Need a Z-pak!

I walked into see my next patient in the clinic.  She was a 30ish year old mother with two small children in tow. 
“HI, I’m Sharon, I’m a physician assistant, how can I help you?”
“I have a sinus infection, and I need a z-pak.”
“I see, well why don’t you start by telling me what your symptoms are?”
“I’ve got sinus congestion with yellow drainage.”
“Okay, well how about any coughing, sore throat, fevers or ear congestion?”
“No fevers, my throat’s a little scratchy, some cough and my ears feel full.”
“How about teeth pain?”
“No, none of that.”
“How long have you been sick?”
“About 4-5 days.  I caught it from my two year old son who had it last week and I took him to his pediatrician’s office who said he had an ear infection and gave him amoxil with some sort of nasal decongestant prescription.”
“Hmm, well what color are you coughing up?”
“The same yellow stuff that’s coming from my nose.”
“Looking at your medical chart, I see that you don’t have any medication allergies and you’re not on any prescription medications, is that still correct?”
“Alright, well let me exam you and then I’ll explain what can be done.”
The patient’s physical exam showed what I expected, some ear congestion, sinus congestion,  a slightly red throat, with clear respirations heard from her lungs.
“Okay, well why don’t you sit down here in this chair and I’ll explain everything to you.”
Over the next 10 minutes I reviewed with the patient the difference between an actual bacterial sinus infection, for which an antibiotic would work (i.e. amoxil, omnicef) and sinus congestion caused by a virus which is what she had.  And as usual, she kept insisting that the z-pak was the only thing that would clear up her sinus problems. 
I have come across this same scenario too many times in my many years of working in medicine.  So if you are like this patient and believe that sinus congestion equals to an acute bacterial sinus infection for which you need an antibiotic, please read on. 
Viral Related Sinus Congestion
Virus’ can cause you to have sinus congestion, some sinus discomfort, and low grade fevers up to 101.  You can have yellow to green sinus drainage, productive cough and a sore throat.  Your ears can feel full or be congested.  You might have some dullness in hearing due to the ear congestion.  Your low grade fevers are related to your viral infection, which typically is an adenovirus or rhinovirus.   Now compare that to a patient who has a bacterial related sinus infection.  They will have acute facial pain, sinus congestion, fevers generally in the range of 101-102 F, green to bloody drainage from sinus’, a sore throat, ear congestion and teeth pain.  I believe you can see the differences between the two. 
So in an effort to help my patients understand the differences between sinus congestion and an actual bacterial sinus infection which requires antibiotics I came up with the following chart which many of my patients have told me really helps them understand what to do. 
Sinus Allergies
Sinus Congestion
Sinus Infection
type of drainage
amount of pain
facial pain
due to
presence of fever
mild up to 100-101 F
usually over 101 F
ear symptoms
sometimes feels full
popping, feels congested
congested, can be painful
can be irritated, dry
teeth pain
no to minimal
head movement
no relationship
can be uncomfortable
pain with head movement
sinus tenderness to palpation
Yes! (typically acute pain over involved sinus)
Treatment of Above:

steroid spray
generally no
anti-viral medication
yes, if due to the flu virus
antibiotic (amoxil, omnicef, etc)
Frequently Asked Questions:

What is an antihistamine?
It is a medication which dries up your sinus drainage, and blocks the histamines which are released due to the presence of an allergen
What is a decongestant?
It is a medication which breaks the mucus free of the sinus membranes and opens your sinus passageways up so as relieve pressure
What is a steroid spray?
It is a medication which decreases the inflammation in the sinus’ passageways
What does mucinex do?
It thins out the secretions and allows drainage of the mucus
What is a virus?
A single stranded RNA particle which can infect cells and then replicate
What is a bacteria?
It is a living cell, which can invade your system and causes a bacterial infection
What is an antibiotic?
It a medication which is geared towards killing bacterial living cells.  It is incapable of killing viral particles. 

Progression of Sinus Symptoms
Sinus problems generally start in a patient who has a history of sinus allergies.  Their allergies begin to kick in and cause clear drainage.  Patients at this stage typically do very well taking over the counter antihistamines.   Then in some patients , sinus drainage and inflammation increases and they become congested with limited ability to drain the mucoid-like fluid.  It’s at this point in time that the patient’s sinus’ become infected with a virus (usually one of the virus’ that cause the common cold or a flu virus).  Once the virus has set up house, the  patient begins to have problems with yellow-to-green drainage, sinus congestion, sinus discomfort and possible low grade fevers.  It’s at this point that the patient has sinus congestion due to a viral infection. 
If the viral infection is left alone, then typically the patient will over time come down with an acute bacterial infection.  It’s at this stage that antibiotics will work to get rid of the bacterial culprit.  Patients will complain of fevers generally in the range of 101-102, acute facial pain over one or more of the sinus’, teeth pain, green/bloody drainage, productive cough, and a sore throat. 
But as a patient there are things you can do to address your sinus congestion to prevent the sinus’ becoming infected with a bacteria and your needing an antibiotic.  You can take ‘real’ Sudafed (from behind the pharmacy counter), you can take some mucinex, you can begin or increase your saline nasal washes.  All of this will help to address your sinus congestion and should prevent  it from progressing onto a bacterial infection. 
If your sinus problem is truly an acute bacterial sinus infection then you need the attention of your primary care physician or an ENT physician.  They can give you an antibiotic prescription and advise you to take guaifenesin, with a decongestant and/or the saline nasal washes. 
Symptoms Relief
One of the major ways to relieve your sinus symptoms and to address the sinus congestion (either from sinus congestion or an acute bacterial sinus infection) is to flush the sinus’ out of it’s mucus.  This is best done with either the saline nasal washes, guaifenesin, a decongestant  or all three.  Using an antihistamine in this scenario is just going to dry up the mucus and not allow it to drain which is what you need.    
Using saline nasal washes are very handy, easy to do.  And the most important part about them is that they do work to decrease your sinus problems by as much as 72%.  If you are going to do saline nasal washes I advise my patients to use a nasal bulb for ease of getting the saline wash into the sinus’.  It is also advisable to do the saline nasal washes at least 3-4 times a day to make them effective. 
Saline Washes:
Saline rinses of your sinus’ may reduce sinus symptoms by as much as 72 percent and even cut the number of infections for those with chronic sinus problems, researchers from England’s Royal National Throat, Nose and Ear Hospital concluded after reviewing a series of studies.  This ancient remedy softens and removes crusty mucus, thins nasal secretions, and helps wash away viral particles, bacteria and irritating immune system compounds. 
You can purchase a sinus rinsing tool called a neti pot at a natural foods store, get a special attachment for electric water-jet irrigators (like Water Pik), use a squeeze-bottle sinus rinse (such as NeilMed rinse), use a nasal bulb, or simply cup your hand to deliver the saline solution to your nose. 
The mixture:  ½ tsp non-ionized salt plus 1 pinch of baking soda with 8 ozs of warm water.  Another mixture you can use is ¼ tsp of salt, ¼ tsp of baking soda with 8 ozs of warm water. 
Rinsing directions:  Lean over the sink with your head down (some neti-pot instructions advise tilting your head to the side slightly).  Gently squirt the saline into each nostril (or inhale one nostril at a time, from your palm).  Breathe through your mouth at the same time will help keep the solution from entering your mouth (if it does spit it out).  Gently blow your nose.  Repeat until you’ve used the 8 ozs of salt water. 
Repeat as often during the day as needed. 
Using the over the counter medications generally doesn’t work.  These over the counter medications have ‘pretend sudafed’ in them, an antihistamine, or both.  They also have other unnecessary meds in them such as tylenol, ibuprofen, dexomethorphan, etc.  The ‘real’ sudafed which decongests your sinus’ is behind the pharmacy counter and you have to show your photo identification to acquire it. 
Precaution for Those Patients Who Have Hypertension
If you are a patient who has hypertension and is currently being treated for it, before you take an antihistamine or Sudafed (decongestant) please discuss it with your primary care provider.  Both Sudafed and any antihistamine are known to cause an increase in your blood pressure.  Your physician may tell you its okay to take them for the short duration you will need them to address your sinus congestion or they may tell you to address is with saline nasal washes and a steroid spray, so discuss this with them.   
So in the future if you think you have a sinus infection, please review the table and address your symptoms based on which column you fall in.   

Monday, May 30, 2011

A Nasty Spider Bite

I was at work one day when I walked into the clinic exam room to find a new patient waiting for me. 
“Hello, my name is Sharon, I’m a physician assistant, how can I help you?”
The patient, whom I’ll call Roy, looked at me, then looked down at his bare knee.  My eyes followed his and I instantly knew why he had come.  The patient’s right knee was swollen and erythematous (red) on the outer aspect. 
“Okay, when did this happen, Roy?”
“A couple of days ago.  Initially I thought it was just a bad mosquito bite and it would go away the next day, but instead it got worse.”
“So this happened over the weekend, I presume?”
“Yes, I was doing some spring cleaning of my garage, getting rid of some trash, old things I didn’t want anymore.  I took some of the trash bags and a piece of broken down patio furniture out to the curb for the trash men to pick up.  And when I came back into the house to clean up for dinner that’s when I noticed something had bitten me.  I left it alone, thinking it was a mosquito bite, but like I said it only proceeded to get worse. Now it’s three days later and I can barely walk it hurts so bad.”
“I can see that.  Okay, well do you have any brown recluse spiders in your house or garage that you know of?”
“No, not that I know of.”
“Well, your knee reminds me of that kind of a bite.  Your history of doing spring cleaning in your garage, is a perfect scenario for such a spider bite.  Brown recluse spiders love living in a dark environment, where it’s quiet and they are unperturbed by anyone.  Your garage is such a place, until you started cleaning it out that is.”
“A spider did this to my knee?”
“Afraid so.”

Spring and summer tends to be the times that patients come in with spider bites they have encountered while cleaning their house, or garage.  Most spider bites are just bothersome, they go away within a few days, but then there is the brown recluse spider. 
This particular spider is a very small spider, no larger than a quarter in size.  But for its size it packs a powerful amount of venom in its bite.  Based on whether the patient has been bitten before or not will then judge the amount of response the patient has.  Patients can have a response from a bad spider bite which resolves over a week or so to full fledged immunological response where the whole area swells up, the patient has erythema, increased heat, fevers and the possibility of an infection. 
For us, medical providers we have to assess how widespread the spider bite/venom has gone, whether there is a surrounding infection, is the site draining infected fluid, what is the level of pain, is there the possibility of joint involvement, and whether the patient needs steroids to calm the immune system down. 

I proceeded to ask him the usual questions as to what medications he was one, what his past medical history was and what medication allergies he might have.  I then did my physical exam and measured the width of the erythema (redness) around the spider bite on his right knee, felt for warmth over the bite area, as well as over the medial aspect, palpated for any drainage of the center wound area, and had Roy bend his knee back and forth for me to make sure that his joint space was not affected, in other words he didn’t have any pain upon passive movement of his knee joint.  I also felt for any increased warmth or swelling over the upper aspect of his knee cap to make sure he didn’t have involvement of his bursa. 
Once I ascertained that the spider bite had not involved his knee joint, he just had cellulitis (inflammation and infection of his skin and skin structures) with swelling/pain due to the brown recluse venom I advised Roy of my findings. 
Roy, I’m going to give you an antibiotic to take at home twice a day for the infection as well as some steroids to take for the next 6 days.  The antibiotic will take care of the infection and the steroids will knock off your immune response as it’s trying to attack the venom.  This is going to take a while to resolve, you’re going to have pain for a while so I’ll also give you a narcotic prescription to take for the next 3-4 days.  If the antibiotic, Bactrim gives you any nausea, then take some yogurt with it every day.  The steroids can change your moods or make you hungry, so be aware of that and the Tylenol with codeine might make you a little ‘loopy’.  Any questions about your medicines?”
“No, I don’t think so.”
“Okay, well then let me explain to you how to keep the wound clean and keeping it bandaged.  I also need to see you back in two days, because of the location of your spider bite to make sure it hasn’t progressed into the knee joint and it’s responding to the medications.”
Once Roy agreed, he slowly hobbled out of the exam room and went to the front desk to acquire a return appointment to be seen on Friday.  I had already e-faxed in his prescriptions, so he could pick them up on his way home.  
Friday afternoon I looked at my schedule to see that Roy was scheduled to see me at 3 pm.  He was a no-show.  At 4 o’clock I had a phone message from his wife which said that he had been admitted to the hospital the previous evening with increasing pain, swelling and fevers.  The message stated that he had been seen by the orthopedic surgeons who had to drain his knee and the infectious disases doctors had come by and started him on IV antibiotics. 
I read the message again and thought to myself, “exactly what I didn’t want to have happened, happened to Roy. Crap!”

What happened to Roy can happen with any patient who has a severe response to the brown recluse spider venom.  One of the complications of a spider bite that is near a joint space is that the surrounding cellulitis (skin infection) will spread on into the joint space and it will become infected with the same organisms that the bite area/skin is infected with. 
At this time the joint has to be aspirated and drained for relief of pain as well as to do bacterial cultures on.  Patients then need to be treated for 6 weeks with antibiotics to make sure that the joint space does not remain infected.  Joint spaces are treated for this length of time due to the minimal amount of circulation it has. 

A week later, Roy was on my appointment schedule again.  I knocked on the exam door and went into to see him.  Roy was sitting down, crutches by his side, with his right knee totally bandaged up.
“Wow, Roy, I’m surprised to see you.  Bring me up to speed on what’s happened?”
“Well the infectious disease doctors told me that my knee joint became infected from the spider bite and that’s why I started running fevers the day after I saw you.  The bacteria that was involved was resistent, I think that’s the word they used, to the antibiotics you put me on.  So they had to put me on IV Vancomycin.  They also stopped the steroids because they told me that with the infection spreading like it was, the steroids were doing me more harm than good.  I was discharged from the hospital 4 days ago and the infectious disease doctors wanted you to check my wound to make sure it was healing up.  I’m supposed to go back and see them next week, until then I stay on my twice daily IV infusion of Vancomycin.”
“Wow, I’m sorry to hear what happened to you.  Let’s take a look under those bandages and see how your knee is.”
Roy removed the knee bandages and I could see that the wound was becoming smaller, it wasn’t quite as erythematous (red) or swollen, although the center of the wound was still draining out clear serous yellow fluid.  He was able to move his knee, fully extending it and then almost fully bending it without pain. 
“Roy, the message your wife left last week said that the orthopedic physicians had to drain your knee joint, so are the infectious disease doctors treating you for an infected knee joint or just for the skin infection?”
“The infectious docs said that my knee joint had become infected, so I have to stay on the IV Vancomycin for six weeks.”
“Alright, well you can bandage your knee back up.  You’re scheduled to see the infectious doctors again next week and I assume they will be following you until you finish your antibiotics.  If you have any questions or problems with it, you can call me otherwise just follow what the infectious disease doctors tell you to do.”
“Okay, well thanks for all your help.”

Being aware of the presence of brown recluse spiders is the best way to protect yourself from their venom.  Be aware of dark quiet spaces where they like to hide.  Be aware of where they live, they are typically in the Southern and Western U.S. not the Northern U.S.  And if you see one, kill it, you don’t want to end up being bitten by it!

Wednesday, May 25, 2011

Brittle Bones

I walked into the clinic exam room to find a new patient sitting quietly on the table.  I introduced myself and asked her why she had come in.
“My husband and I just retired and moved down here from Chicago.  So I’m in need of setting up medical care.  I have high blood pressure and need my medication refilled.”
“Okay, well then let’s start with what blood pressure medication you’re on.”
“I take lisinopril 5 mgs and hctz 25 mgs a day.”
“Sounds to me like you’re on a relatively low dose of blood pressure meds.  What do your blood pressure readings at home generally read?”
“I’m supposed to be taking my blood pressures at home?”
“Yes, you should be taking your blood pressures at home with a reliable machine.  I like to recommend you pick up an omron blood pressure machine, they can be bought at most drugs stores.  Don’t buy the one that measures your blood pressure at the wrist, but buy the one that measures your readings on your arm, just above your elbow.”
“I see.  Well it looks like I’ll need to drop by the drug store on the way home.”

High blood pressure (medical term: hypertension) is a very common chronic medical condition found in patients being treated by their primary care physicians.  It can lead to a patient having a stroke, heart attack, blood vessel disease (aneurysms), kidney disease, and eye disease (retina).  Due to it not typically causing symptoms it is called the ‘silent killer.’ 
Too many patients don’t stay on their blood pressure medications, or they have side effects to them and stop them without letting their physicians know.  Another part of the puzzle is that patients don’t understand why they need to take a daily medication for their blood pressure when they are not having symptoms.     
Patients also need to be taught to take control of their hypertension by taking their blood pressures at home with a reliable machine.  They need to be informed that their at home readings (if normal) are showing them that the medications they take for their blood pressure are working and to not stop them. 

“Well, your blood pressure here this morning was 132/80, which is okay.  Your blood pressure readings should be below 140/90, preferable they should be below 130/80.  Why don’t you go buy a good blood pressure machine, like you said, start writing down your readings that you acquire and bring them back into me in 2-3 weeks so that I can see them.  It would be preferable if you took a reading in he am, just as you wake up and before you get out of bed, then again midday, and again just as you go to bed.”
“Okay, well it sounds as though I can do that.”
“Alright, well then why don’t you tell me what other meds you are on, and what medication allergies you have.”
“I take some calcium for my bones and it has Vitamin D in it.  I don’t have any allergies.”
“Do you have any other medical problems besides your high blood pressure?
“No, I just have some occasional seasonal allergy problems, which I take some Zyrtec for when I start having a drippy nose.”
“Okay, well how about any prior surgeries?”
“I had two C Sections, and my gallbladder removed.”
“And what about your family history, do you have any history of cancer, heart disease, osteoporosis, for example?”
“My father died of a heart attack and my mother died of a stroke.  My sister died of breast cancer, and my two brothers are both on blood pressure medicines. 

After I did my physical exam, Dorothy and I settled on her returning to the clinic to be seen with her home blood pressure readings in 2-3 weeks.  I gave her a lab slip to have some preliminary blood work done, which would check her kidney function and electrolytes.
Three weeks later I walked into the clinic exam room to see Dorothy again. 
“Morning, Dorothy, how are you?”
“I’m fine.  My husband and I are settling into our new home and I think we’re going to enjoy living down here.”
“Well I hope so, it’s generally thought of as a nice place to retire.”
“Here’s what you requested, I have a list of my blood pressure readings for you.”
Dorothy handed me the sheet of information, which I reviewed with her.  I was happy to see that her blood pressure readings at home were good with an average of all of her readings being 115/74. 
“I’m glad to see these readings, Dorothy.  The medicine you’re on is working well for you, so we’ll keep you on it.  Your lab work from a few weeks ago was normal.”
“Glad to hear it.”
“Okay, now the other medicine you’re on is calcium with Vitamin D.  When was the last time you’ve had a bone scan done to look at your bone density?”
“I don’t think I’ve ever had one of those done.  I’ve been more concerned about making sure to get my mammograms done every year due to my sister’s breast cancer history.”
“Well that’s understandable.  When was the last time you had a mammogram?”
“Three months ago, it was normal.

Patients who have a family history for cancer need to be screened differently than the general population.  For those who have breast cancer in their family they need to be diligently screened with a mammogram and advised to be seen by their medical provider if they notice any changes in their breast, such as a new nodule, dimpling of the skin, drainage from their nipple).  If the patient has a family history of colon cancer they need to begin screening with a colonoscopy (done by a gastroenterologist) 10 years prior to the first episode of colon cancer in their relative (i.e. relative with colon cancer at age 50, the patient needs to begin screening at age 40). 

“Okay, well then let’s get you scheduled for a bone scan to assess your bone density.  Why don’t I see you in about 3 months as a follow-up after your bone density is done and you can bring in another list of your blood pressure readings at home at that time.”
“Okay, sounds good to me.”
As Dorothy got up to leave, I gave her the order for her bone density to hand to the front desk clerical staff. 
Upon Dorothy’s return to the clinic a few months later, she handed me another list of blood pressures that she had taken at home, and again they were in the normal range.
“Very good, Dorothy,  I see you got your bone density scan done several weeks ago.  Unfortunately, it shows that you have osteoporosis, which means that you’re at an increased risk for fracturing a bone.  Your Z score is a negative 2.5.  That means in comparison to a normal healthy 20-30 year old woman your bone density shows very little density and probably a lot of empty holes in your bones.  We need to get your started on a medication that you can take once a week to help your bones re-build themselves.”
“I thought my being on calcium and Vitamin D was all I needed to address that.  Why do I need to take an additional medicine over the calcium with D supplement I already take?”
“Well if you don’t take it, you’ll be facing the risk of having a major fracture, especially a hip fracture from just tripping over a chair leg for instance, or catching your shoe on a piece of carpet.  Calcium and  Vitamin D are important and they certainly play a role in helping to keep your bones strong, but for some women they need additional help, which is where you are.”
“So you’re telling me that if I don’t take this medicine I could break my hip or something?”
“Hmm, that reminds me,  I remember my grandmother fell down and broke her hip, she ended up in a nursing home where she died about 6 months later from a blood clot.  That’s not how I want to go.  So tell me about the weekly medicine I have to take and what it will do for me.”
I proceeded to tell her about the weekly pill she would have to take, the side effects to it and that we would do a repeat bone scan on her in two years to assess her response.

Osteoporosis is a common disease among the elderly population.  It is more common among women than men and by the time it is diagnosed is has been present for many years.  It takes years for it to develop, the patient’s bone slowly depletes bone deposition, and over time the patient’s bone become brittle and easy to break because there is almost nothing left in them to give them strength and prevent any possible fracture. 
A part of the reason that women have this disease more than men is that they lose their estrogen production after menopause and estrogen is one of the hormones that is responsible for making the bony matrix. 

About six months later I saw Dorothy again for a visit.  She needed to have her mammogram ordered and needed her blood pressure medication refilled.  I walked into the exam room to find her sitting on the exam table with the usual of her at-home blood pressure readings and a cast on her right arm.
“What happened to you?”
“I  fell down a bunch of stairs about two weeks ago.  My high heel shoes I was wearing caught the edge of the step and I fell forward, I heard a crack and looked down at my arm and knew it was broke, it was at this weird angle.  I also bruised my leg and rib cage pretty badly, in fact the bruises have just gone away in the last couple of days.”
“Wow, I’m sorry to hear that.  So when do you go back to see the orthopedic surgeon?”
“I saw him a week ago, that’s when he took me out of the splint and put this cast on.  I have to go back and see him in another 3 weeks for him to take an x-ray of my arm to make sure that it is healing correctly.” 
“Oh my, it just makes me wonder how much worse it would have been had you not started your weekly medication for your bone density six months ago.”
"Yes, the bone doctor mentioned that.  He told me he was glad that I was on it, otherwise he told me the break most likely would have been worse.”
“Well, I like your blood pressure readings at home.  The reading here in the clinic is also fine so we’ll stay the course with your medication for it.  Let me listen to your lungs and heart and then I’ll give you an order slip for you to get your annual mammogram.”
“Fine with me.  Will you just let me know the results of the mammogram once it’s done?”
“Yes, you can expect something in the mail about a week after the mammogram is done.”
“Alright, well here’s your mammogram order, you can give it to the front desk clerical staff, they can schedule it for you.  I’m glad to see that you’re doing so well, and I hope your arm heals up nicely for you.”
“So do I.”
“I’ll see you back in six months.  Good luck with your arm.”

Preventive medicine is important.  Patients need to remember that taking care of themselves before a medical condition occurs is one of the best ways for them to prevent disease.  Patients need to remember that they need to be appropriately screened for colon cancer, breast cancer, stay on a nutritious diet, exercise, address your stress levels, and keep the weight off.  Doing those little things for yourself each and every day will pay off in the long run.  Stay at it, and remind your primary care provider if they forget to schedule you for an appropriate screening.