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. 

Friday, November 11, 2011

A Personal Reflection on Hypertension

After being a PA for 17 years, I thought I had learned just about everything I needed to effectively practice in an academic medicine practice.  “Yes, there was always new studies that came out, which I needed to know about, but the basis of how I practiced clinical medicine I thought was sound.” 

That was until I was diagnosed with severe hypertension, with a blood pressure reading of 170/100.  Now, I admit that’s not much to be concerned about, you treat it with anti-hypertensive medications.  The medicine is titrated to effectively bring down the blood pressure to normal levels.  After that, it’s just a matter of making sure I took the daily medicine and it continued to work.

That’s the way it’s supposed to work, right?  Only problem was, I found out I had inherited a particular gene which dictated I had one drug allergy after another.  Too many relatives, (grandmother/aunts/uncles/sister/niece) all had the same problem, you give us a prescription drug and we have an adverse side effect to it that necessitates discontinuation of it.  Between the episodes of Stephen-Johnson like syndromes with sulfa in my family members (which included myself), to a near-permanent sleep status induced by an anesthetic, we are a physician’s nightmare when we need to be treated for a medical condition. 

I should have expected to have had problems with anti-hypertensive medications, knowing my family history and my own personal history of drug allergies.  Before I had reached my 25th birthday, I was already allergic to three of the major antibiotic families. 

It had been 20 years since my last drug reaction though.  So I just didn’t think about it.  I was now at my internist office being given a prescription for an ACE inhibitor.  I thought, “Fine, I’ll deal with the ACE induced cough.”  I did and after about 3 weeks it went away.  I titrated the dose up until it kept my blood pressure within the normal range.  I had a follow-up appointment scheduled to see my internist two weeks later. 

Then my problem started.  Every time I stood up, I felt as though I was going to pass out.  No preamble, no dizziness, just pure and simple syncope.  And if I somehow managed to stay erect, it would immediately be followed by cardiac palpitations with a discernable irregular pulse. 

I told my internist what was going on, and there went the ACE inhibitor.  I was switched to a beta-blocker.  That shouldn’t have caused a problem.  Wrong!  Within just a few days of titrating up the dose to an effective level, I came down with a rip-roaring pharyngitis accompanied by a fever.  I initially thought it was just a ‘bug’ that I had caught from one of my patients.  It didn’t dawn on me to look up the side effects of my beta-blocker.  Had I done so, it would have necessitated my being discontinued from my newest anti-hypertensive medication. 

For a fever with pharyngitis upon starting a beta-blocker is listed as a true allergic reaction to the drug and stipulates that it be stopped. 

Well after a few weeks I got used to taking my new medication, and my blood pressure was under control.  Three years went by, all the while, slowly but surely my system was building itself up for an all-out assault on my beta-blocker. 

I first noticed that I had a psoariatic skin rash.  I thought to myself this is weird, but okay, I’ll take care of it with changing my shampoo.  Then I started having ocular pain.  It was so intense that when I made it into to see my opthalmologist I was on the verge of crying, if only I could have.  For I had such ocular dryness from my beta-blocker that I had no tear production at all, which is what was causing my ocular pain.  Two more medications were added to what I was already taking. 

If I had been playing baseball, my system had now scored two hits against my beta-blocker.  Two months later while I was on vacation in Europe, it scored two more to make it a home run. 

Two days into my grand Mediterranean cruise, I was in the exercise room when I noticed that my ankles had disappeared.  I pressed my finger into an ankle and immediately noticed that I had 3+ pitting pedal edema.  “Oh crap,” I thought.  Had I a PDR in front of me and read the side effects to my beta blocker I would have immediately become concerned about the 19% associated incidence of heart failure with my anti-hypertensive. 

And if that wasn’t enough, the following day I noticed a horrid rash on my legs and feet.  I thought to myself, “where did this come from?”  I had already been treating my hands with an anti-fungal cream for several weeks prior to my vacation for a presumed outbreak of seborrhea.  The cream was working on my hands, maybe it would work on this new rash.  Thankfully it kept my leg rash under wraps as long as I lathered myself in it every day. 

My system had now scored a home run.  And I finally took notice and began listening.  Once I arrived home, I was back in my internist’s office, recounting the side effects I was having and asking for a change in my meds. 

As I assumed, my internist readily agreed.  With the knowledge that it would take a week to receive my new medication (non-formulary drug request authorization had to be submitted), I began the required beta-blocker taper.  Three days into the taper, my rip-roaring pharyngitis returned only this time with laryngospasms.  I couldn’t talk, five minutes later I could, and vice versa.  The following morning I couldn’t talk at all.  My voice didn’t come back for 24 hours.  For the next several days I could palpate muscular spasticity in my neck, which was always accompanied by a horrid coughing spell. 

I was finally listening to my system, and it was saying, ‘no more beta-blocker!’  It took me two full weeks before my cough finally disappeared.  A week after visiting my internist, I received my new ant-hypertensive medication. 

I began to titrate my dose upwards.  On the second and third day I took a small dose of it and both nights I ended up with insomnia.  I also noticed the return of my pedal edema with tachycardia.

I couldn’t believe this was happening.  Two of three of these symptoms were listed as side effects to the drug.  Now what?   I didn’t feel as though I could continue on it.  I needed my sleep, walking through my days filled with seeing sick hospitalized patients/clinic patients I needed to be fully alert and coherent, having insomnia was incongruent with that. 

I was running of out options.  The only thing left was to try an alpha blocker, calcium channel blocker, or a vasodilator.  The vasodilator choice wasn’t very appealing, I thought I would probably just end up with my pitting pedal edema again.  So did I try the alpha blocker, or the calcium channel blocker next?  And what would happen if I had side effects to them?  Then what? 

While I was thinking through my options, I happened to be in a local bookstore, a favorite hideout of mine.  I could spend hours browsing through a bookstore.  I wasn’t looking for anything in particular, I don’t even know why I was scanning the medical books section.  All of sudden my eyes landed upon a book written by Mark Houston, MD.  My immediate thought was, “oh crap another book written for patients, giving them yet more ammunition to question their physician unendingly about their hypertensive medication.” 

Too many other books on the shelf were just like that, all with catchy titles, but all basically leaving the patients feeling like they may not be receiving the best medications, or the best treatments, or why aren’t they on this or that alternative medication?  It’s working for this or that book author, so why not them? 

I don’t know why I even picked up Dr. Houston’s book.  But I did.  I read his title, a Vanderbilt Medical School faculty member, the Director of their Hypertensive Center, a phi beta kappa graduate as well as having graduated AOA (alpha omega alpha, i.e. in the top 10% of his medical school class at   
Vanderbilt).  “Okay, I thought, I’ll give it to him, he at least has the right credentials.”  I cracked the book open and perused some of the chapters. 

I was familiar with some of the information contained within his book, the DASH diet, exercising, losing weight, quit smoking, limit or totally stop any alcohol intake, etc.  “Nothing new in all of that, I thought to myself, I had already been doing that.” 

I flipped to another book chapter.  Nutrition, hmm, that’s a different slant.  As I quickly scanned the chapter he was speaking about all of the various minerals and vitamins our body needs to support our vascular system.  Okay, that makes sense, it’s just basic physiology, what’s the big deal? 

Well it was basic physiology that he was applying to a rampant health problem, hypertension.  He would discuss a particular mineral or vitamin and then talk about how it applied to blood vessel vascular physiology.  His discussion of it would then immediately be followed up by study upon randomized study of how effective the nutritional supplement was in decreasing a person’s blood pressure. 

I thought to myself, “okay the studies he was discussing had to be published in journals of ‘no repute.”  No way were they published in major medical journals such as Circulation, British Medical Journal, New England Journal of Medicine.  So expecting to see some unknown journal article as references I was totally surprised to see reference upon reference for the studies as being published in major and very distinguished medical journals such as New England Journal of Medicine.

That’s when my interest became more than a little piqued.  I planked my monies down at the cashier’s and walked out with the book.  I read it through in one night’s sitting. 

I thought to myself, “okay no one is going to be the wiser to my plan.  I’ll give what he had to say about the vitamin and mineral supplements a try for one month, if they don’t make a difference in my blood pressure, then I’m the fool, and no one will ever know.” 

Well two weeks into my new plan, I started to notice a change, my pressure readings were decreasing.  And amazingly, a nice side benefit was that my hot flashes which had come every forty minutes were gone.  Hmm, was I onto something in regards to Dr. Houston’s book?

One month into my trial of the vitamins and minerals I was now taking, my blood pressure readings, which originally been upon my diagnosis in the range of 170/100 were now totally normal and stayed normal all day long and went down to 100/60 when I slept.    

I continued to take my blood pressure readings for two more weeks and every time, the same, a normal reading.  My follow-up appointment with my internist was coming up in a few days.  How would I explain what I did to him?  He’d probably have the same reaction I initially did, “yeah, right, you’re just another alternative medicine kook now!”  

  Nutrition, eating right, I came to conclude, was more than just eating a salad for dinner, or limiting my salt intake, or watching my weight.  It was  more systemic than that.  It involved eating the right foods, in the right combinations, each and every day.  It involved giving my system what it needed to physiologically function the way it should.  It involved giving it the magnesium it needed, the calcium, the vitamin C and omega fatty acids it required to function at it’s best. 

That’s when I started to think, as a group of medical providers (both physicians/PAs/NPs) our medical knowledge of nutrition is truly lacking.  How many classes during my PA program did I take in nutrition?  A big fat zero, that’s how many! 

How many times had I snubbed my nose up at a patient when they came in telling me they were on this or that vitamin or taking that alternative medicine?  Too many to count.  And it wasn’t until my own system called me up short, gave me all sorts of problems with prescriptive medications that I started on a new path of learning more about proper nutrition, and the appropriate use of vitamins/minerals our body requires. 

I thought I had basically learned clinical medicine and was comfortable in what I knew after 17 years in the field.  Well this experience taught me even more, it opened my eyes to the field of nutrition, opened my heart to learning something new, and closed the door on my judgmental attitude when it came to patients who walked into the clinic room and told me he was taking a form of some alternative medication.  Next time, I’m going to be more willing to read the medical evidence behind the supplement, and not be so quick to judge. 

Not only has my own personal health benefited from such an attitude, but so can each and every one of my future patients.

Tuesday, November 8, 2011

Persistent Headache in a 35 year old Woman

I was working in the urgent care clinic when I went into see my next patient.  She was a 35 year old who was sitting on the exam table, holding her head in her hands, looking down at the floor.  It seemed my entrance into the room didn’t even stir her. 
“Hi, I’m Sharon,” I said to the unmoving patient. 
“I’m Shelly,” was her response.
“How can I help?”
Without moving again, Shelly replied, “I ran out of my Imitrex and I need some for this migraine headache I have right now.”
“I see.  Well what can you tell me about your migraine history?”
“Is there anyway to dim those overhead lights?” Shelly asked.
“Well, I can turn them off and just use these smaller desk lights if that will help.”
“Yes, please,” she sighed.
I turned off the overhead lights and walked back over to the desk to turn on the smaller desk lamps.  The room was definitely darker.   With that, Shelly let out her sigh of relief and sat upright. 
“Is that better?”
“Yes, thanks.  You asked about my migraine history.  I’ve had migraines since I was in college.  Maybe it was the stress that brought them on, I don’t know.  But back then my family physician totally worked me up for them with a CT scan, some lab work and didn’t find anything.  He treated me with naprosyn which after two years quit working.  Then I was switched over to Cafergot, which worked until I had my first child 10 years ago.  At that point he wanted me to see a neurologist.  So I saw Dr. Hummel, who’s wonderful. “

Migraines affect 12 perecent of all patients.  It’s more frequent in women than men, and it’s most common in those aged 30-39. 
There are some typical factors that will trigger a migraine.  These can include: 1) menstrual changes, 2) emotional stress, 3) not eating, 4) changes in weather, 5) sleep disturbances, 6) odors, 7) alcohol, 8) lights, 9) smoke, 10) neck pain, 11) heat, 12) foods, 13) exercise, 14) sleeping in.  Obesity is associated with an increased frequency and severity of migraine. 

Typicallly there are four stages of a migraine.  Prodrome (24-48 hours prior) which can include euphoria, depression, food cravings, constipation, etc.  Aura: this can involve visual changes, sensory changes, verbal or motor disturbances.  Migraine headache: tends to be throbbing or pulsatile, typically on one side of the patient’s head, nausea, vomiting, problems with light sensitivity or sound sensitivity.  Then there is the postdrome: after the headache is gone patients can feel drained or exhausted. 

Migraines, if left untreated can last at long as four hours or be around for as long as several days.  There are several different forms of migraine: menstrual migraine (those migraines associated with the patient’s menstrual cycle, they can show up two days prior to the cycle and stay around for 3 days into it), basilar-type, ocular migraine, migraine headache without aura. 

“Dr. Hummel looked over my records and thought I might have menstrual migraine seeing that I quit responding to Cafergot with my pregnancy.  So he decided to try and treat me with a low dose of Inderal for 6 days a month, 3 days prior to my period and 3 days into my cycle.  That has really helped me out.  It’s dropped my migraines down from 2-3 a month to usually one a month.  The migraine I have with my period is gone but I still get one about mid-cycle, which is where I am right now. “
“Dr. Hummel gives me imitrex to take for the headache I get in my mid-cycle.  But I’ve run out of them and I don’t see him again until next month.  I generally have to take an Imitrex twice a day for two days and that takes care of my migraine. “
“So where are you right now, have you taken any Imitrex for this headache?”
“I had two left, so I took them yesterday, but I didn’t have any for today and my headache has just rebounded back without the imitrex.”
“Okay, so knowing that you were going to run out of your Imitrex before you saw Dr. Hummel, why didn’t you call his office and get a refill of it until you saw him next month?”
“Well, I called his office and I was told he was on vacation and therefore my refill wouldn’t be taken care of until he returns on Monday.”
“I see.  So what medications are you on?”
“I take Imitrex for the two days once a month for my migraine, I’m on Inderal for 6 days a month.  I also on a birth control pill, yaz.”
“Okay, anything else in your medical history?  Any high blood pressure, diabetes, etc?”
“No, just my migraines.”
“Are you allergic to anything?”
“Does anyone in your family have a history of migraines?”
“My aunt has them, I’ve been told.”
“Alright, well then let me do a quick physical exam and then I’ll refill your Imitrex prescription until you can get into to see Dr. Hummel again.”
The patient didn’t have anything significant on her physical exam, which included her neurological exam which was normal. 
“Okay, Shelly, what dose of Imitrex do you take?”
“Dr. Hummel has me on 25 mgs. of Imitrex twice a day when I have the migraine and it makes it go away.  Sometimes I have to take the Imitrex three times a day, like every 8 hours instead of just taking two a day.  That’s what happened with me last month.”
“What about any nausea, do you take any meds for that?”
“I don’t have any nausea, if I take my Imitrex soon enough.”
“Alright, well then here’s you a refill of your Imitrex medication, it should get you through next month until you see Dr. Hummel again, okay?”
“With a heavy sigh of relief, Shelly took the prescription from me and left the exam room. 

There are various treatments for migraines.  They can involve acute therapy, chronic prophylaxis (prevention of the headache), and avaidance of triggers. 

Acute therapy can include: Tylenol, NSAIDs (naprosyn, motrin, etc), ergotamine medications (Cafergot), and triptans (Imitrex and 4 other triptans).  Chronic prophylaxis for migraines include: blood pressure medications (beta blockers such as Inderal), ace inhibitors, calcium channel blockers, angiotension receptor blockers, Elavil, or even CoQ10 enzyme supplement.    

Wednesday, November 2, 2011

Eye Pain in a 20 Year Old Patient

I walked into the urgent care clinic exam room at about 6 pm one evening,  to see a new 20 year old obese African-American patient.  She was there with both of her parents. 
“Hi, I’m Sharon, how can I help?” I asked.
TaRhonda stood there leaning against the exam table with her hand over her left eye.  She moved her head up a little bit and mumbled, “my left eye hurts again and I’ve got this green stuff on my eyelids.”
“Okay, when did this start?”
“Last night,” replied TaRhonda. 
“You’re protecting your eye, which tells me that light hurts your eye?” I asked.
TaRhonda nodded her head ‘yes.’
“What about your sight, are you having problems with it out of your left eye?”
TaRhonda mumbed, “it’s blurry.”
“How bad is the pain in your eye?”
“It’s a constant hurt on this side of my face, “ TaRhonda replied as she gently stroked her left side of her face with her right hand.
“Can you take your hand away from your eye so that I can see what’s going on?”
TaRhonda moved her right hand towards the light switch and with a few flicks of her free hand up and down, motioned for me to turn the overhead light off.
“You’re telling me you need the light off?” I confirmed.
TaRhonda moved her head up and down with a positive nod. 
I turned the overhead light off,  afterwhich TaRhonda moved her hand down, and using the wall mounted welch allyn otoscope’s light I shined it on TaRhonda’s lower left forehead so as to not shine direct light into her eye.  The reflected light showed green drainage coming from her left eye, it was very injected, red, and looked somewhat swollen.  I looked at her right eye and it was normal. 
“Okay, I’m going to give you a clean small dressing to put over your eye with some tape so that your hand doesn’t have to continue to protect it from the light.”
Hearing this, TaRhonda nodded ‘yes’ with her head.
After TaRhonda taped the dressing to her face I turned the overhead light back on. 

This patient had typical signs of scleritis, which means inflammation of the sclera, which is the fibrous outer coating of the eyeball.  Evidence of scleritis includes:
1)      Redness of the eye
2)      Pain
3)      Being light sensitive
4)      Visual changes in the affected eye

Patientts who have scleritis typically are young adults.  Many times the cause of scleritis is idiopathic, meaning ‘unknown.’  But in 50% of the cases the patient’s scleritis is a sign that they have an auto-immune disease (i.e. their immune system is attacking themselves), or they have an infection from a virus (herpes) or tuberculosis. 

“Okay, you said that you’d had this before, when was that?”
TaRhonda’s mom who had been sitting in the one exam room chair was primed and waiting for this question.  She quickly handed me a slip of paper with the name of two medications listed on it.  In a demanding tone, she said, “she’s needs these two medications, that’s all we need from you.  We came here so that she wouldn’t have to be seen by the eye doctor.”
I took the slip of paper and looked at the two medications listed on it.  One of them I wasn’t familiar with, and had to look up what it was.  After I checked what the second medication was, it confirmed what I had been thinking.  TaRhonda’s eye condition was something an opthalmologist had to take care of, she most likely had scleritis.  The second medication was an opthalmic non-steroidal medication.  The first medication listed was a mixture of steroids and antibiotics in an opthalmic drop solution. 
I turned to TaRhomda and asked her when did the first episode of her eye condition happen.
“I think about 6 months ago.”
“Who did you see for it?”
“An eye doctor near our house.  He gave me both of those medications on the list, my mom gave you.”
“Well, I’m going to give you an opthalmic eye drop for any possibility of a bacterial infection, but I need you to call first thing in the morning the opthalmologist you saw 6 months and make sure you see him tomorrow.  You have to be seen by him tomorrow, you don’t have an option about that, do you understand?”
After barely getting those words out of my mouth, TaRhonda’s mom immediately said in an irritated, inpatient voice, “all she needs is these two meds,” flipping the piece of paper in her hand.
“I’m sorry, but TaRhomda has to be seen by her opthalmologist tomorrow, she doesn’t have an option about that.  She most likely has scleritis again and that demands an opthalmology appointment within 24 hours.”
TaRhomda’s mom now yelling at me, “you don’t understand, all you need to do is give her a refill of these two meds and she’ll be fine, just like she was before!”
Turning to TaRhomda’s mom I replied in a firm voice, “I’m sorry, I’m not allowed to prescribe opthalmic steroid drops, nor am I allowed to prescribe the non-steroidal opthalmic drops.  Both of those drugs have to be prescribed by an opthalmologist.  He has to see her and follow her to make sure this heals correctly.”
Her mom replied in an angry voice, “just give us the meds, damm it!”
“I can’t, they’re out of my scope of practice.  She has to be seen by an opthalmologist tomorrow, there’s no choice about that.  I’m sorry.”

Patients with scleritis have to be seen by an opthalmologist (eye physician) within 24 hours of their being seen by their primary care physician.  The opthalmologist will then treat them with an anti-inflammatory opthalmic drop solution, or possibly steroids.  This will calm the inflammatory response down.  They also have to follow the patients for any visual changes which can occur.  After the scleritis has been treated, the patients then need to be sent to their primary care physician for a thorough work-up of any possible auto-immune disease.  If one is found, this needs to be appropriately treated. 

At this point, TaRhonda’s  dad finally chimed in.  In a quiet questioning voice he asked, “You’re telling us that she has to be seen by the opthalmologist who saw her six months ago.  Why does he have to see her?”
I turned to TaRhonda’s dad standing at the end of the exam table and explained, “TaRhonda has had a previous episode of scleritis.  Now she most likely has a second episode in her same eye.  The opthalmologist has to see her to treat her appropriately.  But more importantly he is probably going to be in contact with your family physician and get a work-up ordered for the possibility of an auto-immune disease, which this scleritis could be a sign of.”
“You think she has the same problem as she did last time?”
“Yes, I think so.”
“What sort of auto-immune disease could she have?”
“There are several auto-immune diseases that she could possibly have.  That’s why she needs to be worked up for them.  And of course, auto-immune means that her own immune system could be attacking herself.”
“My sister has lupus, that’s an auto-immune disease, right?”
“Yes, lupus is one of the auto-immune diseases.  But just because your sister has lupus doesn’t mean that your daughter has it, please understand that.”
“I understand.  Can you write down exactly what we are supposed to say to the person who answers the opthalmologist’s phone in the morning?”
I took a piece of paper and wrote down exactly what was supposed to be said so that TaRhonda would be seen tomorrow and gave it to her father.  “Here, this is what you need to say, “ as I handed him the paper as well as TaRhonda’s prescription for her antibiotic eye drops.
“Thanks.  Let’s go, TaRhonda, let’s get your one prescription filled and then I’ll call first thing in the morning for you an appointment to be seen by the opthalmologist again.” 
With that, TaRhonda’s mom grumbled under her voice as she got up to leave, and TaRhonda meekly followed her father out of the exam room.
As they left, I breathed a sigh of relief.  I never liked having to deal with confrontational situations.   

Tuesday, November 1, 2011

Your Comments are Welcomed!

To all my readers:
I've posted  > 40 patient stories of people I've seen and taken care of.  I have many more stories to eventually post, but I'd love to have you post some comments back to me and tell me what you would like to read and learn about.  Some questions you might want to think about:
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3) What sort of patient stories would you like to read that would help you?
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I'd really like to hear from you.  So please do post your comments, I've had 1200 hits on my blog so far, and I'd love to hear what you have to say.