Thursday, November 22, 2012

A State Patrolman

I was working in an out-patient medicine clinic when I went into to see my next scheduled patient.  He was a 50ish year old cop who worked for the State Patrol.  As such, he had ended up chasing more than enough suspects through the open fields, as well as in and out of old buildings.  But he loved his work so much he didn’t want to stop doing it, even though he had received several offers over the years for promotion.  Being a street cop was what got his juices going, he told me. 

I knocked on the door, and then opened it to find Stan sitting on the exam table.  I had known Stan for a while, He was always enjoyable to talk to, as he usually told me of his latest escapade catching yet another suspect. 

“Morning, Stan, what brings you in today?”
“My knee.  I think I really did it in this last time chasing a suspect up and down one of the rocky hillsides.”
“Okay, which knee and what day was this?”
“It’s my left knee, and it was three days ago.  My knee hasn’t quit hurting since.”
“Okay, what were you doing, exactly, like did you feel your knee give out on you, or did you fall down on it, what exactly happened?”
“I don’t remember much about my knee that day, I was trying to nab this suspect with the help of another patrolman.  He took off running and before I knew it, he was trying to climb up a rocky incline that had a lot of loose dirt.  I started climbing the rocky incline and my partner took off running up the grassy side of the incline to get to the top of the hill before the suspect.  The suspect didn’t make it up the incline, he kept sliding back down, so I was finally able to nab him and pull him down.  My partner immediately slid down the incline on his butt and grabbed his cuffs to put on the suspect.  We were standing him up as I was reading him his Miranda rights.  It wasn’t until after we got the suspect back in my partner’s patrol car that I started noticing my knee was hurting.”
“Well, you know as well as I do, that you have had a couple of injuries to both knees over the years.  You also played sports as a kid for many, many years.  So you knees are not what they used to be.”
“I know.  I talked to my supervisor yesterday and he re-offered me the permanent desk job I was offered six months ago.  The department still wants me to do it.  I’ll be heading up the drug smuggling operations in the state, which is what I’ve basically been doing out in the field for too many years.  I told him I would do it.  I know my knees can’t handle anymore running, climbing and wrestling suspects out in the field.”
“Good choice, Stan.  Now, let me take a look at that knee.”

His left knee was a little swollen over the medial side (inner side) of his knee, right next to his kneecap.  He did have some increased heat felt there and it was tender to palpation.  There was also a small amount of fluid felt. 
“Stan, I think you have patellar bursitis going on.”
“What’s that?”
“It’s a condition where the bursa, or fluid sac between your knee cap and your knee has become inflamed or swollen.  It therefore hurts to walk.  I’ll start you on some anti-inflammatory medication called motrin and have you take it three times a day for the next two weeks.  I also want you to put either an ice pack or a heating pad on the inside part of your knee here where it hurts.  Then I want to see you back in two weeks.”
“Okay, but why do I need to come back in and see you?”
“Well, take a look at your knees, don’t they look a little like door knobs to you?”
“Yeah, now that you mention it, they do.”
“Well, remember what the orthopedic surgeon told you a few years back when you injured your left knee and he went in and repaired your ACL (anterior cruciate ligament which helps stabilize the knee joint)?”
“Yeah, he said something along the line that I was going to end up with arthritis in my knee before too long because he saw several bony growths in my knee with his scope, which he proceeded to remove.”
“That’s right.  I think in two weeks you’re going to come back in here, the bursa is going to be healed, but you’re still going to be in pain due to the presence of osteoarthritis.  Those ‘knobby knees’ tells me that you now most likely have osteoarthritis, so you took a desk job in time, thank goodness.”
“Oh, brother.  I was hoping that wasn’t going to happen for a while.”
“Well, let’s see how you’re doing in two weeks and take it from there.”

Risk factors for acquiring osteoarthritis include:
--age (the older you are the more likely you are to have it)
--female sex
--obesity (the more weight your joints carry on the more likely they are to breakdown)
--lack of osteoporosis (the higher the bone density in women, the more likely they were to  have osteoarthritis)
--occupation: those who do a lot of bending, squatting, stair climbing have a higher risk
--previous injury to the joint from playing sports, etc.
--weakness of the quadriceps muscle (the major muscle that goes the length of the upper portion of the leg, on the front side)
--gout:  crystal deposition from gout eventually destroys the cartilage
--gene inheritance

Stan returned in two weeks for his follow-up exam.  His bursitis was almost gone, but I had been right, his knee pain was still present. 
“So, tell me Stan, what’s going on with your knee now?”
“It still hurts, mostly on the inner side of the knee.  I’ve also noticed that it occasionally makes a ‘cracking sound.’”
“Well, the cracking sound is what we call, crepitus.  That’s a sign of osteoarthritis.  Let me take a look at your knee and then we’ll take it from there.”
Stan had what I thought I would find.  His tests for any lateral or medial (basically side to side) movement which is called a varus and valgus stress tests were negative.  His anterior drawer test was negative (a movement where you try to pull the knee out towards you while it is in a 90 degree angle).  His increased heat I had felt was gone. 
“Stan, the orthopedic surgeon was correct.  You now have osteoarthritis in this knee.  It’s not going to get much better, it’s a chronic condition that typically slowly progresses and some patients end up having to receive a total knee replacement due to their pain and limited mobility.  What I want to do is send you to the physical therapist and let them help you with daily exercises you can do for your knee which will help with all of the pain.  I also want you walking at least 30 minutes a day on it.  If you can find a swimming program, in other words water aerobics class nearby sign up for that.  You don’t need to lose any weight, which most people do, so that doesn’t affect you.  I want you to continue with your daily motrin which will help with your pain.  I’ll see you back in two months after you’re done with the physical therapist, okay?”

To diagnose osteoarthritis of the knee, the following must be present:
--knee pain (not related to acute trauma)  AND
Within the following scenario: (3 of the following 6 signs must be present):
--age > 50 yrs
--morning stiffness for less than 30 minutes
--crepitus (crunching sound) upon active motion of the knee
--bone tenderness
--bone enlargement (patient generally looks like the have ‘knobby knees’)
--no increased heat felt over the joint

Most patients should have the following done prior to their receiving a diagnosis of osteoarthritis:
--a sed rate (to make sure that the arthritis is not related to any auto-immune disorder)
--rheumatoid factor titers (to rule out any auto-immune disorder)
--withdrawal of some joint synovial fluid (to assess it for any presence of crystal formation which would lead you to believe it is gout)
--x-rays of the patient weight bearing which should show decrease in the cartilage space as well as osteophytes (excess bony growth)

Treatment of osteoarthritis includes:
--weight loss (if the patient is obese)
--exercise program (water aerobics is especially good seeing that it gives buoyancy to the body and helps to support the joint)
--wedged shoe insole
--over the counter medication: glucosamine and chondroitin

If the above does not deal with the patient’s pain then full dose Tylenol is generally put in the mix (at 3,000 mg a day).  If patients have failed Tylenol then they can be tried on a NSAID (non-steroidal anti-imflammatory drug).  An NSAID can be either motrin (ibuprofen) , naprosyn (aleve),  celebrex or other forms of NSAIDs.

If NSAIDs don’t work then patients can have their knee injected with steroids, which generally gives relief for several weeks up to 3 months.  Narcotics can be used intermittently, if at all.  If the symptoms persist beyond this and the patient has significant functional impairment then they are seen by an orthopedic surgeon for a total knee replacement. 

Stan returned in two months.  His knee felt better, he had stayed with the physical therapy program and was doing daily knee exercises at home.  He was also walking every day after work.  He was glad that he had switched over to the desk job, he noticed his knee wasn’t so swollen and painful due to him resting it at work during the day. 

Due to his age, I could assume, down the road that he would need steroid injections from the orthopedic surgeon and then eventually a knee replacement, He had just done too much damage to it over the years.  But at least the State Patrol now has someone in charge behind his desk who really knows the ins and outs of drug smuggling along the state’s highways and interstates. 

Tuesday, November 20, 2012

A Father's Love

I was working in an infectious disease medicine group at a major academic hospital.  The holidays were fast coming upon us, so the hospital was all decked out with merry decorations of green and red.  As I came into work that day I was still feeling stuffed from all that I had eaten the day before on Thanksgiving.

Usually such a holiday weekend, though being a long with needing to work 3 days, would be quiet.  We didn’t get a lot of admissions, and most patients were asking to be discharged, instead being followed as out-patients. 

It was into this picture, that I received a page from my supervising physician to go down to the emergency room and see a 35 year old male patient.  From the sounds of it, he was ill and needed to be admitted to the hospital.  I scurried down to the emergency room and began working the new patient up.

Upon arriving in the emergency room, I walked over to the curtain and pulled it aside.  Laying in the bed was a middle-aged man, with his eyes closed trying not to move.

“Hi, I’m Sharon, I’m a physician assistant and was asked to come down and see you.  Am I to assume you’re Tom Arnold?”
“Um, yeah, I’m Tom.”
“I’ve been told you have a really bad headache and a fever.  What can you tell me about your symptoms?”
“Um, can you pull that curtain behind you, so that it’s closed?  The light is really bothering my eyes.”
“Sure,” and with that I pulled it closed again, trying to block as much light as I could from the emergency room overhead lights.
“Okay, can you tell me when you started getting sick?”
“Yesterday, I woke up not feeling very well, but with it being Thanksgiving and all I had to get up and help my wife keep an eye on our three kids.  So with my keeping an eye on the kids, my wife stayed in the kitchen fixing our holiday meal.  As yesterday wore on, I started feeling worse, my head really started hurting and I started feeling somewhat nauseated.  By dinner,  I just didn’t want to eat, I was afraid that I would just throw it back up.  So I sat at the dinner table and just sipped some cold water.  After dinner, I couldn’t stay awake any longer, I felt so bad I went back to bed.”
“So, when did you fevers start?”
“Probably some time in the afternoon, yesterday.”
“Do you have any other symptoms?”
“Yeah, now that you ask, my neck really hurts.  I also have a runny nose, it’s like a water faucet, just clear drainage.”
“Any rash, or other symptoms?”
“Anyone in your family ill, lately?”
“Yeah, my three year old son just got over a really bad cold, he’d had it for over a week, before he finally cleared the cold virus.  I spent quite a few nights rocking him to sleep because he was having a hard time sleeping due to his cough and nasal congestion.”
“Okay, well I have a few more questions for you.  Do you have any chronic medical conditions, such as hypertension, or diabetes?”
“So, you’re not on any daily medications?”
“No, I don’t take anything.”
I asked him about his family history, social history and found out that it was all non-contributory.  He worked as an electrical engineer for the local gas company.
“We’re going to have to do a lumbar puncture on you to see whether you have meningitis.  I’ll also have the nurse come in and draw blood cultures, a blood count and blood chemistry panel on you.  I’ll be back with the infectious disease fellow who will do the lumbar puncture.    I see that they have already started an IV on you and begun to run some fluids into you, which should help to bring down your fever of 102 F.  I’ll also have the nurse give you some Tylenol for your headache/fevers.   We’ll get the testing done as soon as possible.   Any questions?”
“No, I don’t think so.  What do you think I have?”
“It sounds as though you have meningitis, it could be viral meningitis, seeing that your son has had a  cold.”
“Oh, that sounds bad.”

“No, not necessarily.  Let us finish our testing first.  Let me go get the nurse assigned to you to draw your blood work and I’ll come back and do my exam, listening to your lungs, heart, etc.  After that I’ll page the the infectious disease fellow to come down and do your lumbar puncture.”
“Um, okay, as long as I can get that Tylenol pretty quickly, my head is just throbbing.”
“I’ll be back shortly.”

A half-hour later, I had completed the patient’s physical exam and the nurse had gotten all of his blood work drawn.  Besides his stiff neck and runny nose I didn’t find anything else on his physical exam.  I called my infectious disease fellow and he showed up within a few minutes to do the lumbar puncture.  After drawing off several tubes of spinal fluid, the ID fellow left and I completed writing out the admission orders.  Now it was time for the lab to tell us what the cell count was and we would know shortly what kind of meninigitis we were dealing with. 

Patients who present with meningitis generally have acquired it from one of several risk factors. 
Viral meningitis:  which is typically caused by herpes, HIV, mumps, varicella (chicken pox), or enterovirus (typical common cold virus for instance).
Fungus (in immunocompromised patients who are on chemotherapy for cancer, for instance),
Tick borne from lyme disease or rocky mountain spotted fever,
Bacterial related, such as from strep bacteria, gonorrhea strains, H. flu
Neoplasm spread: usually from leukemia
Drug induced: several different drugs can induce a meningitis type picture

The usual signs and symptoms of meningitis include: light sensitivity (photosensitivity), nausea, vomiting, fatigue, malaise, neck rigidity, headache, fever, abrupt onset of symptoms as well as a possible rash.  Patients typically look ill, they don’t want to move around and they prefer a dark room.

I went back upstairs and joined my team on afternoon rounds, which had just started. Twenty minutes later the ID fellow was paged and came back to tell me that our new patient we had seen in the emergency room looked to have viral meningitis, based on his spinal tap results.  The nurses were getting him situated on 21East, a medicine floor.  That was our next floor down, so the team would be seeing him shortly.

The patient’s cell count from his lumbar puncture showed him to have a white blood cell count of 150, a normal glucose, a normal protein count.  His blood work showed that he had a blood white blood cell count that was predominately lymphocytes (which fight off virus’), a normal chem 7 (electrolytes and renal function).  With the history of his son having a recent viral infection, he did indeed have a case of viral meningitis.  So now he just needed to be kept hydrated, get plenty of Tylenol for his headaches, give him some Ativan for his nausea/vomiting and see how he was in the am.  If he, as other patients with viral meningitis have done, felt better then we could discharge him home and have him see his primary care physician in a week to make sure all of his symptoms had resolved. 

Doing a lumbar puncture (spinal tap) is the most important test to do on patients who are suspected of having meningitis.  The various tests that we can run on the spinal fluid tells us a lot.  The cell count will tell us whether we are dealing with a viral infection (the count will come back with a predominance of lymphocytes), bacterial infection (cell count will be a predominance of neutrophils), or some other etiology, such as neoplastic spread (immature cells called blasts will be present).  Gram staining will be positive if it is a bacterial infection.  In bacterial meningitis there is also usually a high protein and low glucose count.  (bacteria produce protein, use glucose). 

Blood counts for the patient’s white blood cell count, differential of those white blood cells, as well as the patient’s electrolytes and renal function (kidneys) is important to know.  Electrolytes and renal function will tell you how hydrated the patient is (i.e. how much nausea/vomiting they’ve had). 

Patients who have a bacterial origin for their meningitis need to be started on IV antibiotics immediately after their spinal tap.  The type of IV antibiotics is based upon the patient’s age, immune status, and possibly risk factors.  They also need to receive IV hydration to help keep their fever down as well as help prevent any pre-renal azotemia (dehydration that leads to increased renal parameters, i.e. renal insufficiency.)

The following morning before rounds I went to go check on my newly admitted patient.  He was sleeping comfortably, with his wife sitting in the chair besides him.  I quietly asked her whether he had been able to eat anything and she said he had a snack last night and keep it down.  The nurse’s notes stated that his fevers had stayed down with him being on Tylenol.  I excused myself and went out to the nurse’s station and began writing his discharge orders.  This father would do fine.  He had learned yet another lesson in parenting, how kids love passing on their bugs to anyone around them, especially their mom and dad. 


Tuesday, September 25, 2012

A Nurse Manager

I was sitting next to my gastroenterology clinic nurse reviewing a couple of patient phone calls and what they needed, so my assigned nurse could take care of them.  As we were finishing up the last patient contact, when in walked the clinic nurse manager, Kate. 
Kate leaned up against a desk close-by and waited for my clinic nurse and myself to finish our conversation over the last patient contact. Then she asked, “Sharon, what causes leg pain when I’m out walking my dog?”
I had a quizzical look on my face as I turned to face Kate.  “What do you mean by leg pain, Kate?”
Kate replied, “Well when I’m out walking my dog every morning and after I get home at night I’m able to walk about 3-4 blocks before I have to sit down somewhere and rest my legs, they become heavy and my lower legs just hurt.  I rub them which helps, and after a few minutes I’m able to stand back up and walk home at which time my legs hurt again.”
“Kate, that sounds like you could have some peripheral vascular disease.  What’s your family history, is there any cardiovascular disease in your family members?”
“Yeah, my younger brother is 53 and he’s had a heart attack, a subsequent surgery to have a quadruple bypass.  My dad died from a heart attack when he was 60.  My mom is in her 80’s and has congestive heart failure due to long standing hypertension (high blood pressure).”
“Okay, that’s a rather positive family history for cardiac disease.  When was the last time you had your lipids checked?”
“I haven’t had them checked.”
“Well, then I would make an appointment with your primary care provider pronto, let him know what your symptoms are, make sure to get your lipid levels drawn and ask him to send you to an interventional cardiologist who can assess your vascular structures in your legs, you’ll probably end up with having either stents placed or the cardiologist will do a balloon angioplasty based on how extensive your disease is.  The cardiologist will also send you to a cardiac rehab program so you can be involved in a supervised exercise program.”
“You think my problem with my legs is due to a lack of blood flow?”
“That’s what it sounds like.  I seem to also recall that you used to be a smoker and quit about 10 years ago, right?”
“Yeah, that’s right.”
“Well, that’s another risk factor for peripheral vascular disease.  So if I were you, go make that phone call to your primary care provider.  In the meanwhile, you can take a baby aspirin every day until you complete your work-up, that will help your platelets to not stick to each other.”
“Thanks for the info, Sharon.  I’ll start the aspirin today and go call my primary care provider.”
“Let me know what happens, Kate, good luck.”
“Sure thing.”

Peripheral vascular disease, is a disease of the lower limbs where they have atheroslerotic plaques within the blood vessels.  Peripheral vascular disease is very similar to coronary artery disease, where there is plaque formations in the coronary arteries.  As just like in the coronary arteries, which have plaque formations with patient’s having angina (chest pain) due to not enough blood flow being presented to the heart muscle, the same thing happens in the legs.  The plaque formations prevent an adequate amount of blood flow from getting to the legs/muscles.  When this happens patients end up with leg pain.
The risk factors for peripheral vascular disease include: 1) hypertension, 2) hypercholesterolemia (high levels of blood lipids or fats), 3) history of smoking, 4) diabetes.
Most patients also have a family history of cardiac disease, which Kate’s family had. 
Patients can present to their clinician with symptoms (as in Kate’s case) or be asymptomatic.  20-50% of patients will be asymptomatic, 40-50% of patients will have atypical leg pain, 10-35% will have classic claudication symptoms, and 1-2% will have critical limb ischemia (totally impaired lack of blood flow).    

I didn’t follow-up with Kate for several weeks, due to a busy clinic seeing patients.  One day in clinic I was sitting at my clinic nurse’s desk, signing some prescriptions for patients that needed to be faxed off.  Kate just happened to walk by my clinic nurse’s desk and I called out her name. 
“Kate, hey what happened about your leg pain?”
Kate turned around and seeing that there wasn’t anyone else in my clinic nurse’s office, she walked in and sat down. 
“Sharon, I saw my primary care physician a few days after we talked about a month ago.  He ordered my lipid panel and it came back with high levels, so I’m on 40 mgs of lipitor.  He also listened to what I had told you and immediately sent me off to the cardiologist over at the University who specializes in peripheral vascular disease.”
Kate continued, “I saw the University cardiologist, and he ordered an arteriogram of my lower legs.  They found quite a bit of atherosclerotic plaque in both legs.  So, as you probably know I was gone on Friday, that’s when the interventional cardiologist went in and did a balloon angioplasty on one of the lesions and put in a long stent into another lesion in my leg.  Both of the lesions were up in my femoral arteries.  I’m still a little sore from the procedure site today.  I’ve been referred to the cardiac rehab program and I’m supposed to start it later this week.  But the one good thing is that I’ve been walking my dog and my leg pain is gone.  So now every day I’m having to take two medications, the lipitor and cilostazol, which is supposed to help with my intermittent claudication.”
“Oh, Kate I’m so glad you got everything worked up.  Is your cardiologist going to order any additional testing on your heart, like looking at your coronory vessels to assess for plaque there?”
“Yes, I’m scheduled for that in about 3 weeks.  The cardiologist told me that he can only give me so much dye in one sitting, so that’s why he did my legs first, seeing that I was symptomatic from my legs.  He told me that I could have some plaque that needs to be taken care of in my coronary arteries, so I’m scheduled for a coronary CT calcium scan in about 3 weeks.  He told me that based on my test result, he may have to go in and do a coronary angioplasty on any plaque found there.”
“Well, I’m glad that you are getting everything taken care of.”
“Well, I owe you a big thank you, had you not told me what it was I would have just continued to ignore it.  It was a wake up call for me.  I knew my brother and dad had coronary heart disease, I just never thought I would have it.  I thought I was taking care of everything by quitting my cigarette smoking and keeping my blood pressure under control by keeping weight off and walking my dog every day.  So thanks.”
“You’re welcome.  Talk to you later, I have to get going, I’ve got some work to do back in my office.”

Prevalence of peripheral vascular disease increases with age.  For those over age 50 the prevalence is 2.5% in the general population, for those over age 60 the prevalence is 4.7%, and for those over age 70 the prevalence is 14.5%. 

A quick and easy way to determine whether a person has peripheral vascular disease is to do take a blood pressure reading of the patient’s ankle vs. their brachial artery.  The two systolic pressures are compared.  If the pressures are the same, i.e. comparison is 1 to 1, then this is considered a normal test.  If the pressures are different, i.e. less than 1 to 1, ankle systolic pressure less than the brachial pressure, <.9 then this is considered a positive test and the patient most likely has peripheral vascular disease.

Patients are treated for peripheral vascular disease based on how extensive the plaque formations are.  Type A formations usually show only a single formation.  Type B is multiple plaques.  Type C is multiple, long lesions.  Finally, Type D is lesions which are 20 cms or longer.  Based on the type of lesions patients have they receive either medical intervention (balloon angioplasty, stent placements) or surgical intervention (arterial bypass, i.e. some type Cs and all type Ds).  

Thursday, September 20, 2012

A "Skunk Whisperer"

Recently, I was doing some temporary locums work as a PA in an occupational medicine clinic.  This type of clinic is for employees who have been hurt on the job, and their employer sends them into be seen by us, for medical treatment.

I knocked on the exam room door and walked in to be greeted by a women in what looked to be a police uniform.  The patient’s name was Anita.  After introducing myself, I began asking her some questions as to what happened that brought her to our office. 

Anita replied, “I was retrieving a skunk this morning,  which had wandered into a guy’s kitchen.   In trying to remove the little critter, I snagged him with my long nosed skunk handler.   I then flung the skunk a short distance out the open back door, and into the guy’s back yard.  Using the long nosed handler allows the skunk to go airborne for a short distance.   So I aimed my fling for a pile of dead leaves where I knew the skunk would land and then wander away, like it should.  Well, the skunk landed in the pile of leaves, then  shook his head and slowly walked off.  The only problem was in my using the long nosed handler, my finger got caught in the hand gripper and now it hurts.  So I need you to take a look at it.”

All the while, Anita was telling me this, my eyes were getting wider and wider, and my jaw was beginning to drop.  My facial expression went from a quiet content, listening to a patient’s story, to one of ‘no way, did you just do that!”

“Ok, Anita, I’ve heard of ‘dog whisperers, horse whisperers,’ but never a ‘skunk whisperer.’  How many times have you been sprayed by them?”
“Never?  Like zilch, never?”
“That’s right.”
“How many times do you have to go out and deal with a skunk?”
“About 3-4 times a week.”
“And you’ve never been sprayed?”
“Okay, now I have to know, how do you manage that?”
“I just understand skunks.  I know what they’re going to do, and I use my long nosed handler in such a way that it doesn’t hurt the skunk and they can’t spray me.”
“Amazing!  I’ve now met my first ‘skunk whisperer.”

“Even my boss is amazed that I’ve never been sprayed.  Many of the other animal control officers get sprayed every once in a while, but not me.”
“You know you could open your own business and become the ‘skunk whisperer’ consultant.  There’s probably money in that somewhere.”
“Yeah, but I like working where I’m at right now.  So I don’t see a need to change anything.”
“Suit yourself.  Alright, well then, let me see your finger.”

Anita extended out her right hand and showed me her second finger which was by this time beginning to ooze some blood, close to her palm.  I cleaned the wound, and as it was small enough to only need some steri-strips on it, I applied them.  I then put a clean bandage on her finger.  The medical assistant gave Anita a tetanus vaccine because she couldn’t remember the last time she had received one.

“Alright, Anita, I want you to keep an eye on this minor wound, if it starts to swell up, turn red around the edges or drain excess fluid from it, get right back in here and let us take a look at it.  Also, if you start to run a fever, get back into us.  Otherwise, get into the shower starting tomorrow, take the outside bandage off, keep the two steri-strips on, let warm soap and water run over the area, pat it dry, put  some neosporin ointment on it and then put a clean band-aid on it.  The steri-strips will come off on their own in about 5-6 days, just let them.  This wound should be healed up in about a week, so we’ll see you then, just to make sure everything is fine.”

“Okay, thanks a lot.”
“You’re welcome.  Oh, and no more skunks for a little while, let your finger heal up before you use your long nosed skunk handler again.”
With that I went to go see the next patient who was waiting. 

Wednesday, February 29, 2012

Low Energy, Fatigue, A Sign of Hypothyroidism

I was working in the hepatitis clinic when I saw a patient of mine who was currently on therapy for her chronic hepatitis C infection.  She had been doing well, minimal to no side effects to her medications with her taking the nutritional supplements I put all of my patients on who were taking the FDA approved medications, pegylated interferon and ribavirin. 
I knocked on the door of the exam room and walked in.  Delores was about 3 months into her therapy program and had acquired her labs that morning, so I had the results in hand. 
“Hi, Delores, how are you?”
“Tired, I just don’t have any energy.  It’s hard for me to ‘get up and go.’  I noticed I started having problems about 10 days or so ago and it’s slowly become worse.”
“Well, I can explain that to you.  Your blood draw that you had done this morning shows that the interferon medication you’re on has affected your thyroid gland it is now having problems with producing enough thyroid hormone for you.  If you remember correctly, that was one of the side effects I discussed with you that could happen with your being on this medication.  It’s easy to treat, I’ll start you on a thyroid replacement medication that you will need to take once a day.  The medication is called Synthroid.”
“My thyroid, isn’t that a small gland in my neck, right here?” (she pointed to the front center of her neck)
“Yes, that’s where your thyroid is located.”
“Wow.  How long will it take for the new medicine you want me to start to begin working?” 
“You should notice a change in a couple of days.”

Many patients have problems with their thyroid gland.  It is quite common, with up to 4-5% of the American population having it.  Problems with the thyroid can arise from an auto-immune disease (your own immune system begins to attack the thyroid), side effects from medications, such as amiodarone, or a medication used for tuberculosis, lithium (used for bipolar disease), interferon (used in cancer patients, hepatitis), or problems with too much iodine or too little iodine, anti-seizure medications or radiation.  Problems with the thyroid can also be caused by an infiltrative disease process which can be due to sarcoidosis, amyloidosis or leukemia for instance. 

There are many symptoms of a low functioning thyroid.  They can include: fatigue, dry skin, cool/pale skin, decreased sweating, coarse hair, brittle nails, non-pitting edema, swelling around the eyes, a decrease in the red blood cell counts (anemia), decreased pulse, decreased heart contractility, shortness of breath, high blood pressure, increased blood pressure, constipation, weight gain, changes in menstrual cycle, joint pains as well as decreased lipid clearance. 
“Well, I do have some good news for you.  Your liver function tests are normal, your blood counts are still normal and from the looks of it, you should be in viral remission, which we’ll know in a few days.”
“So, who do I call in a few days to find out the results of my viral load?”
“You can call my nurse, Jenny, and she should know those results in about 4-5 days, so you can call her then.”
I gave Delores her new prescription for Synthroid and gave her a lab slip to have her blood drawn in 2 months, which would give her enough time to show a response to the Synthroid.  If her thyroid was still off at that point, I could adjust the medication as needed up or down.  I would see her after those labs were drawn. 
Delores came in 2 months later and her thyroid studies were back to normal, so I kept her on her current dose of Synthroid.  She was so happy that she had shown she was in viral remission for the past two months. 
Delores finished her medication treatment program after being on them for 11 months.  She came back into the clinic 6 months later and had her viral load re-drawn, which showed that she was in permanent remission from her chronic hepatitis C infection.  Her thyroid studies showed that they had remained normal.  Delores would have to stay on the Synthroid for the rest of her life. 

An appropriate work-up for thyroid problems is easy.  Generally you just need to draw blood and order a TSH test (thyroid stimulating hormone), along with a free T4 level.  If the TSH comes back high (normals being from .9 to 5.0 usually), and the free T4 is low then you can start the patient on replacement thyroid,  i.e. Synthroid. You have to follow-up on the replacement and make sure about 6-8 weeks later that the patient’s TSH/T4 is now in the normal range.  If the TSH is now very low (below .9) then you need to cut back on the patient’s Synthroid dose. 

Tuesday, January 31, 2012

Acute Appendicitis in a 9 year old Child

               I was working in the rural health clinic, thankfully it had been a quiet morning.  I was looking forward to having lunch shortly, seeing that I had only managed to eat a small amount for breakfast, due to my waking up late and rushing out of the door to get to work on time.
                “Sharon, there’s a little 9 year old girl with her mom who just checked in at the front desk.  She’s crying.  Can you please see her before you leave for lunch, please?” pleaded my medical assistant. 
                “Okay, Carla,” I said as I let out a sigh.  “You check her in and I’ll go back and at least eat my sandwich so that my stomach will quit growling.  Agreed?”
                “Agreed, thanks Sharon,” sighed Carla.
                I scurried back to the break room and grabbed my lunch bag out of the refrigerator.  I ate my sandwich so fast, even I was surprised.  I had just eaten the last bite of it when Carla’s head popped around the corner of the door.
                “She’s ready for you, Sharon.  She’s in room two.”
                “Thanks, Carla.”
                I put the rest of my lunch back in the refrigerator and walked down the hall to exam room two.  I knocked on the door and went into see an upset little girl.  I was thinking she probably had a painful ear infection or strep throat.  But what she had, I was definitely not expecting. 
                “Hi, I’m Sharon.  And your chart here says that you’re Melody, is that right?”
                 Melody, sitting uncomfortably on the exam table, nodded her head ‘yes.’
                I immediately noticed that she was in real pain and this wasn’t just an ear infection, she was wiggling around trying to find a comfortable way to sit without pain.  She also had a white chalky look to her face. 
                “Melody, would it help if you laid down on the table?”
                She nodded, ‘yes’ and slowly laid down on her back.
                I turned to her mom and asked her what had happened during the last day or so to bring this pain on.
                “Melody didn’t eat a whole lot yesterday.  She went to school and they called me around lunch and said that she was complaining of being tired and had fallen asleep.  I went and picked her up and brought her home.  She took a nap and when she got up she said that she just didn’t feel well.  She didn’t eat anything for dinner last night, she just wanted some watered down 7-up and that was it.  I noticed that she started running a low grade fever last night.  She went to bed early.  I was woken up around midnight when I heard her in the bathroom throwing up.  She threw up a couple of times, just yellow fluid mostly.  She told me that her stomach hurt, but nothing else.  I thought she probably just had the flu seeing that it was going around her school.  So I let her go back to bed and she woke up this morning with a fever of 101 F.  So after I got her brother off to school, I finally got her dressed and came over here.”

Patients who could have acute appendicitis acquire it due to blockage of it’s small opening into the intestine or from undigested food or other foreign matter that gets caught in it.  It is the most common condition in children requiring emergency abdominal surgery. 

                I turned to Melody and asked, “Okay, Melody, where in your tummy does it hurt?”
                Melody pointed to her right lower quadrant of her abdomen.
                “Okay, Melody is that where it hurt last night when you told your mom that your stomach hurt?”
                Melody nodded, ‘yes.’
                I quickly looked at the vital signs Carla had taken and noticed that her fever was 101.4 F.  Her pulse was a little on the high side. 
                “Melody, when was the last time you had anything to drink?”
                Melody answered in an almost inaudible voice, “this morning.”
                I turned back to her mom and asked some more questions.
                “Is she on any medications for asthma, or allergies or anything?”
                “No, she doesn’t take anything.”
                “Is she allergic to any medications?”
                “What’s the family history?”
                “I have high blood pressure, her father has type 2 diabetes.  Her grandparents have some heart problems.   That’s it.”
                “Okay, great.  Let me do her physical and then I’m going to send her across the street to the county hospital’s lab to get some labwork done.  But I can tell you right now that she doesn’t have the flu.  I think she has appendicitis.  If the labwork shows what I think it will, then she’s going to need to be seen by a general surgeon to have her appendix taken out. “
                With my saying that, Melody’s eyes enlarged and she gave me this pained look on her face. 
                I looked Melody directly in the eyes.  “Melody, I think you have a little tiny piece of your intestine that is causing you a major problem right now.  If I’m right, then it can be taken care of very easily.  The doctor that I’ll send you to will put you to sleep and then he’ll make a lttle incision with his instrument in your lower abdomen right where it hurts, snag this little piece of intestine, what we call an appendix and remove it from your abdomen.  You’ll then wake up and feel so much better.  Do you understand that?”
                Melody  nodded ‘yes’.
                “Okay then, Melody, I need to feel your tummy  and listen to your chest.  I’ll try real hard to not hurt, but if it does you have to tell me, agreed?” I asked her.
                Through her ever increasing watery eyes, Melody nodded, ‘yes.’
                I took out my stethoscope and put the end piece on her chest wall to listen. I had her roll over so I could listen to her back side.  I then listened to her heart sounds.  Everything was normal.  I gently put the end of my stethoscope on her abdominal wall and listened.  It was unusally quiet.  Taking the stethoscope end piece out of my ears, I wrapped it back around my neck. 
                “Okay punkin, now I need you tell me when it hurts as I feel all around your abdomen.  I’ll be gentle as possible.”
                As I felt her abdomen, first away from where it hurt and then started moving my hand over her right lower quadrant she was becoming more apprenhensive.  I knew then, that if I tried to palpate where it hurt she would not trust me to finish the needed exam.  So I changed tactics a little bit.  I put my hands down by my side and asked her a question.
                “Melody, I want you to use one of your fingers and I want you to put that finger right where the pain hurts the worst.”
                With a tear running down the side of her face, Melody moved her right hand and used her second finger to touch her lower right abdomen just above her hip bone, almost midline.  She was pointing right at McBurney’s point, the anatomical spot where the appendix lies.
                “Okay, punkin, you can put your hand back down.  I won’t touch where you pointed your finger.  I’m going to send you across the street to the county hospital’s lab to get some tests done and once you’ve done that you can come back in this room and lie down.  So I’ll give the lab slip to your mom and the two of you can walk across the street.  I’ll see you again once I get the lab results back.”
                With that I gave her mom the lab slip.  The two of them left the room, Melody walking very gingerly and slowly.   I quickly went back into the breakroom and grabbed the rest of my lunch and ate it while Melody was across the street at the hospital’s lab.

Patients who have acute appendicitis will generally present with nausea, vomiting, anorexia, abdominal pain, fever, right lower quadrant pain, and sometimes diarrhea or constipation. Patients can also have guarding of their abdomen due to the pain and/or rebound tenderness (this is where you press down with your hands and then let up suddenly, if it hurts, then this is considered rebound tenderness). 

As a part of the physical examincation you can have the child hop on one foot, if this elicits pain in their abdomen, it is considered a positive sign. You can also internally rotate their right leg (i.e. turn the leg towards the midline), if this elicits pain then it is considered positive. 

If a patient is suspected of having acute appendicitis the amount of lab work/radiology tests you need depends upon the age of the patient.  If they are a child or adolescent you typically only need to acquire a complete blood count (which should show an elevated neutrophil count).  Neutrophils are a form of white blood cells and they fight off bacterial infections.  You should also acquire an urinalysis to make sure that the problem is not coming from a urinary tract infection.  If the child does not have the typical findings for appendicitis, then it is advisable to acquire an abdominal ultrasound or CT study of the abdomen to ascertain the status of their appendix (is it inflammed vs. does it look normal in size).

Some pediatricians and surgeons will use what is called a pediatric appendicitis score.  The patient is given 1 point for their physical exam findings, laboratory findings and/or radiology test results.  If the patient has a score of 7 or above then they are considered at high probability of having acute appendicitis. 

If the patient is an adult then you also typically need to acquire a CT scan of their pelvis after you have made sure that if it is a female patient they are not pregnant. 

                About 45 minutes later, Melody and her mom walked back into the clinic and Melody proceeded to slowly crawl back up on the exam room table and laid down.  About 30 minutes later the hospital lab called me with Melody’s stat lab results.
                The lab results confirmed what I thought they would.  Her urinalysis was normal, and her complete blood count showed a high total white blood cell count with a high neutrophil count (neutrophils are used to fight off bacterial infections).  So these lab values confirmed what I thought, Melody had appendicitis. 
                I walked back into the exam room and advised Melody and her mom that she would need surgery.  I called the emergency room next door at the county hospital and asked who was the general surgeon on call.  They asked why, I advised them of Melody’s condition.  The emergency room registered nurse said she would immediately put in a page for Dr. Thomas.  I asked her to call me back when he had replied.   About five minutes later I received a call back and the county hospital advised me that Dr. Thomas had called and he was on his way in to see Melody and to send her over.
                I walked back into the exam room and advised Melody and her mom that Dr. Thomas was on his way in.  Melody sat up and slowly starting to get down off of the exam table.  She again walked slowly and gingerly down the hallway towards the front door.  She was followed by her mom.  They moved slowly back across the street and walked into the emergency room. 
                About an hour later, Dr. Thomas called me and advised me that Melody did indeed have appendicitis and he was taking her to the operating room as soon as they could get her an intravenous dose of pre-op antibiotics.  He thanked me for working her up and he expected her to do just fine, he didn’t think her appendix had ruptured.
                A day and a half later I walked into the rural health clinic and was given a telephone note from Carla.  The note was from Melody’s mom.  It basically said, ‘thank you, Melody is going home this morning.’  I was glad that she had done so well and would soon be back to her normal self. 

Typical treatment for acute appendicitis consists of:
prompt general surgery consult
intravenous antibiotics
intravenous fluids for hydration
pain control
surgery: usually can be done with a laprascope (1 inch incision) to remove the inflammed appendix
hospital discharge generally within 24-36 hours

Again, thanks for reading.  I solicit your comments and feedback.  –sharon