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.