Monday, December 2, 2013

An Elderly Patient with a Fainting Spell

I was the primary care provider for an elderly 78 year old man who had been a patient in the clinic I worked in for several years.  Dan was very friendly and always appreciated my help.  He had made an urgent appointment to be seen that morning, so when I walked into see him early during my afternoon shift of patients, I knew something was up. 

“Sharon, I passed out yesterday morning at home.  I don’t remember what happened except I was feeling light-headed and then woke up on the floor of my bedroom.  Thankfully it’s carpeted, so I don’t have any nasty bruises anywhere.”

“Well, how long were you out and what did you do after you came to?”

“I don’t know how long I was out, probably for just a few seconds, I know it wasn’t longer than a minute.  I felt fine after I came to,  so I got up and finished getting ready for church.  My wife wasn’t happy with my not wanting to go to the emergency room, but I didn’t see any reason for it.  I finally told her I would come in here to be seen today, instead.”

“Okay.  Did anything else happen to you yesterday or this morning?”

“No, my wife and I went for our usual morning walk and then I’ve been home reading the newspaper and doing odds and ends.”

“Alright, well when people pass out like that it can mean they are having heart problems or problems with their thyroid for instance.  Is this the first time that you’ve passed out?”


Risk factors for syncope (fainting)

Vasovagal reactions (a episode of simple fainting due to the patient smelling a strange odor for instance, or other similar episodes)
Changes in blood pressure (what is called orthostatic hypotension, there has to be a difference of >20 systolic/10 diastolic) when the patient has his blood pressure taken in the 3 different positions: laying, sitting and standing.
Diurectic medication which can deplete the blood pressure

“Okay, well then let me take a look at your labs for a minute and re-check the medications you’re on.  I seem to recall that you’re not on any water pills.”

“I’m not.  I’m just on my blood pressure meds and a medication for my cholesterol.  That’s it.”

I flipped through his paper chart (the clinic was getting ready to change over to an electronic health records, but we were still using paper charts at that time).  I quickly found the section with his lab results listed.  His thyroid had just been tested within the past six months and it was normal.  I flipped over to his medication list to make sure that he wasn’t on a diurectic which could deplete his blood volume too much and cause him to have a fainting episode.  Dan was right he wasn’t on any diurectics.  He was on a beta blocker and a calcium channel blocker for his blood pressure and cardiac angina.  He was also on a statin drug to keep his cholesterol levels in the normal range, as well as a daily aspirin.  I also knew from having taking care of Dan in the past that he was not one to drink any alcohol, nor smoke.

“Dan, when was the last time that you saw your cardiologist?” 

“I see him every six months for my angina.  I’m supposed to see him again I think in two weeks.  I haven’t had any problems with my angina since he started me on, hmm what’s it called, it starts with an n, umm Norvasc, that’s it.”

“Norvasc is your calcium channel blocker, it’s used for blood pressure and cardiac angina and it works very well for both.”

“Okay, so why did I pass out yesterday morning?”

“Well, I think you passed out because of your heart, I think you might have problems with what’s called atrial fibrillation, which is a common condition in elderly patients like you who have a history of high blood pressure and cardiac angina.  But I’m not sure as of yet.  So let me do a physical exam, then I’ll have the medical assistant come back in and take your vitals signs while you’re laying down, sitting and standing.  That will tell me whether you are having any orthostatic changes that could have caused your fainting spells.  I’ll also have her do a ECG on you to see whether there is any difference in your cardiac rhythm.  If that’s negative, then I’ll have you move your appointment up with your cardiologist and he’ll have to finish up the work-up.  Okay?”

“Whatever.  I just need to be able to tell my wife that I’m being taken care of.” 

Risk Factors for Atrial Fibrillation

Cardiac surgery
Heart Failure
Hyperthyroidism (thyroid gland that is overactive)
Heart Attack
Myocarditis/Pericarditis (infection of the heart muscle or outer lining of the heart, the pericardium)
Acute lung disease
Cardiac arrhythmias (especially Wolff-Parkinson-White syndrome)
Symptoms of Atrial Fibrillation
Syncope (fainting)
Chest palpitations (feeling your heart beating)
Shortness of breath
Chest discomfort

So I proceeded to do his physical exam (which was negative and unchanged from prior visits) and then walked out of the exam room and asked the medical assistant to do his vitals in 3 positions (laying, sitting and standing).  After that I asked her to do a 12 lead electrocardiogram (ECG).  

After she had completed the ECG, she brought me his 3 sets of vitals signs (not enough of a change to classify him as having orthostatic hypotension).  His ECG showed the answer.  He had atrial fibrillation.  Prior to his QRS complex he didn’t have a clear P wave and had lots of waves before his ventricular contraction (QRS) would take place. 

I went in to talk with Dan and advise him that he needed to move up his appointment with his cardiologist. 

“Dan your ECG tells us what’s going on.  You have new onset atrial fibrillation.  As I handed him his ECG I pointed out the waves prior to the QRS complex.  Your cardiologist is going to have to do a 2 weeks study of your heart rhythms, where you will wear a constant monitor and then have you come back in to be seen by him.  From the 2 week study he’ll know how frequent your atrial fibrillation is and then he’ll decide on what to do about it.  He may also do another echocardiogram on you to assess any structural heart changes.  Something else he may also decide to do, is an acute cardioversion where he tries to shock your atrium out of it’s abnormal rhythm.  So with this in mind, I’m going to go call your cardiologist’s office and see whether we can get you into to be seen by him tomorrow.  I’ll be right back.”

I left his exam room to go out and call his cardiologist’s office.  I explained to the front desk person that I had a patient of Dr. Taylor in my office and that Dan needed to see him within the next 48 hours due to new onset atrial fibrillation.  As I expected she put me on hold to go talk to his nurse.  She came back and told me that he could see Dan on Wedsnesday morning at 8:30 am.  So I told her to go ahead and book the appointment and I went back into Dan to inform him of the appointment. 

“Dan, Dr. Taylor can see you on Wednesday morning at 8:30 am.  So make sure to keep this appointment.  Meanwhile I’ll fax over to his office the office note from today, your ECG and your thyroid results.  Any questions?”

“No, don’t think so.”

“Oh, and one more thing.  Seeing that you have an appointment so soon with Dr. Taylor I’m going to let him decide when to start you on Coumadin or Xarelto which will not allow the platelets to clump together.”


“Alright, well I wish you well and I’ll find out what happened with Dr. Taylor when we receive the consultation note back.”

Treatment of Atrial Fibrillation

Beta-blocker medications which decreases the pulse rate
Calcium channel blockers which also decrease the pulse rate
Cardioversion or ablation or maze surgery (which would only be done at the time of open heart surgery)
Anti-coagulation (either Coumadin or Xarelto or a similar agent) – this prevents the platelets from sticking together, forming a clot due to the upper atriums of the heart not beating correctly.  Patients are anti-coagulated based on their CHADS score (CHADS score goes from 0-6, any score above a 2 requires that the patient be anti-coagulated).  Patients receive 1 point for each of the following: hypertension, age > 75, diabetes, heart failure.  Two are given for previous stroke or transient ischemic attacks.
If the patient has sick sinus syndrome (sinus tachycardia followed by sinus bradycardia, i.e. pulse above 100, then pulse below 40) then they can be treated with a pacemaker which paces the heart as well as addresses the atrial fibrillation. 

A few days later via fax, I received the consult note from Dr. Taylor.  He had seen Dan, ordered a follow-up echocardiogram on him and decided against trying to cardiovert him, per patient request.  So instead he had started him on Xarelto and discontinued his aspirin.  Dan was set up to have two weeks of his cardiac rhythms monitored.  He was to return to the clinic in two weeks which had been his originally scheduled appointment time. 

Two weeks later I received another follow-up note from Dr. Taylor.  Dan had completed his two weeks of monitoring, as well as his echocardiogram.  There wasn’t any change in his echocardiogram except the occassional atrial fibrillation.   His two weeks of monitoring showed that Dan was having episodes of atrial fibrillation that lasted for several minutes and then quit, only to re-start again. 

So Dr. Taylor decided to increase his beta blocker in an effort to acquire heart rate control.  Dan was scheduled to return to see him in follow-up in another two weeks.  Eventually, Dan’s atrial fibrillation was controlled with the increase in his beta blocker and he was symptom free.   

Thursday, September 19, 2013

A Patient's View of Multiple Sclerosis

Recently, while working in a rural agricultural town in Colorado, I walked into see a patient, who had been coming to this particular family practice for 20 years.  She had initially been diagnosed with multiple sclerosis 25 years ago, when she and her husband had been living in Denver.  For the first few years she had been seen at the multiple sclerosis center, based out of one of the community hospitals in Denver.  It had a large referral base from six surrounding states. 
Georgia told me that she was very happy with the care she received there from a physician who was very compassionate and willing to work with her.  When he retired, she saw his colleague, but didn’t get along with him, so she quit going, and hence hadn’t received care for her MS since.
Then her husband, a dentist, decided to accept a position in this rural, agricultural town that I was working in. During this time, Georgia had learned to handle her multiple sclerosis relapses through mental determination, rest, tylenol/motrin and lots of physical therapy.  She knew that it would eventually go away, it always had in the past.  But with each episode (thankfully they only came along every few years) she was left with a little more pain and disability to chronically live with. 

Risk Factors:

--genetic predisposition among Northern European Caucasians
--increased risk with increasing latitutde, which implies a potential environmental trigger
--Vitamin D deficiency
1/400,000 people affected, femaile to male ration of 3:1.
--usual presentation between the ages of 20-40.

Signs/Symptoms of Multiple Sclerosis:

optic neuritis (pain in the eye with loss of vision)
myelitis (inflammation of the spinal cord with sensory and/or motor loss below the affected area)
muscle spasticity/pain
electric shock sensation provoked by head/neck movement
changes in bladder and bowel function

Then there was the day that I saw her in clinic.  Georgia was complaining of non-stop diarrhea, low back pain which almost had her immobilized.  She also had generalized abdominal pain with referred pain down both legs.  To say it mildly, she was miserable. 
I ended up working up her diarrhea/abdominal pain and got a MRI of her back.  Her diarrhea was caused by her MS (no surprise there), as was her lower back pain/abdominal pain which the MRI revealed was due to partial myelitis (another sign of active MS).  I gave Georgia some lomotil to control her diarrhea, and Cymbalta to help control her pain.  But that still left her with her MS, in its acute flare-up.

Diagnosing MS:

Done by doing a MRI of the brain which needs to show white matter disease (the brain, typically black on the MRI shows white spots within it)

Over the course of working her up, I ended up seeing her three times in a two weeks.  Each time I saw Georgia I continued to try to counsel her that she needed to return to Denver to be seen by a MS specialist.  Georgia’s memories of the last MS specialist she had seen were still so strong that she would barely even discuss this with me.  I kept trying.  I gave her loads of updated information on MS, the newer treatment modalities available and what she could expect from them.  She brought them home for both her husband and her to read.  She later told me that her husband had devoured the information, and had even looked some additional information up on the internet.

It wasn’t until I kept reiterrating (over the three clinic appointments) my having previously worked alongside Dr. James (pseudonym), a MS specialist who saw patients at the medical school in Denver, how compassionate he was, how willing he was to work with patients, how caring, kind and friendly he was with all of his MS patients, that she finally relented and gave me permission to make her an appointment with him. 

Clinical Course of MS:

MS can take one of three pattersn: relapsing-remitting (my patient), secondary prgoressive or primary progressive. 

Treatments Available:

--interferon based (interferon beta)
--monoclonal antibody (natalizumab)
--anthracycline based (mitoxantrone)
--glatiramer (copolymer of four amino acids)
--fingolimod (phosphate modulator that restricts activated lymphocytes)
I quickly called and made the referral.  I asked the receptionist to make it an urgent appointment due to the patient’s symptoms.  Thankfully, there was a cancellation and my patient was able to take this appointment, two weeks away.  She would have to be in a car for two hours driving back to Denver to see him, but I knew it would be worth it.  The next day she called in to leave me a message.  Her husband was so estactic that she had finally decided to pursue treatment again for her MS, that he had taken the day off from his dental practice and was going to take her up to Denver himself. 
Fortunately I was still working at this clinic when she showed up six weeks later.  She hobbled in, using a cane, but had the biggest grin on her face you would ever see.  She told the clinic secretary that she had to talk to me. 
I was just coming out of one of the exam rooms when I saw her at the front desk.  I motioned for her to come on back into one of the empty exam rooms, which she did. 
“So, tell me I want to know what Dr. James said.”
With tears running down her cheeks, “Sharon, you were so right.  He is the kindest, most compassionate physician I have ever met.  My husband just thought the world of him.  He’s started me on a oral medication, Fingolimod which is working wonders for me.  I saw him two weeks ago for follow-up and I’m supposed to go back in two more weeks for another follow-up.  The medicine is working so well for me that I’m back doing physical therapy and am able to walk short distances again.  I can’t thank you enough.”
“Oh, I’m so glad you went, because he was exactly what you needed!  I’m happy that you finally found someone you can work with.”
“So am I, so am I!”

Friday, July 5, 2013

A Sports Injury

I went into see a teen-ager who had suffered an acute injury at school.  Amanda was a patient I was familiar with, she was very sports orientated, usually ending up playing at least two sports per school year.  She was known as the best volleyball spiker on her team and during the spring season she was involved in cross country running.  I could well imagine her bedroom wall.  It was most likely decorated with all of the local, regional and state awards she had won from her sports endeavors.  She was very smart, tall and lanky.  She was the type of teen-ager that any parent would be proud of, responsible, mature and focused on her school studies. 
“Hey, Amanda, what’s going on?”
“Sharon, I was getting ready to spike the volleyball last night during our tournament when I hit the ball the wrong way and all of the sudden I had this intense pain in my hand and wrist.  I tried to shake it off, but that didn’t work.  So I had my coach take me out of the game for the rest of the period and sat on the sidelines with an ice pack on it.  That helped, I also iced it last night at home.  But it still hurts today and I can’t make a fist with my hand without pain here in my arm.”
“Okay, well let me take a look at your arm.  You’re right handed aren’t you?”
“Okay, well then let’s start with your showing me whether you can rotate your right arm back and forth.”
“I can do that, it hurts a little bit over my lower arm though.”
“Okay, well now can you fully extend your hand and then make a fist out of it?”
“I can extend my fingers, but I can’t make a fist, my third finger doesn’t want to cooperate.  It really hurts over the top part of my hand when I do that and it causes pain down my lower arm up to my elbow when I do it.”
“Okay, then try bending your hand back and forth.  Does that hurt?”
“Yeah, when I try to bend my hand in towards my wrist.  The same areas hurt.”
“Okay, when I tug on your third finger does that hurt?”
“Yeah, that hurts all the way down to my elbow.”
“Okay, well it looks as though you have tendonitis, you have sprained the tendon that serves your third finger.  I think it happened when you went for the ball and the ball forced your thrid finger backwards.  Your tendon to the third finger goes from the tip through your wrist and onto the elbow where it hooks into your radial bone.  It’s going to take about four weeks for your tendon to heal.  So if there is any more tournaments to be played with your volleyball team, I think that’s off the table.  I’m going to put your hand, wrist and lower arm into an ace wrap to help support it.  I want you to keep putting ice on your hand/wrist, 15 minutes on, 15 minutes off until tomorrow.  Then you can start applying heat, 15 minutes on, 15 minutes off.  You’ll find that if you keep your hand/wrist in the ace wrap it will help with the discomfort and prevent you from moving your finger.  I want you to take some motrin every day, try taking two over the counter strength tablets three times a day for the pain.  I also want you to slowly extend and flex your right hand several times a day to help slowly stretch out the tendon, which will help loosen it up.   It should take about four weeks before the tendon is totally healed, afterwhich you should be able to go back to your regular activities.  If it’s not healed by then, please come back in and be seen.  Any questions?”
“No, I don’t think so.   Although, how am I supposed to write in school?”
“Hmm, I think you’ll have to ask your teachers how they want to handle that.  It’s going to be cumbersome at best.   By the way how did your team do last night?”
“We won.  So we’re going onto the district tournament next weekend.”
“Oh, dear , they’re going to be playing next weekend without their best spiker.  Sorry about that.”
“Yeah, I know, bummers!”
“Alright, well there’s always next year, Amanda.  Do well, come back and see me if your arm doesn’t feel totally normal in about a month, okay?”

I didn’t hear back from Amanda again through the rest of her school year.  She came in during the summer for her sports physical and told me that her tendonitis had healed up nicely and she was able to use her arm without any pain after about 3 weeks.  She had just finished school for the year and told me she had won the state cross country championship. 

Thursday, July 4, 2013

An Infection Way Too Common in Women

I walked into the exam room to see a patient I was familiar with.  I had taken care of her kids many times before when they had strep throat, upper respiratory infections and when she had problems with her sinus allergies. 
“Hi, Liz, what brings you in?”
“Oh, Sharon, I think I’ve got one of my bladder infections back again.  I woke up yesterday morning with that initial feeling that I knew something was wrong.  It burned to urinate.  So I started drinking my cranberry juice yesterday and that helped some, but my symptoms are worse today.  I had to get up and go use the restroom several times during the night, even though I had very little urine to get rid of.”
“Well, Liz, I have yet to come across a woman who didn’t know that she had an urinary tract infection.  Women are very good about picking up these types of infections.  So did you give the medical assistant a sample of your urine before you came in this room?”
“Yeah, she had me leave a sample in the lab.”
“Great.  Have you had any back pain, fevers, nausea or vomiting?”
“Well this morning it began to hurt on my left side of my back.  Nothing else.”
“Okay.  What antibiotic do you typically take that works for your urinary tract infection?”
“I think it’s called Cipro, I know it’s a white pill I take twice a day, and it works real well for me.”
“Well, Cipro is one of the antibiotics we use, that’s for sure.  How frequently do you get these infections?”
“Maybe once a year, no more than that.”
“Okay, well then you don’t need a prescription for antibiotics to use at home when you’re symptoms start up.  We usually give patients their own antibiotic prescriptions to use if they have a history of having numerous urinary tract infections  (UTI) during the past year.   I note you don’t have any drug allergies and besides problems with seasonal allergies you don’t have any other problems.  Are you taking your Allegra right now?”
“Yeah, I started taking it about a week ago  when the trees started blooming.”
“Ok, well  then let me take a look at you by listening to your chest, heart and feel your abdomen.  Then I’ll go find out what your urine sample shows.”
Liz’s physical exam was normal except for mild tenderness over  her lower abdomen in the midline (corresponds to where her bladder is located) and she did have some costovertebral tenderness on the left side (back pain which corresponds to urinary tract infections).

Risk factors

female > male
urinary tract malformation
hospitalized patients (especially those who have foley catheters in)
presence of renal stones
immunocompromised patient (kidney transplant)
diabetic patient
sicke cell disease
polycystic kidney disease


lower midline pelvic discomfort/pain (over bladder)
pain over lateral posterior back (either right or left, or both sides)
burning with urination
blood in urine
protein in urine
bacteria +
leucocyte esterase + (on urinalysis), this shows the presence of white blood cells

“Liz, I’ll be right back, I’m going to go see what your urine results are.”
I left the exam room  and walked over to the lab station.  The tech gave me her urinalysis results which showed what I expected a typical UTI to show, she had positive nitrates, leucocyte esterase, bacteria and a small amount of protein.    I walked back into the exam room and advised Liz of her results. 
“Liz, I’m going to give you Cipro to take for the next 7 days twice a day to make sure the infection is totally cleared up.  I’ll send off your urine to have a culture done on it just to make sure that you’re not infected with an unusual  bacteria or that the bacteria is not resistent to the Cipro.  Go ahead and acidify your urine by drinking lots of cranberry juice, and you can pick up some ‘Azo’ over the counter which will help with your urge to urinate and well as address your burning sensation. It will turn your urine orange so don’t be concerned about that. You should only need to take the ‘Azo’ for 2  days or so, then stop it.”
With that I handed her a prescription for her antibiotics. 
“Thanks,  for your help.”
“No problem.  Now I hope you enjoy your weekend.
“I will.”


urinalysis shows bacteria, leucocyte esterase, +nitrates, ? protein, ?blood
Culture (if done) will reveal 80-85% E. coli, a gram negative bacteria
Treatment consists of antibiotics for 3-10 days.  The length of time is decided upon by the clinician and the extent of symptoms the patient has.  Many women can be treated for 3 days if the clinician believes it is an uncomplicated infection (i.e. bladder infection only).  If the clinician believes the bacteria has gone up into the kidneys then the patient needs to be treated for 7-10 days. 
Kidney involvement can be suspected if the patient has positive pain over their back sides on the lateral aspects, nauea/vomiting and/or fevers.
Typical antibiotics can include: Macrobid, Cipro, Bactrim DS, or a Cephalosporin. 

Sunday, June 30, 2013

I Need Help, My Allergies are Back!

I walked out to go call my next patient back into an exam room and when he responded I was pretty sure of what was going on.  For you see, this patient’s facial appearance of ‘raccoon eyes’ gave it all away. 
“Why don’t you come back into the exam room and tell me what’s happened.”
“Okay,” he replied, with a very definite nasal twang to it. 
“How long has your nose been plugged up like it is now?”
Answering in his nasal twang voice, “For about a week.  It has just gotten worse with all of the cottonwood trees blooming and the ragweed out.  I took my Zyrtec, but it hasn’t done anything this time.  I can hardly breathe and I cough all night.  My sinus’ are just stuffed full of crap.”
“What about your ears, do they feel full?”
“Yeah, oh and my throat is sore.”  As he sat there his nose started to drip and he needed to use some Kleenex.
“Okay, what’s typically draining from your nose, what color in other words?”
“I think it’s a dark yellow to sometimes green.”
“Any fevers, or wheezing?”
“Have you had any past surgeries or have any other medical problems?”
“So, besides your problems with your sinus allergies, nothing else is going on?”
“How long have you had problems with allergies?”
“I started having problems with all of this stuff that blooms in the spring about five years ago.  Since then it has just gotten worse every year.  Now I have problems with allergies from spring until late fall.  The only time I get any relief is when it’s cold outside,” he twanged, as he reached for another Kleenex.
“Alright, well let me take a quick look at you and then you can tell me what you want to try for your allergies.”
The patient’s ears showed a dark gray tymphanic membrane (which meant his ears were full of sinus congestion), his nasal membranes were bright red, swollen, he had peri-orbital swelling going on (‘raccoon eyes’, swelling around his eyes due to his swollen, congested sinus’), as well as his throat was pink and swollen.  The rest of his exam was normal.
“Ok, Drew, you go by Drew correct?  Not Andy or Andrew?”
“I go by Drew.”
“Ok, Drew, why don’t you tell me what you have tried for your sinus congestion, what has worked and what hasn’t.”
“I’ve tried Claritin, Allergra and Zyrtec, all of which I get over the counter.  Zyrtec worked the best for me until this year and now it doesn’t even work anymore.  My primary care physician gave me some nasal steroid spray which helped until two years ago and then it quit.  I took some Afrin yesterday, but it’s not helping.  Gad, I need these sinus’ open again, I almost can’t breathe because they’re so clogged up.”
“Have you tried nasal saline washes?”
“No, what are those?”
“Well, ENT physicians, ear, nose andthroat doctors love saline nasal washes for their patients who have sinus congestion.  You use a small blue rubber bulb with 1 cup of saline water.  You gently squirt ½ cup of the saline mixture up each nostril three times a day.  This gently washes out your sinus’ and keeps all of the allergens washed out so that you don’t have problems with all of the ragweed, cottonwood flowering, etc.  Do you want to try it?”
“I’ll try anything at this stage.”
“Okay, well let me give you the instructions for it and then you can go pick up the supplies for it at the drugstore or grocery store.  Because your allergies have gotten so bad so quickly, I also want to send you to an allergist.  I think it’s probably time for you to get started on allergy shots.  Is that okay?”
“Yeah, that sounds really good.”
“Okay, hang tight, let me go make a call for you to see how soon she can get you into be seen.  I’ll be right back.”
I left the exam room and went to go call Dr. Miller’s office.  After I explained to the receptionist that I had a patient who needed to be seen in the near future instead of weeks away, her receptionist advised me that Dr. Miller had a patient cancellation for 3 pm that afternoon and could my patient be there then?
I advised her that Drew would be there and after giving her the details of his insurance plan, I hung up the phone to go tell Drew his good luck.
I walked back into the exam room and told Drew of his appointment time after which his facial appearance changed into a smile and in his nasal twang voice replied, “Thanks.”
After Drew left the clinic, I didn’t expect to see him again.  But two weeks later he walked back into the clinic and asked to speak to me.   I walked out to the patient waiting room after the receptionist called and told me who was there waiting.
“Hi, Drew, what can I do for you?”
“Look, my face, I’m not swollen.  I can also talk like normal, I don’t have a frog in my voice anymore.”
“I’m impressed.  What all did Dr. Miller do for you?”
“Oh, she started off by telling me I was one of the worst cases of seasonal allergies she has seen in a while.  I spent the next two hours in her office getting all sorts of allergy testing done, she did who knows how many allergy tests on my backside.  Boy did I itch that night.  She also started me on allergy shots last week. She then told me to use Zyrtec-D, the stuff that she says has Sudafed in it, along with a different kind of nasal steroid spray and the saline washes you put me on.  What a difference it’s made.  At any rate, I just wanted to say thanks for sending me over to her, now I can go outside and not immediately close up from all the pollen in the air."
“Well, you’re quite welcome, Drew, I’m glad she helped you out.”
“So, am I.  Having those ‘raccoon eyes’ wasn’t fun.  Now no one at work is asking me what’s wrong.”

Signs/Symptoms of Allergic Rhinitis

Sinus congestion
Runny nose
Seasonal exposure to either indoor or outdoor allergens (pollen, ragweed, etc)
Pet exposure


Saline nasal washes
Anti-histamines (Zyrtec, Claritin, Allegra) and/or with decongestant (Sudafed)
Intranasal steroid sprays (either prescription or over the counter
Oral leukotriene inhibitors (Xyzal or Singulair)
Allergy shots (for those patients with severe symptoms, patients state that these work after 1 year of injections and the effect can last up to 3 years after the last shot).

Friday, June 28, 2013

Colicy Back Pain

I was working in an urgent care clinic when I went into see a new patient.  His name was David, and he worked as a math teacher at the local high school.  He was slightly overweight, carrying his excess weight around his midline.  David was in his mid-forties, with a smile and welcoming appearance. 
“Hi, my name is Sharon, I’m filling in at this clinic as a physician assistant, until they can hire another permanent provider.  What brings you in?”
“Oh man, I’ve had this back pain that just won’t quit.  It’s on my left side and when it starts up I just want to scream, it hurts so bad.  I’ve tried changing positions, nothing helps.  It started last night.  I really need help!.”
“Alright, are you in pain right now?   You’re winching your face, is why I ask.”
“Yeah, the pain has started back up again.”
“So the pain comes and goes at any time?”
“Yeap, but now mostly it just stays, last night it did come and go somewhat.”
“Okay, have you taken anything for the pain?”
“I took some Motrin last night and this morning, it helped a little bit.”
“Are you having any blood in your urine, changes in your bowel habits, abdominal pain, nausea, vomiting or fevers?
“I started noticing my urine was turning pink last night and this morning it was just red.  I’m not throwing up, nor do I think I have a fever.”
“Okay, have you had any previous history with urinary tract infections?”
“No, I don’t recall one.”
“Have you had any history of having kidney stones?”
As David squirmed trying to find a comfortable position to sit in, he answered, “No.”
“What medications are you on?”
“I take a blood pressure medication, I think it’s called lisinopril??  I also take something for this troublesome gout I get, when it occurs, which only happens about once, maybe twice a year.”
“Ah-ah, that could explain the possible cause of your back pain.  I think you could have a renal stone, seeing that uric acid is the cause of your gout and it can also form renal stones.”
“Oh, no, are you serious?”
“ ‘fraid, so.”
I finished taking his history and then did his physical exam, which revealed he was quite tender to palpation over his posterior left side.  He also had a swollen, red joint over his first toe on his right foot. 
“David, how long has you toe joint been swollen?”
“Huh, oh yeah, It’s been like that since yesterday.  But I forgot about it because my back is hurting so much.”
“Have you taken your medicine for your gout because of your toe?”
“Yeah, I started taking it last night, but I’ve only taken one dose, I’ve been too distracted by my back pain to think about my toe.” 

Risk Factors
High calcium level in the urine
10-12% incidence rate (i.e. 10-12% of all patients will have at least 1 renal stone episode in their lives)
Males > females
Diet: high intake of chocolate, spinach, green/black tea which can all increase the amount of oxalate in the system which then has to be excreted and can lead to stones
Genetic disorder (autosomal recessive genes)

Nausea /vomiting
Back or abdominal colicy pain
Blood in the urine
Urgency/increased frequency
Possible crystals in the urine

“Okay, David I need you to give us a urine sample, get some blood drawn to assess your kidney function and then I’m going to send you over to the x-ray department for a CT scan of your abdomen and pelvis.  I’ll have the nurse come in and give you something for your pain, so that you’re not squirming while you’re having your CT scan done.”
“Okay, thanks for the pain med.”
I left to find one of the clinic nurses and gave her the written orders to give David sixty mgs. of Toradol IM, draw the blood work and give him the specimen cup for his urine sample.  After that she sent him over for his stat CT scan.
David was back in the clinic waiting room waiting for me to see him an hour later.  So with the news that he was waiting, I walked over to the radiology department to check on his CT scan results.  Thankfully the after-hours radiologist was still there and was willing to review the scan with me.
Dr. Earl, the radiologist asked, “you say, left sided pain?”
“That’s right.”
“Well here’s the reason for your patient’s pain.  See this right here?  He’s got a nice sized stone caught in his left ureter.  I’d say it looks to be about 7 mm in size.  Boy, does that have to hurt.”
“Well, the patient will agree with you there.  Thanks for reading the CT scan for me.”
“No problem, that’s why we’re here.
I went back to the urgent care clinic and looked up his lab results.  His kidney function was normal, as was his calcium and phosphorus levels.  He had gross blood in his urine sample, but nothing else was out of whack except his specific gravity which showed his urine was concentrated. 

Diagnostic Work-up
Urine sample to assess for blood
CT scan (non-contrast) to look for the presence of a renal stone
Blood work to assess for kidney function, phosphorus, calcium, uric acid levels
Analysis of stone (if captured upon passage)
24 hour urine collection to assess for kidney function, urea, calcium, phosphate, citrate, sodium, oxalate, uric acid (usually done by the patient’s primary care physician at their follow-up appointment)

General Treatment Guidelines
Treatment of renal stones is based on what type of stone the patient has: stone composition can be either uric acid (10% of stones), cystine, or struvite (composed of magnesium and calcium, 10% of stones), or calcium oxalate (80% of stones).  
All patients need fluid hydration, fluid hydration, fluid hydration
Pain medication
Tamsulosin or Nifedipine (either of which will help decrease muscular spastic pain from the ureters)
Most stones <7 mm can be passed with supportive help, if stone is not passed then patient has to be seen by urology who can then decide on shock therapy lithrotripsy, ureteroscopy (usage of a scope to retrieve stone), or open surgical procedure (nephrostomy).
Based on the type of stone patients can also be given potassium, sodium, or calcium supplements to help dissolve the stone.   

I went to call David out of the waiting room, to have him come back into an empty exam room. 
“Come in here, David, I have your test results back and I need to explain them.”
David walked gingerly into the exam room and sat down.  “Thanks,”  he said.
“I reviewed your CT scan you had done with the radiologist.  Your CT scan shows you do indeed have a renal stone caught in your ureter, in other words the draining tube from your kidney to your bladder on the left side.  It’s a sizable stone, 7 mm.  So it may or may not pass on its own.  Your uric acid level is quite high, it came back at 11, when normal is around 6.  Your calcium and phosphorus levels are normal.  So I do believe you have a uric acid stone.  The stone has rough edges and this is why it hurts so much as your system is trying to pass it, every time it moves down your ureter, it goes into spasms and you end up in pain.”
“Wow, a little thing like a stone that small can cause this amount of pain?  Oh, geez.  What can I do about it?”
“Well, first let me ask a question.  Your urine sample showed your urine was really concentrated.  What quantity of fluids do you drink per day?”
“I thought I was keeping up with my fluids, but maybe not.  It’s been really hot outside, seeing that it is summer.  I’ve been working out 4 times a week to lose this extra weight I have put on.  As a part of my trying to lose weight, I’ve been on a high protein diet.”
“That answers the reason you ended up with a renal stone.  Your system is dehydrated, you’ve overloaded your system with purines, or protein to you, and you are somewhat overweight.  So we need to push IV fluids on you and continue your pain medication.  We’ll give you 6-8 hours of IV fluids here in the urgent care clinic as well as a medication called Tamsulosin which will help with the ureter spasms.  I’ll also start you on allopurinol which you will have to take every day.  The nurse will give you a cheesecloth to strain your urine with, in hopes of catching the stone.  We need to send it in for analysis if you are able to pass it.”
“Okay, so you’re saying this stone I have will pass in the next few hours.”
“No, I’m hoping you pass it in the next few hours, but you may not.  If you don’t then I’ll have to send you home with instructions to chug fluids at home, use the cheesecloth and continue taking the two meds I’m going to start you on.  If you don’t pass the stone within the next 24 hours or so I’ll have to send you to a urologist who will have to schedule you for a procedure called, lithotripsy.  Lithotripsy is where the urologist sends shock waves through your skin and into the stone to break it up so you can pass it.  But let’s cross that road after you’ve had lots of IV fluids and see what happens.”
I walked with him down the hallway to our observation unit and gave the nurse his orders for intravenous fluids which would have potassium bicarbonate in it.  Hopefully he would be able to pass the stone, but only time would tell.  He was also given pain medications.
I went back to the clinic and started seeing other patients.  At the end of my shift, I walked over to the observation unit and checked in on David.  I found out that he still hadn’t passed the stone, but he did think it had moved a little bit, due to his continuing to have spastic pain, masked by the pain meds he was on. 
“Okay, David it looks as though the IV fluids haven’t been successful in getting the stone to pass.  I’m going to go ahead and discharge you home.  You have to promise me that you will continue to chug fluids at home, take the prescription meds I gave you, i.e. the allopurinol, the pain medications and the tamsulosin.  You need to come back tomorrow afternoon if you still haven’t passed the stone.  You’ll know you will have passed it because the pain will be gone but right before you pass it you’ll have symptoms of needing to urinate frequently.  This will be your bladder’s response to the presence of the stone in it.  If you pass the stone, please make sure to bring it back into us so that we can test it for what sort of stone it is.  Most likely it is a uric acid stone, but only the lab will be able to tell us with 100% certainty that it is.
“Okay, well I hope that I don’t spent the night in the bathroom, but I promise I’ll just continue to drink water until I can’t stand to look at it again.”
“Alright, I hope you have progress tonight.”
:So do I.”
The following afternoon, David checked back into the urgent care clinic.  I saw him shortly after he arrived.
“Hi, David what’s happened?”
“I’m still having spastic pain and I’ve drank more water than I can stand.  I don’t even want to look at it again.”
“Okay, am I to assume you still have back pain on the left side?”
“Alright, then let me go call the urologist who’s on call.  He’ll come down and see you and then decide on how to proceed.  I’ll be back shortly.”
I went out to the nurse’s station and paged the urologist.  When he called back I told him what was going on with David, he said he’d be down to see him shortly.  Thirty minutes later the urologist showed up and went into see David.
He came out a little while later and advised me that he was taking David up to the procedure room to do shock therapy lithotripsy.  He wanted to get him up to the procedure room before the daytime urology nurses left for the day.
David was brought back down by one of the urology nurses to the urgent care clinic about 4 hours later.  I could tell by the look on his face that the stone was gone. 
“Hey, David you’re back.  How did it go?”
“I’m free of that stone, at last!  They put me in a big tub of water and then used some machine to break up the stone.  I passed the stone in pieces about an hour after they put me in the tub.  Boy am I glad it’s gone.”
“Well, I’m glad to hear it!  Let me get that IV line discontinued for you and then you need your discharge orders.  So hang tight, let me get the clinic nurse to take care of your IV line for you.”
After the clinic nurse removed his IV line, I went over his discharge meds.  I told him he had to stay on the allopurinol every day, his lisinopril, and take the colchicine whenever  he had another attack of gout.  I also advised him to increase his daily fluid intake and to stop his high protein diet.  I asked him to see his primary care physician in a few weeks for follow-up. 
I checked his labs 3 days later and found out that the urologist had indeed sent the stone fragments in for analysis to the lab.  The fragments were tested and they were indeed formed from concentrated uric acid.  Hopefully with David on allopurinol and drinking lots of fluids he wouldn’t have another episode of renal stones.   

Long-term prevention of renal stone re-occurrence
This is based on the type of stone the patient has. 
All patients have to be taking in a high amount of fluids every day
Uric acid formers are put on allopurinol (which prevents uric acid formation)
Calcium stone formers can be advised as to dietary changes, and given diuretics which prevent the formation of subsequent stones.
All stone formers are advised as to a low sodium and low protein diet.