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?”
“Yeah."
“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?”
“Alright.”

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.”
“Okay.”
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

Signs/Symptoms

lower midline pelvic discomfort/pain (over bladder)
pain over lateral posterior back (either right or left, or both sides)
urgency
frequency
burning with urination
blood in urine
nausea/vomiting
fevers
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.”

Diagnosis/Treatment

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.