Alert to Artists: Painting is Hazardous to Your Health

A retired man came in for severe, persistent lower back pain. He had finished painting his basement and his wife asked him to paint the second floor.
Unfortunately, he fell off the ladder. He had slipped and fallen on his back. He got acupuncture treatment for one month including x-rays which showed L2 compression fracture. He has more pain when sitting down (which compresses the vertebrae compared to when he stands)

Thus, the patient had severe pain any time he was sitting down. Other specialists tried to give him steroid shots which were not successful.

After the failed shots, Doc referred the patient to a spine surgeon. The patient underwent vertebroplasty which is an procedure for stabilizing compression fractures in the spine. Bone cement is injected and the cement hardens, stabilizing and supporting the spine.

This kind of surgery will usually relieve the pain compared to all of these conservative treatments.

It was initially said to see that the couple could not fulfill their lifelong dream of traveling around the world together.  Fortunately, when I saw them the second time around when they came back to the office, the patient was almost pain free. And their trip around the world was just delayed by just a year.

I might think about being an orthopedic surgeon because the surgery literally changed the retiree's life around.

Babysitting

Middle aged woman came in today complaining of hand pain for sixteen years. The pain was on and off and began after the birth of her first child.

Every time she uses her hands, she gets numbness in her 2nd, 3rd, and 4th fingers of her hand. She denies any strength problems. In her daily life, she lifts alot. She baby sits 6 months to 15 month old babies.

Upon physical examination, she had clear tinnel signs. (The Dr. uses the hammer and taps the patients flexor side of the wrist.) The patient's wrist would clearly withdraw every time she was tapped. (Doc demonstrated this when she tapped me and nothing happened)

Patient did not have any signs of thenar atrophy in her hands.  Which is good because that means the medial nerve was not significantly damaged. She did not have positive phalen sign.

The patient was told to rest the wrists and keep the wrists at 15 degree mild dorsi flexion while she is sleeping as well as avoiding overuse of the wrists.

Unfortunately, if her job is to babysit fairly heavy children who must be lifted because they cannot walk, patient may eventually suffer more.....

The Tilt Test

A longtime patient of Doc, a middle-aged Asian woman, came in for a checkup.She was completely fine. She did however have certain episodes from a decade ago.

She would have prodromal symptoms like sweating in the palms and feet and hazy, blurry vision. Then all of a sudden she would pass out! Whether she was sitting or standing, it would not matter, she would pass out if she incurred these particular symptoms. Non-specific beta blocker had to be prescribed for the patient. Since she was prescribed the medication she did not have another episode for almost20 years and had been Doc’s patient since.

The patient went to nationally known emergency rooms three separate times. Each time, the ER did a CT scan, blood work, and the all of the results came back negative for any abnormalities.

 Doc happened to be on call for one of those ER visits.  They stated it was not a seizure and there was no indication of cancer or other serious diseases. However, when Doc answered the phone, she had a strong inclination that it might be neurocardiogenic syncope.

To confirm this, the patient was immediately scheduled for a tilt test. This is a controversial test. Patient would be given isoproterenol in an effort to induce symptoms of passing out to confirm the diagnosis. (The tilt is gradually increased upwards, which would then induce higher blood pressure, but because of the isoproterenol, the patient’s blood pressure would decrease thereby creating fainting episodes). Isoproterenol is supposed to increase the blood pressure and heart rate but her body was reacting in a completely opposite manner.

In all their years, the cardiologists doing the tests had never seen someone react so quickly to isoproterenol.  Her beta fibers were reacting oppositely.

Cardiogenic syncope is thought to have 3 separate causes:  1) the brain; 2) the patinet's own psychology or mental state; and 3) the heart.

For the patient, it was obviosuly her heart that was the issue.

Liver

A patient came in with known history of liver cancer. He came in with itchy skin and it was clear the patient of suffering from jaundice. He had yellow eyes and yellowish dark skin. Even though he has a dark tanned complex it was still obvious that he had yellow skin. Yellow eye (sclera)

He was also having a fever, loss of appetite, and indigestion plus abdominal bloating and mild chills. Doc thought that he might have growing existing hepatoma blocking the bile duct causing obstructive jaundice associated with fever consistent with acute bile duct infection(acute colongititis) Or bile duct stone. He was sent to ER and admitted to regular medical care. They confirmed acute colongitis from growing hepatoma. He underwent immediate ERCP(define) endoscopic Sphrinctroctomy.

The surgery relieved the obstruction but he suffered arterial injury complications. He had to take 4 units of transfusion.

I just found it really interesting how the symptoms were so pronounced in his skin color and general condition.  One look and it was clear the patient was seriously ill.

Boops! I did it again...

50 year old lady came in with a history of RA, rheumatoid arthritis. She also had many joint deformities. Her symptoms were nasal congestion, yellow phlegm, hoarseness, shortness of breath, and severe coughing. Her condition was not improving before she came to Doc. An x-ray order showed a hazy density in her lungs. She was then referred to her pulmonologist (or pulmonary disease specialist, one who specializes in treatment of pulmonary conditions or diseases).

The pulmonologist determined that she had boop. (Yes, this is an actual term. It is an acronym for Bronchiolitis obliterans with organizing pneumonia.) Basically the tiny sacs or alveoli and small bronchi become very inflamed and infected causing severe pain, coughing, and other symptoms.

She underwent a very high dose of steroids.

However, from the huge influx of steroids the patient developed Cushing syndrome.

Cushing syndrome is developed in two ways, either intrinsically or extrinsically. This was an extrinsic case as she was consuming prednisone.

Cushing Syndrome Symptoms: moon-face, weight gain, increased blood pressure, hump neck, increase in blood suger, edema, and reddish, unusual stretch marks.

Her steroids were gradually tapered off over time and she was eventually cured.

I see people...

A young woman came in complaining of a severe headache in the front part of her head.

According to the patient, the headaches would usually happen before the start of her periods. This time however the headache started after her period. The patient was experiencing nausea and vomiting. She was very sensitive to loud sounds and light. It was a recurring headache every menstrual cycle. But there were no other neurological symptoms. Patient denied any family history of migraine headaches.

Doc concluded that menstruation related to migraine headaches was the likely cause. This diagnosis makes sense because of hormonal changes during a period.

Treatment options were simply anti-migraine medicine (sumatriptan). The medicine does not prevent headaches, only relieves the symptoms before it starts.

Doc noted that some some patients experience a visual "aura". Some people see some light changes in their vision. So it is almost like a clue that a migraine headache was the likely cause.  In extreme cases, some people can get a stroke from their migraine headaches.

Allergy

In the office, we decided to bring in allergy prick testing. It is very simple. All you have to do is grab the prick device dip it in the wells and apply it to the patient's skin. Then after 30 minutes compare it to the positive control (histamine) and compare.

The common treatments for allergies are usually OTC medications like allegra or claritin. However, for some patients these medications are not enough. So they turn to treatment options such as SCIT(subcutaneous immunotherapy). This involves the patient coming into the office and receiving shots of the specified allergens according to their allergy test. They then receive shots of increasing concentration until they can reach "maintenance" or to the point where they only need to take a shot once a month to maintain their allergy relief.

I personally did SCIT at one point. However, continually going into the office and continually paying a copay adds up very quickly. In Europe, there is a very similar treatment called SLIT(sublingual immunotherapy). You simply apply the treatment under your tongue and increase the concentrations over time. It is not as accepted in the states but it very well could be.