Close call

Pt called the office complaining of nose bleed and post nasal dripping.

Pt insisted that he did not have any other associated problems. Dr. advised him on the phone that he should go to the ER given that he underwent recent heart surgery and stress related issues.

Pt checked into ER for nose bleed and bloody sputum(a mixture of saliva and mucus coughed up from the respiratory tract.)

Chest x-ray in ER revealed some infiltration suggestive of pulmonary tuberculosis which was confirmed by sputum stain.

The ER had to immediately isolate the Pt. Pt is now taking multiple anti-tb medications under supervision. (They need to be supervised because if the pt misses a dose, it can be detrimental to cause multi-resistant TB.)

We still have to be vigilant of infectious diseases like TB.

It certainly was a close call as we could have also been infected.

Tech Docs...

So, even docs are not being lured by the tech siren calls....guess it's true that people went into medicine for money after all...

But young docs thinking about making millions in health tech may want to keep in mind that out of 19 named employees in the hot health startup, Rock Health, only one has an MD degree...not much of an opportunity for MDs there...

Although I can understand why the lure of tech for a group of highly educated people who are likely forced into mind-numbing routines might happen.  I work in a doctors office as an office manager and I can truly say that if policy makers don't make it a priority to keep docs in the profession, they will soon find themselves on the operating table without anyone to attend to them.

Dr. Google

Young white female presented with a history of chronic eczema or atopic dermatitis. She had this condition over several years all over her body. The chronic skin condition not only affected her physical wellbeing but negatively affected her mental wellbeing as it was very visible across her face and limbs. As a result, she had not maintained a full time job for two years.

She was using a topical steroid cream, cortisone for about one and a half years, as recommended by her doctor. After some time of steroid use, the patient was disappointed with the progress of the her skin condition, And in fact, when the patient googled the fact that steroid creams were actually bad for the skin, she was even more alarmed. So, the patient decided to suddenly stop using the cream without consulting Doc.

For the next two months, the patient had difficulties controlling her temperature when it was either cold or hot, persistent dizziness, nausea, loss of appetite, and her entire skin was swelling and oozing. She did not, however, visit the doctor because her parents told her that her reactions were the result of her own mental and psychological problems, not because of any other issues.

Finally, the patient decided to go see the doctor and explained everything, including how she found out that steroid creams were not good for her and why she stopped it suddenly and the additional conditions after she stopped using the steroid creams.

 The doctor explained that when you administer exogenous (originating from outside the patient) corticosteroids, it disturbs the negative feedback loop. The body stops producing its own corticosteroids, because the it is constantly receiving it from outside sources. So, when the patient stopped using the steroids, it has severe adverse effects on the body and can push the body into an adrenal crisis. The Doctor mentioned that in some cases the death rates for adrenal crisis like the one that the patient suffered from by stopping the steroid cream is extremely high, as much as 50%.

Why???????

An oncologist in Detroit was purposely misdiagnosing patients with multiple myeloma. Then gave chemotherapy treatments to over 500 people. In some cases, repeatedly giving them chemotherapy treatments until they were nearly dead.

Seriously, even if it was for the money just why?

The Price is Right!!

A 54 year old white male came in for a check up post motor vehicle accident (MVA) to claim for insurance or something. Anyway, Doctor asked when did the patient have his last regular check up. The patient apparently had never seen a doctor so he had a whole battery of blood tests and physical.

After his follow up, the blood tests showed some interesting results. His liver enzyme was a little elevated. His liver profile showed that he had hepatitis c. Upon a follow up appointment, the ultrasound showed that he had hepatoma and showed some significant symptoms of liver cancer(jaundice, yellow skin, etc.)

If it was back in 2000s, there would be limited treatment options, and for many a death sentence. However, starting this decade Gilead Sciences developed a drug called ledipasvir/sofosbuvir--its trade name being Harvoni. It's an absolutely revolutionary treatment and can successfully treat hepatitis c! Obviously, if you have a miracle drug that can essentially cure a life threatening disease, it will not come cheap. The total cost of a three month treatment(it is taken orally and the length of the treatment depends on the severity of the disease.) is $100,000. But if its worth your life, even at $100k, the price is right...

Treat the Patient, Not the Disease

A teenager presented with years of bed wetting (enuresis) problems, nearly every night.  As a result, he was socially isolated and had no experience of sleepovers, etc. because of his condition.

He is a very athletic, active, and academically strong teenager boy, an outstanding kid actually. Upon further examination and questioning, it appeared the boy had anxiety issues because of his mother. His mother would go to work every morning at 4 am. As a result, his father took care of him during the day. The father was apparently very strict with him.  Mother would come back home very late so as an only child he was mainly with the father and raised in a very strict environment.

One obvious solution was imipramine which is the common treatment for bedwetting as well as depression.  But the Doctor decided to forgo that usual treatment because she was concerned about side-effects, and frankly, he was not depressed.  Bed-wetting was a subconscious issue.

Instead, the Doctor asked that the patient write a monthly schedule of when he wets or doesn't wet on that night. If he doesn't wet the night, Doctor told the mother to reward him at the end of each week. Within 6 months, the patient did not have any more bed wetting problems and without the use of drugs.

I thought about this and realized that the patient had basically cured himself by visualizing on his chart his progress.  The things that caused his issues, an absent mother, a strict father, could not be changed, but the patient could be.

Too often in today’s medical environment, few doctors would take the time to understand the patient, a more difficult and more time consuming process than understanding the disease, especially since drug companies make it easier for doctors to just medicate. But that method only serves as a temporary solution not a permanent one. The Doctor went beyond that and systematically solved what was affecting the patient, psychosomatically by treating the patient rather than treating the disease.

Remember that Magic School Bus episode?

Back when I was a kid, I would watch a show called the Magic School Bus. It was about an eccentric school teacher named Ms. Frizzle who would lead her third grade class on this magical school bus that could take them anywhere.

Arnold turns orange in one episode and the whole class goes on an adventure trying to solve why he is orange. I actually had a similar case with the Doctor.

A middle aged man came in complaining of his skin tone. When I first saw him I thought that he was experiencing jaundice and other liver problems. It was that pronounced.


Of course, his skin tone was not as dramatically orange as Arnold was in the picture above.  After a long diagnosis with the patient, he just simply ate and took a lot of other stuff that made him become orange.  On a daily basis, he ate as much as two bags of carrots, drank at least a gallon of orange juice, and at least half a bag of clementine oranges.  He had originally been scared that it might be a liver issue or even cancer, and this "orange" condition even affected him personally, including his relationships and his job.

The remedy was for him to just simply stop.  In a few weeks, when he came back for a followup, he was fine.  And his color returned to normal.