U.S. Preventive Services Task Force Sucks
8 hours ago
Monday, December 7, 2020
Welcome! (sticky post)
Welcome to "Doctors in the House", an experiment in virtual medicine. We will be unlike anything you have seen on the web in that we will discuss your case with you at length as you obtain diagnosis and treatment for your disease from your physicians. Specifically, we can translate medical speak into plain language, and explain the 'whys' and 'wherefores' of modern medicine to you. As a consequence of the mess of American medicine and specifically the fact that our government has created a system where physicians are forced to see more and more patients per day in order to turn a profit you may have discovered that actually speaking to a physician is well nigh impossible. That's where we come in. Please read the information on this page to find out how we work and how we take cases onto the blog for discussion. I hope we can help you and I hope this turns out to be better than "House", but maybe we should set the bar higher than the ground?
Thursday, July 16, 2009
New Policy
So, "JustAnswer" is up and running with a great site where people ask questions, figure out how much they are willing to pay for an answer, and then experts choose to answer or not. I'm on there now and love it. I make about 7$ to answer simple medical questions. We will continue to post cases on this site but for the meager sum of $25 sent as a donation your question will go to the head of the line and will be answered quickly. Also, with the donation, you may feel free to continue to ask questions and I think it will be a great deal for us all. In fact, if you have questions that I can not answer I will attempt to get someone who CAN answer.
Fine print stuff. This site does not create a doctor patient relationship. The donations will go towards site maintenance and to pay for consultants to come to the site and answer if necessary. Also, a portion of the donations will go to my local free clinic to keep them up and running.
If this does not work the site will be taken down as it is a real time sponge for me and I often spend an hour or two answering questions. These same questions, if answered in your physician's office would cost you a lot more than $25. Our goal is to increase your understanding of your disease process and to point you in the right direction to get your problem taken care of by your physician as quickly as possible.
Best,
911doc
Fine print stuff. This site does not create a doctor patient relationship. The donations will go towards site maintenance and to pay for consultants to come to the site and answer if necessary. Also, a portion of the donations will go to my local free clinic to keep them up and running.
If this does not work the site will be taken down as it is a real time sponge for me and I often spend an hour or two answering questions. These same questions, if answered in your physician's office would cost you a lot more than $25. Our goal is to increase your understanding of your disease process and to point you in the right direction to get your problem taken care of by your physician as quickly as possible.
Best,
911doc
Monday, June 1, 2009
Socialism Does not Work
Just a friendly note to tell you all that this site will remain open, but, since, to date, we have received exactly $ 0.00 for about twenty hours of work (with some very positive reviews) it is not exactly something that makes us want to give this more attention than MDOD, which is fun and a hobby.
So, our experiment in goodwill and socialism has proved, so far, that if you give something away that actually has some worth, people will take it and thank us (sometimes), and that's all. Were we to realize some profit we would, as mentioned in the sidebar, self-insure and go live.
Accordingly, we will attempt to get to all cases submitted which do not appear to be litigation scams or are too complicated to deal with properly in this format, but we will do so when the mood strikes, and not because we stand to realize some monetary success.
We Remain,
Your Humble Servants,
The "Docs in the House" Team
So, our experiment in goodwill and socialism has proved, so far, that if you give something away that actually has some worth, people will take it and thank us (sometimes), and that's all. Were we to realize some profit we would, as mentioned in the sidebar, self-insure and go live.
Accordingly, we will attempt to get to all cases submitted which do not appear to be litigation scams or are too complicated to deal with properly in this format, but we will do so when the mood strikes, and not because we stand to realize some monetary success.
We Remain,
Your Humble Servants,
The "Docs in the House" Team
Monday, May 4, 2009
Peripheral Neuropathy
A reader writes...
What is peripheral neuropathy?
November 2008, my feet started feeling like they were on fire. I've learned that this can be caused by diabetes or by pernicious anemia - family history of both. My father was diagnosed with type-2 diabetes at age 47. My mother was diagnosed with adult-onset IDDM at age 46. I am not diabetic; I am 5'6" and 145#, if that matters. Over the past two years, five CMPs have been done; my blood glucose has ranged 80-87. My grandfather had pernicious anemia and got monthly B12 shots; one uncle and cousin also have pernicious anemia (Scandinavian heritage). Lab work in Feb '09 showed my B12=501 and my folate=30.2 (this is higher than the 3-17 normal range, but I don't know what that means). I was referred to an electrodiagnostician for an EMG/NCV study. The March '09 report includes, "Impression: This is an abnormal study. The findings are compatible with mild, early distal peripheral neuropathy involving both lower extremities. This appears to be predominantly a distal axonal neuropathy. I suspect this could be due to an underlying rheumatoid arthritic process. There is no strong evidence of peripheral entrapment neuropathy, including tarsal tunnel syndrom. No evidence of root pathology involving anterior primary rami. Please correlate these findings with other clinical workup."
The doctor who ordered the EMG and labwork just initialed the reports and had them added to my chart. He did not contact me and does not return patient phone calls. I am not complaining about these things to you, just stating facts - I have no way to get information from that doctor, and at this point am in the processes of transferring my records to a new doctor, but it will be another two months before I am seen. I would really like to learn about peripheral neuropathy and what impact it is likely to have on my life.
Does "other clinical workup" mean that I'm going to need MORE tests? Is this condition progressive or will treatment halt progression? How is it treated? Does treatment result in a cure? What would be the result if I declined treatment? Any chance that my feet will ever feel normal again? (Yes/No doesn't matter; at this point I just want to know)
Dear Reader.. all good questions. Good for you for taking the proactive approach. Sounds like your primary care doctor is either overwhelmed with patients or... I am surprised that you have not been treated with medicine for this painful condition. The usual 'starter' medicine is neurontin, which is low on side effects and works well for this condition.
If you are someone who has developed neuropathy without the 'normal causes' like diabetes or vascular disease and the radiologist is suggesting a 'rheumatologic cause' your next step is either to see a neurologist or Rheumatologist. If you have a progressive disorder the Rheumatologist may be a great aid in arresting the disorder and getting to the right diagnosis faster.
A neurologist is likely to start you on neurontin and refer you to a Rheumatologist so getting to one sooner rather than later is a good idea. In the meantime continue to be proactive with your diagnosis and see if you can't get an answer from your primary care provider. At the very least you might suggest that he prescribe neurontin for you and you may get some relief while you wait for your definitive diagnosis.
Finally, unless I am way out of date, the test for pernicious anemia is a 'schilling test' and it doesn't sound like you have had one yet. The serum markers are important in other forms of anemia but do not diagnose pernicious anemia. Also, just so you know, B12 shots are the only treatment for pernicious anemia, the oral B12 will not work.
Hope you get better soon. Please let us know how this turns out.
What is peripheral neuropathy?
November 2008, my feet started feeling like they were on fire. I've learned that this can be caused by diabetes or by pernicious anemia - family history of both. My father was diagnosed with type-2 diabetes at age 47. My mother was diagnosed with adult-onset IDDM at age 46. I am not diabetic; I am 5'6" and 145#, if that matters. Over the past two years, five CMPs have been done; my blood glucose has ranged 80-87. My grandfather had pernicious anemia and got monthly B12 shots; one uncle and cousin also have pernicious anemia (Scandinavian heritage). Lab work in Feb '09 showed my B12=501 and my folate=30.2 (this is higher than the 3-17 normal range, but I don't know what that means). I was referred to an electrodiagnostician for an EMG/NCV study. The March '09 report includes, "Impression: This is an abnormal study. The findings are compatible with mild, early distal peripheral neuropathy involving both lower extremities. This appears to be predominantly a distal axonal neuropathy. I suspect this could be due to an underlying rheumatoid arthritic process. There is no strong evidence of peripheral entrapment neuropathy, including tarsal tunnel syndrom. No evidence of root pathology involving anterior primary rami. Please correlate these findings with other clinical workup."
The doctor who ordered the EMG and labwork just initialed the reports and had them added to my chart. He did not contact me and does not return patient phone calls. I am not complaining about these things to you, just stating facts - I have no way to get information from that doctor, and at this point am in the processes of transferring my records to a new doctor, but it will be another two months before I am seen. I would really like to learn about peripheral neuropathy and what impact it is likely to have on my life.
Does "other clinical workup" mean that I'm going to need MORE tests? Is this condition progressive or will treatment halt progression? How is it treated? Does treatment result in a cure? What would be the result if I declined treatment? Any chance that my feet will ever feel normal again? (Yes/No doesn't matter; at this point I just want to know)
Dear Reader.. all good questions. Good for you for taking the proactive approach. Sounds like your primary care doctor is either overwhelmed with patients or... I am surprised that you have not been treated with medicine for this painful condition. The usual 'starter' medicine is neurontin, which is low on side effects and works well for this condition.
If you are someone who has developed neuropathy without the 'normal causes' like diabetes or vascular disease and the radiologist is suggesting a 'rheumatologic cause' your next step is either to see a neurologist or Rheumatologist. If you have a progressive disorder the Rheumatologist may be a great aid in arresting the disorder and getting to the right diagnosis faster.
A neurologist is likely to start you on neurontin and refer you to a Rheumatologist so getting to one sooner rather than later is a good idea. In the meantime continue to be proactive with your diagnosis and see if you can't get an answer from your primary care provider. At the very least you might suggest that he prescribe neurontin for you and you may get some relief while you wait for your definitive diagnosis.
Finally, unless I am way out of date, the test for pernicious anemia is a 'schilling test' and it doesn't sound like you have had one yet. The serum markers are important in other forms of anemia but do not diagnose pernicious anemia. Also, just so you know, B12 shots are the only treatment for pernicious anemia, the oral B12 will not work.
Hope you get better soon. Please let us know how this turns out.
Sunday, May 3, 2009
A Nurse With an Interesting Hypercoagulable State
I do not have much to add to this story and can not answer the reader's ultimate question but notice, dear readers, the extent to which this patient got involved in her own care. She, ultimately, figured out her problem and was a great aid to her physician in her diagnosis and treatment. Good job!
Last May I came down with what I had believed was bronchitis. I continued to feel increasing shortness of breath, chest pressure, lightheadedness, and even a genuine feeling of doom for several days (always thought 'feelings of impending doom' were bogus - until experienced!). Finally, after sucking back the Ventolin puffer with no relief, I decided to go to the ED. The Dr ordered bloodwork, ABGs, ECG, CXR, and then a CT Angiogram. The results? Multiple Bilateral Pulmonary emboli. I was started on LMWH, then Warfarin, and a week later went home.
I had no obvious reasons for the emboli. No recent surgeries, no long trips, no prolonged periods of inactivity. In effort to determine why I developed the emboli several tests were performed.
Bilateral leg dopplers - negative.
Echo - negative.
Pelvic u/s - negative
Mammogam - negative
Fairly Routine Bloodwork (ie: the usual stuff - forgive my lack of details here) - for the most part negative. Except for a prolonged PTT time and a normal PT time. The one clue I had to go on.
More Advanced Bloodwork - Lupus Anticoagulant - negative, Anticardiolipins (?) - negative, Protein C and S - negative (or normal - whatever the references are).
This is what I had to go on. Each test result (above - although I've probably missed mentioning several) apparently gave no reason specifically for my development of the emboli. This bothered me to no end. I was not content in accepting the fact that just because there was no apparent cause of the emboli I would never know exactly why I developed them. I was told that often times a cause is not discovered.
And so I turned to Pub Med. During my newfound boredom from being off work I began my search for answers. Interestingly I was able to (almost) diagnose myself. No - I am not some sort of freak who reads medical sites so I can tell my Dr what is wrong with me and what I need prescribed. In fact, I am a nurse with a little bit of knowledge and as such was able to come to a somewhat feasible diagnosis. Let me explain a little more. To do this I must tell you a bit more of my own and my family history. Details are lacking here - as they have been to me all my life.
I was born full term weighing 2 lbs 4 oz. Was in hospital for several months before I went home - but otherwise healthy. Was told my mother had some type of a 'partial stroke' while pregnant with me and I stopped growing in-utero @ 7 mths.
When I was two I had eye surgery for some type of blockage. Grew up being told I would be blind by the time I hit my teenage years. Don't know anymore details of the surgery or condition. I wear glasses but am nowhere near being blind (pushing 40 y/o now). To this day I do not know what type of eye condition I had been diagnosed with at the time. And I'm not able to find out from anyone/anywhere.
I also had a sister who had a healthy, normal pregnancy. She had a rather uneventful birth of a healthy daughter. Shortly after delivering she hemorrhaged. Lots. BP dropped to 60/40. She died from complications 10 days later. This occurred when I was quite young and unfortunately I do not recall many of the other details. I've often thought it was a DIC type of thing.
I gave birth to two healthy full term children, both small for gestational age (4 lbs 4 ozs, and 5 lbs 15 oz). No miscarriages no other pregnancies.
And finally, being a fairly healthy person usually, I've been having episodes of RUQ pain throughout the past few years. It comes and goes and seems suspiciously like some type of gallbladder disease. I have gone to the ED on several occasions however bloodwork, u/s, CT, and HIDA scans have all been normal.
I occasionally get some nasty headaches (migraines?) too.
That's it for my past history. Which brings me back to my Pub Med search and my search for reasons for the pulmonary emboli.
I recall reading an article (after SEVERAL others) that stopped me short in my tracks. During all my reading I never once considered ANY of my (or my family members) medical history - quite frankly because none of it seemed to be relevant to my recent diagnosis. So, if you can, imagine my surprise when I read one article that quite literally not only mentioned all of the medical 'mysteries' in my life - but gave me answers for them and a potential reason for my pulmonary emboli.
The article was describing Antiphospholipid Syndrome. It seemed I suddenly had the answers to many of my questions. I was quite pleased, although a little doubtful, of this revelation. I had an appt with my family Dr not long afterward. With more than a little apprehension (of sounding like a self-diagnosing freak) I mentioned my personal research findings. She too thought it might be a likely diagnosis. The following week I had an appointment with my hematologist to review the results of my genetic tests. Turns out I didn't have APS. Instead, I have been diagnosed as having G20210A mutation (prothrombin gene mutation). It looks as though I will be on life-long anticoagulation. And thankfully, our children have since been determined to NOT have the mutation.
Interestingly, I'm not quite sure now HOW or WHY my personal and family medical history seemed to be so geared toward APS (which I do not have) but it does seem as though everything still ties together. And truthfully I'm not even sure if the G20210A mutation could be related to the other problems in a similar manner to that of APS. Seems there's not much info in this relatively new discovery of the prothrombin gene mutation.
And so…
I wonder if my mother had clotting problems in her placenta which caused me to be small at birth. Could this be a type of a 'partial stroke' (she never had any neuro deficits that I recall)?
I wonder if I had a clot causing the 'occlusion' in my eye that required surgery?
I wonder if a similar (prothrombin gene mutation) could have played a role in my sisters post partum hemorrhage?
I wonder if my own children were small at birth due to placental clots?
And, I wonder if my mysterious RUQ pain could be related in some way?
I have a few other questions too.
For example - if my INR stays in the therapeutic range of 2-3 - can I still form blood clots and emboli given the fact that my prothrombin gene is mutated? Does a therapeutic INR just lower my chances of this or does it eliminate it?
What happens - providing anticoagulation remains in the therapeutic range - if I do develop more clots? How would they then be treated?
My INR has become fairly stable since starting on the warfarin. It is usually around 2.7.
Last week I had another episode of RUQ pn x 3 days and at the time my INR was noted to be 3.6. It has since come down to 2.8.
Also, the use of warfarin has had a horrendous impact on my menstrual cycle. Due to having seven or eight solid days of very heavy menses (with irregular and shorter days in between episodes) I have requested a consult with a gynecologist. His recommendations were: an IUD (which I do not want), or the use of progesterone (?) PO, or the use of an antifibrinolytic PO, or an endometrial ablation. I am really confused as to which method to choose. At my appt with him I had agreed to the ablation and a biopsy was done (resulted negative). I've since made another appt to review my options with him again, in light of the fact that I'm now rather scared to have the ablation performed (bleeding? perf? etc). Maybe one of the PO options would be alright - but at this point I am just not so sure what to choose. Again, I've tried to find resources on my own to help me make a decision - but instead I've just become even more confused. Somehow, however, I've got to manage the menses as it's become very unbearable.
I am searching for more information from knowledgeable individuals to help me understand not only my current diagnosis, but that of my past, and considerations for the future too. I'm not sure how interested you may be in sharing this story and providing more info. I do hope to learn more from you and to hear your views on what has happened and what may lie ahead.
Thanking you for your time :)
I had no obvious reasons for the emboli. No recent surgeries, no long trips, no prolonged periods of inactivity. In effort to determine why I developed the emboli several tests were performed.
Bilateral leg dopplers - negative.
Echo - negative.
Pelvic u/s - negative
Mammogam - negative
Fairly Routine Bloodwork (ie: the usual stuff - forgive my lack of details here) - for the most part negative. Except for a prolonged PTT time and a normal PT time. The one clue I had to go on.
More Advanced Bloodwork - Lupus Anticoagulant - negative, Anticardiolipins (?) - negative, Protein C and S - negative (or normal - whatever the references are).
This is what I had to go on. Each test result (above - although I've probably missed mentioning several) apparently gave no reason specifically for my development of the emboli. This bothered me to no end. I was not content in accepting the fact that just because there was no apparent cause of the emboli I would never know exactly why I developed them. I was told that often times a cause is not discovered.
And so I turned to Pub Med. During my newfound boredom from being off work I began my search for answers. Interestingly I was able to (almost) diagnose myself. No - I am not some sort of freak who reads medical sites so I can tell my Dr what is wrong with me and what I need prescribed. In fact, I am a nurse with a little bit of knowledge and as such was able to come to a somewhat feasible diagnosis. Let me explain a little more. To do this I must tell you a bit more of my own and my family history. Details are lacking here - as they have been to me all my life.
I was born full term weighing 2 lbs 4 oz. Was in hospital for several months before I went home - but otherwise healthy. Was told my mother had some type of a 'partial stroke' while pregnant with me and I stopped growing in-utero @ 7 mths.
When I was two I had eye surgery for some type of blockage. Grew up being told I would be blind by the time I hit my teenage years. Don't know anymore details of the surgery or condition. I wear glasses but am nowhere near being blind (pushing 40 y/o now). To this day I do not know what type of eye condition I had been diagnosed with at the time. And I'm not able to find out from anyone/anywhere.
I also had a sister who had a healthy, normal pregnancy. She had a rather uneventful birth of a healthy daughter. Shortly after delivering she hemorrhaged. Lots. BP dropped to 60/40. She died from complications 10 days later. This occurred when I was quite young and unfortunately I do not recall many of the other details. I've often thought it was a DIC type of thing.
I gave birth to two healthy full term children, both small for gestational age (4 lbs 4 ozs, and 5 lbs 15 oz). No miscarriages no other pregnancies.
And finally, being a fairly healthy person usually, I've been having episodes of RUQ pain throughout the past few years. It comes and goes and seems suspiciously like some type of gallbladder disease. I have gone to the ED on several occasions however bloodwork, u/s, CT, and HIDA scans have all been normal.
I occasionally get some nasty headaches (migraines?) too.
That's it for my past history. Which brings me back to my Pub Med search and my search for reasons for the pulmonary emboli.
I recall reading an article (after SEVERAL others) that stopped me short in my tracks. During all my reading I never once considered ANY of my (or my family members) medical history - quite frankly because none of it seemed to be relevant to my recent diagnosis. So, if you can, imagine my surprise when I read one article that quite literally not only mentioned all of the medical 'mysteries' in my life - but gave me answers for them and a potential reason for my pulmonary emboli.
The article was describing Antiphospholipid Syndrome. It seemed I suddenly had the answers to many of my questions. I was quite pleased, although a little doubtful, of this revelation. I had an appt with my family Dr not long afterward. With more than a little apprehension (of sounding like a self-diagnosing freak) I mentioned my personal research findings. She too thought it might be a likely diagnosis. The following week I had an appointment with my hematologist to review the results of my genetic tests. Turns out I didn't have APS. Instead, I have been diagnosed as having G20210A mutation (prothrombin gene mutation). It looks as though I will be on life-long anticoagulation. And thankfully, our children have since been determined to NOT have the mutation.
Interestingly, I'm not quite sure now HOW or WHY my personal and family medical history seemed to be so geared toward APS (which I do not have) but it does seem as though everything still ties together. And truthfully I'm not even sure if the G20210A mutation could be related to the other problems in a similar manner to that of APS. Seems there's not much info in this relatively new discovery of the prothrombin gene mutation.
And so…
I wonder if my mother had clotting problems in her placenta which caused me to be small at birth. Could this be a type of a 'partial stroke' (she never had any neuro deficits that I recall)?
I wonder if I had a clot causing the 'occlusion' in my eye that required surgery?
I wonder if a similar (prothrombin gene mutation) could have played a role in my sisters post partum hemorrhage?
I wonder if my own children were small at birth due to placental clots?
And, I wonder if my mysterious RUQ pain could be related in some way?
I have a few other questions too.
For example - if my INR stays in the therapeutic range of 2-3 - can I still form blood clots and emboli given the fact that my prothrombin gene is mutated? Does a therapeutic INR just lower my chances of this or does it eliminate it?
What happens - providing anticoagulation remains in the therapeutic range - if I do develop more clots? How would they then be treated?
My INR has become fairly stable since starting on the warfarin. It is usually around 2.7.
Last week I had another episode of RUQ pn x 3 days and at the time my INR was noted to be 3.6. It has since come down to 2.8.
Also, the use of warfarin has had a horrendous impact on my menstrual cycle. Due to having seven or eight solid days of very heavy menses (with irregular and shorter days in between episodes) I have requested a consult with a gynecologist. His recommendations were: an IUD (which I do not want), or the use of progesterone (?) PO, or the use of an antifibrinolytic PO, or an endometrial ablation. I am really confused as to which method to choose. At my appt with him I had agreed to the ablation and a biopsy was done (resulted negative). I've since made another appt to review my options with him again, in light of the fact that I'm now rather scared to have the ablation performed (bleeding? perf? etc). Maybe one of the PO options would be alright - but at this point I am just not so sure what to choose. Again, I've tried to find resources on my own to help me make a decision - but instead I've just become even more confused. Somehow, however, I've got to manage the menses as it's become very unbearable.
I am searching for more information from knowledgeable individuals to help me understand not only my current diagnosis, but that of my past, and considerations for the future too. I'm not sure how interested you may be in sharing this story and providing more info. I do hope to learn more from you and to hear your views on what has happened and what may lie ahead.
Thanking you for your time :)
So, if there are any enterprising heme-onc docs out there who can add or subtract from this case please comment. And dear reader, if the menstrual irregularities are as bad as they seem and you are done with having kids the simple solution might be to have a Hysterectomy. The endometrial ablation and/or progesterone therapy might be temporizing (and I don't think you need worry too much about a perforation... the uterus is thick and muscular and this is a rare occurence), but I think you might opt for the definitive. Best of luck and let us know what happens!
Tuesday, April 28, 2009
A Change in Character of Headaches
A reader with previous headaches reports the following...
Well, this really stinks. I believe you are describing a migraine variant, or, more likely, a 'cluster headache'. The tickler here is what they saw on the MRI. Probably what they saw was an indidentaloma or fascinoma meaning that they saw a part of your brain that is not exactly like the 'normal' one in the book so they commented on it and someone threw out the term 'zebra' (which means a rare medical diagnosis) and they shuffled you off to a neurologist which is exactly what they should have done.
If I am correct, then I hope they have better drugs to treat cluster headache than they did when I first learned about them (and I'm sure they do). Know this, I don't think that you need to concern yourself about the terrifying 'brain cancer' possibility though this is probably something you are afraid of based on what has happened. If any of your physicians were concerned about a tumor then you would be off to a neurosurgeon.
I think you will find that your neurologist at least mentions 'cluster headache' and tries you on some different medicines or changes your current meds. You are clearly not 'aphasic' as you have already demonstrated, but whatever they saw on your MRI was probably in 'Broca's Area' which caused the radiologist to ask if you were aphasic.
Please do let me know how this turns out. I hope this helped.
Post-Prandial Pain
A reader writes...
Stomach pain after eating. Started seven days ago and seems to be getting worse. Belly is a little distended. No problem with a BM and urination. I have no health insurance and really am looking for a home remedy before incurring an ER charge!!!
The sky's the limit here. Since you have COPD I take it you are or were a smoker. This adds a little wrinkle. Here's what you need to do and it does not involve a trip to the ER unless you develop fever and vomiting.
Get yourself seen by a good internal medicine doctor. Ask who's the best in your area and then call and tell them you will pay up front and you will be seen quickly. When presented with a constellation of symptoms doctors will formulate a 'differential diagnosis'... a list of the most likely causes of your symptoms. I'm going to give you that list here and it is by no means complete... just a starting point, so please don't be scared by some of these possibilities.
1. Cardiac ischemia. Some people have angina, pain from the heart, after eating. This is known as an 'anginal equivalent' and the theory is that the extra blood flow heading to your guts after a meal will steal blood from the heart and cause the same symptoms that a 'classic' chest pain patient would have... discomfort with exercise or exertion. I think this is unlikely but is where I would start if you saw me in the ER. Unlikely but possible .
2. Gastritis/Esophagitis. You need a good internist to run a helicobacter pylori test to see if you harbor the bacteria that causes ulcers. Good news if you do as this is generally fixed by a course of antibiotics and acid-blocking medicine. Get the test. If it is negative you may need an upper endoscopy... a video scope into the upper GI tract under light sedation.
3. Gall-Bladder disease. This is the most likely diagnosis but tends to occur in females in their forties who are slightly or massively overweight and the pain is in the right upper quadrant of your abdomen and will 'radiate' through to your right shoulder. It is often accompanied by vomiting and can resolve as quickly as it comes on. The fix is surgery and you don't want to have emergency surgery after the gall-bladder gets infected... higher complication rate and more difficult surgery.
4. Cancer. Here's the part where you need to keep calm. If you are a smoker and you are having sever mid abdominal pain after eating cancer is on the list. Gastric or pancreatic. Unlikely. Very unlikely, but also the kind of thing you do not want to let sit. Get in to see that internist as soon as you can.
5. Gastric dysmotility from undiagnosed adult onset diabetes. Diabetics, for some reason, are often prone to gastric emptying problems and a simple finger stick glucose measurement can show if you have diabetes. If you do, also not something you want to let go until you have to come see me in the ER.
In summary, you likely simply have a gall bladder problem or an upper GI issue like ulcers or esophagitis. Until you can see a physician I recommend trying prilosec OTC and follow the package instructions. Quit smoking! Please check back in with us when this is diagnosed. The $150 you spend now to see a good internist will be worth it. Also, you might consider purchasing individual health insurance with a large deductible... you can probably get it for about $100 a month without a physical, and if you require surgery will help you defray the costs. I hope you get better soon.
Saturday, April 25, 2009
Rapid Heart Rate With Excercise
A young woman with asthma and hypercholesterolemia writes the following...
My question is about whether what I am experiencing is normal, or indicative of something specific. I am a 27 yr old female. 5'6" 155-160lbs (not that 5 lbs matters) I have a personal and family history of high cholesterol and am taking 20mg Prevastatin for that. I also take 20mg Lexapro daily for depression. I have albuterol to take if I need it, but have not taken it in over 1 yr. About 6 months ago or so I began a jogging program. I have found that my heart rate accelerates very quickly (within a couple minutes), even at a very slow jog. It gets fairly high (I have a hard time keeping it below 200). I then get very tired very quickly and have to go back to walking. I thought that maybe this was because I was out of shape, and would regulate itself when I got more conditioned, but it hasn't. This does not happen when i am not exercising. My resting heart rate is about 60bpm. I had an ekg last week and it was reported as normal. Is there a specific condition that causes a high heart rate with exercise? Is it safe to continue jogging?
Well, this is a bit of a tough one because to answer this you need to do a little footwork. Being on a 'statin' for your cholesterol is a bit of a pain. Many people can not tolerate these medicines and this may be the simple answer. If you find yourself having myalgias, muscle pain, even without excercise, this may be the culprit. Another more dangerous possibility would be that you could have an 'accessory pathway' in your heart's conduction system which will trip it into a very rapid rate under certain conditions. Even though your EKG was 'normal' there's normal EKGs and then there's the 'oops, missed one' EKGs.
I think a reasonable approach to your problem would be to see your primary care provider and ask the following questions...
1. Is it possible that the cholesterol medicine is producing these symptoms?
2. Do you think you could set me up with a 'holter monitor'? This is a device that will record your heart's rhythm for a set period of time. I would then go and jog and run and let the machine capture your heart's tracing. If you have an accessory tract, kind of a 'short circuit' of the heart's normal circuitry it will likely be caught here and you might need to see a cardiologist who may choose to perform a procedure to fix it (not surgery, done through a catheter).
I hope this helps!
911doc
Friday, March 27, 2009
A Man With Dyspnea
For a very long time. It feels like I can't take a full breath, like my lungs only fill up halfway… I know this sounds odd, but it can be very disturbing. I don't remember any sudden onset of this, and it isn't always there, I however notice that when im riding my bike or working out it very hard to catch my breath *sometimes*. I recently saw my PCP and she said my lungs sound fine, I've had a chest xray a few years back and it was fine too. I actually asked my doc about it when i was 17 (22 now) and he said that I was a teenager and i was just anxious…. that really pissed me off. So if you have absolutely any ideas of what could cause intermitant, serious shortness of breath, I'd love to hear about it. This worries me mainly cause my uncle died of lung cancer in his 40's.
Dear patient, I understand being 'pissed off' at your physician when you came in complaining of the above symptoms, but let me also tell you that she was likely right. Let me explain.
You are in your mid twenties and have only GI problems listed on your medical history. However, you are taking a 'stimulant' medicine for what? You are also taking quite a bit of caffeine and then at night taking melatonin. Why the melatonin?
Here's what I think. If you are, as you say, in your middle twenties, and have no serious genetic predisposition to cardiac or pulmonary disease there are precious few dangerous things that can cause your symptoms. It's a relatively short list and if you went to an urgent care or an ER it is this short list that would have been considered and you would have been sent packing without 'customer satisfaction' in spite of your correct diagnosis.
Here's a short differential diagnosis for increasing "dyspnea" (difficult breathing):
1. Asthma or reactive airway diseases
2. Congestive Heart Failure
3. Pulmonary Embolus (blood clot in the lungs)
4. Cardiac Arrhythmia
5. Cardiac Ischemia (unstable angina... pain from lack of blood flow to the heart)
6. Neoplasia (not really, just reflexive now for me, always have to answer with this in residency and medical school, doubt you have mesothelioma, inside joke, don't worry)
7. VooDoo curse (can't disprove it right?)
Once the doctor who saw you satisfied herself that you had nothing to suggest a serious illness such as those listed above there's not much left on the list that makes sense. If you had any leg pain with this you should have had an ultrasound to rule out a deep venous thrombosis in the leg but you did not complain of leg pain. Also you described this condition as being 'intermittent' and idiosyncratic (occurring willy-nilly), so cardiac disease was simply extremely unlikely.
The one criticism I might offer of the physician who told you that you were 'just anxious' is that he or she evidently gave you the impression that this condition was your fault. WRONG!
People do not choose to be anxious. They may have chosen poorly for years in their coping skills or they might have been poorly SHOWN how to deal with anxiety provoking situations, but look at your medicine list! You take a stimulant with caffeine in the morning and melatonin at night to sleep. Here's a guess, you have problems sleeping... you push yourself really hard and at night when most folks are going to sleep you are reading or watching television. You can't turn off your brain and even when you try to go to sleep you toss and turn and ruminate. You are so sleepy when you wake up you need caffeine and 'a stimulant' to get through the day. Repeat. If I'm close here please tell me because we can get a little deeper with the particular aspect of anxious behavior that you seem to manifest.
I have anxiety. It is a terrible feeling and it took fifteen years for someone to figure it out because I hid it so well. I was also of the mind that it meant something bad about me. Read the above link about anxiety and read all the symptoms you complain of right there. Happy to take any questions you have.
Best,
911Doc
Wednesday, March 18, 2009
Not an ER Patient!
A young woman writes asking our help with the following symptoms...
"Periodic bouts (several times a year) of general (and overall) pain with these accompanying symptoms: muscle soreness; "snapping" or "popping" joints; insomnia; fatigue; sensitivity to light, noise, smell, touch, taste; mouth sores; light, itchy rash across tops of checks; dry eyes and skin; nausea and dizziness; earache and headache."
I wish I had something more than the following to offer but here goes. With this strange constellation of symptoms I think that if there is an allopathic medicine answer that it will come from Rheumatololgy or from Allergy and Immunology. I do not want to list a differential here because, quite frankly, I would be guessing.
After the well known connective tissue diseases are ruled out... Lupus, Scleroderma, and others I would ask you to consider, dear patient, the following. Are your symptoms at all mood related? Are you being treated for depression? If not, I think along with seeing a Rheumatologist and, perhaps, an allergist, that you might want to sit for an interview with a counselor to answer a depression screen test. The mind is powerful and at least consider the possibility that part of your symptom complex may be related to a mood disorder.
If you primary care provider has not referred you to Rheumatology I would specifically request it. Here is a link to a Mayo Clinic depression screening test. You may not believe that depression or a psychiatric illness can manifest with symptoms similar to yours but let me assure you that they can!
And finally, you may get so frustrated with your symptoms that you are tempted to go to your local ER. Please do not. Not because we don't want to help, but because we will almost certainly not be able to give you what you seek... a unifying diagnosis. Best of luck and we are ready with any questions you may have.
"Periodic bouts (several times a year) of general (and overall) pain with these accompanying symptoms: muscle soreness; "snapping" or "popping" joints; insomnia; fatigue; sensitivity to light, noise, smell, touch, taste; mouth sores; light, itchy rash across tops of checks; dry eyes and skin; nausea and dizziness; earache and headache."
I wish I had something more than the following to offer but here goes. With this strange constellation of symptoms I think that if there is an allopathic medicine answer that it will come from Rheumatololgy or from Allergy and Immunology. I do not want to list a differential here because, quite frankly, I would be guessing.
After the well known connective tissue diseases are ruled out... Lupus, Scleroderma, and others I would ask you to consider, dear patient, the following. Are your symptoms at all mood related? Are you being treated for depression? If not, I think along with seeing a Rheumatologist and, perhaps, an allergist, that you might want to sit for an interview with a counselor to answer a depression screen test. The mind is powerful and at least consider the possibility that part of your symptom complex may be related to a mood disorder.
If you primary care provider has not referred you to Rheumatology I would specifically request it. Here is a link to a Mayo Clinic depression screening test. You may not believe that depression or a psychiatric illness can manifest with symptoms similar to yours but let me assure you that they can!
And finally, you may get so frustrated with your symptoms that you are tempted to go to your local ER. Please do not. Not because we don't want to help, but because we will almost certainly not be able to give you what you seek... a unifying diagnosis. Best of luck and we are ready with any questions you may have.
Friday, March 6, 2009
Optic Neuritis in a Young Person
A young person writes in complaining about recurrent bouts of Optic Neuritis (ON). She states that she is concerned about multiple sclerosis (MS) as ON is often the harbinger of MS.
In looking at her history and workup it is very complete. So complete, in fact, that she has been able to see a neuro-ophthalmologist and neurologist on many occasions. This workup includes MRI's of the brain and a spinal tap (lumbar puncture), the latter being, possibly, the most feared procedure that I do on a routine basis.
As an aside a lumbar puncture used to be horrible. The old kits had large needles and local anesthesia was sometimes not used. Here is a link which explains the LP procedure and how it safely allows the treating physician to examine cerebro-spinal fluid to rule out infection, bleeding, or, in this case MS. (*It is probably incorrect to say that it 'rules out' MS as the absence of a high protein count in the fluid does not mean that one does not have the disease... merely that it is probably not active at the present time).
MS is what's known as a 'protean' disease (after the god Proteus, who could assume many forms), for it can present with many different symptoms. The above linked articles explain the signs and symptoms of MS and optic neuritis well so I will not bore you with them here.
When thinking about these two diseases it often helps me to think of the brain as being wired to the body with old-fashioned copper wires with plastic insulation. Imagine what would happen if yo took an old TV and cut parts of the insulation off the copper wires. Mayhem.
This is what happens with MS and with ON (though the ON patients symptoms are limited to the optic nerve and patients with MS can have neurological deficits anywhere in the body (though usually the eye, bladder, and extremities)). In the case of the human body the 'insulation' around the 'wires' is equivalent to the myelin sheath which insulates nerves.
This particular patient is worried that her recurrent bouts of ON and mild peripheral neurologic deficits (an inability to grasp the hand correctly, or an inability to walk in a coordinated fashion) mean that she will eventually be diagnosed with MS, and this is a valid fear.
She also tells us that as a child she had Systemic Lupus Erythematosis (Lupus), and wonders if this puts her at increased risk for a hard diagnosis of MS.
Without having time to pull articles or dust of my neurology text I seem to remember that optic neuritis usually DOES lead, eventually, to a diagnosis of MS, but not in every case. As to how a childhood diagnosis of Lupus plays in I am much less sure, but there may be an immunological link with connective tissue diseases (like Lupus) and with MS/optic neuritis, as both are posited to be based on an auto-immune etiology (the body attacking itself).
Dear patient. You are being well cared for. Please continue to follow up with your current team of physicians and know this, if you have not had a spinal MRI when you have your symptoms, it is possible that the MS lesions might be found in the spinal cord alone and that an MRI of the brain would miss them. If you do eventually end up with the diagnosis of MS, take heart, MS is being tamed if not cured even as we speak and while for most patients it does require lifestyle changes, it almost always can be managed well with minimal consequences for the patient.
Tuesday, February 17, 2009
Marfan's Syndrome
Marfan's syndrome is a 'connective tissue disease' and is truly out of the realm of Emergency Medicine. However, as an emergency physician it is important to know about the complications of Marfan's syndrome so that you do not miss a potential life threat in a young person (such as a dissecting aortic aneurysm in a twenty two year old with "chest pain"). In plain terms Marfan's patients have, genetically, a slightly altered composition of the tissue lining the vasculature and this makes them at increased risk for a variety of problems including dissection.
A vascular dissection occurs when a defect occurs in the lining of a high pressure vessel (like the aorta) and the blood, taking the path of least resistance, enters into the wall of the vessel creating an alternate passage outside the channel where it should run. This can cause disaster as this alternate passage can cut off blood flow to the coronary arteries (causing a heart attack) or to the renal arteries (causing kidney failure) or the aneurysm can rupture causing death. You have probably seen a dissection of sorts if you have seen a garden hose, after being out in the sun for a few years, blow up like a snake that just swallowed a rat... there's a normal caliber portion then a big, fat part that gets bigger the more you use it. Eventually it will start spurting water out of the dissected part and if that were your aorta you would have big problems.
A patient with Marfans writes us asking why his physicians are so focused on the major vessels of the chest and abdomen and not so focused on the smaller vessels within the brain or eye for instance. The question is posed as to why he does not need a 'full body scan' as a ruptured aneurysm in these places might be disastrous.
This is a very interesting question and before I give my non-expert opinion let me direct you to this link which details Marfan's Syndrome exhaustively.
I believe the answer, dear patient, is that the technology available to us today would miss many potential small trouble spots, but, the more direct and correct answer, I believe, is that an aneurysm of any significance in the brain would have been seen already with a contrasted CT Scan or MRI and that aneurysms in the retinal vessels or the smaller vessels of the pelvis or legs would manifest themselves in a NON LIFE THREATENING WAY making looking for an asymptomatic aneurysm a worthless prospect. There is also precious little we can do for microscopic aneurysms though enoscopic procedures are advancing every day.
That being said I completely understand your anxiety and it would be very difficult to be a patient with Marfan's as you know that you are at increased risk for any number of problems from the disease. I will open this discussion up to the gang and see if there are any more helpful comments than what I have provided. Bottom line is what you know already, take chest and abdominal pain symptoms seriously, get regular eye exams, and otherwise try to achieve an acceptance of your own mortality. I am not saying this to be funny or crass or hurtful... All of us need to be aware of our own mortality... it makes for better decisions and a better life focusing on things the immediate... carpe diem if you will.
If you find yourself scared to live a normal life you may benefit from counselling and, perhaps, medication to help you stave off anxiety and depression. We have improved in our ability to care for Marfan's patients to the point that there is reason to hope that when you die it will be from something other than a complication of Marfans.
Your questions about Marfans are better answered by your Rheumatologist. I recommend keeping a notebook and when you see your doc ask your top three questions. As you are no doubt aware it is hard to speak to your doctor one on one and that's why we started this site... to try to stand in the gap a little bit at least.
Finally, be aware of the following. The symptoms of clinical depression are disturbed sleep (can't go to sleep, wake up too early etc...), loss of a feeling of happiness even while doing things that make normally make you happy ('anhedonia'), crying, feeling helpless or hopeless, and persistent thoughts of death or suicide. If you have any of these symptoms please see your primary physician immediately. Anxiety is sometimes not recognized by the sufferer as anxiety and when it progresses to panic you may feel chest pain, a feeling of imminent doom ('angor animi'), numbness around the lips and in the fingers and feet... this also is a reason to see your primary care physician.
Please ask any questions you have.
Best,
Doctors in the House
A vascular dissection occurs when a defect occurs in the lining of a high pressure vessel (like the aorta) and the blood, taking the path of least resistance, enters into the wall of the vessel creating an alternate passage outside the channel where it should run. This can cause disaster as this alternate passage can cut off blood flow to the coronary arteries (causing a heart attack) or to the renal arteries (causing kidney failure) or the aneurysm can rupture causing death. You have probably seen a dissection of sorts if you have seen a garden hose, after being out in the sun for a few years, blow up like a snake that just swallowed a rat... there's a normal caliber portion then a big, fat part that gets bigger the more you use it. Eventually it will start spurting water out of the dissected part and if that were your aorta you would have big problems.
A patient with Marfans writes us asking why his physicians are so focused on the major vessels of the chest and abdomen and not so focused on the smaller vessels within the brain or eye for instance. The question is posed as to why he does not need a 'full body scan' as a ruptured aneurysm in these places might be disastrous.
This is a very interesting question and before I give my non-expert opinion let me direct you to this link which details Marfan's Syndrome exhaustively.
I believe the answer, dear patient, is that the technology available to us today would miss many potential small trouble spots, but, the more direct and correct answer, I believe, is that an aneurysm of any significance in the brain would have been seen already with a contrasted CT Scan or MRI and that aneurysms in the retinal vessels or the smaller vessels of the pelvis or legs would manifest themselves in a NON LIFE THREATENING WAY making looking for an asymptomatic aneurysm a worthless prospect. There is also precious little we can do for microscopic aneurysms though enoscopic procedures are advancing every day.
That being said I completely understand your anxiety and it would be very difficult to be a patient with Marfan's as you know that you are at increased risk for any number of problems from the disease. I will open this discussion up to the gang and see if there are any more helpful comments than what I have provided. Bottom line is what you know already, take chest and abdominal pain symptoms seriously, get regular eye exams, and otherwise try to achieve an acceptance of your own mortality. I am not saying this to be funny or crass or hurtful... All of us need to be aware of our own mortality... it makes for better decisions and a better life focusing on things the immediate... carpe diem if you will.
If you find yourself scared to live a normal life you may benefit from counselling and, perhaps, medication to help you stave off anxiety and depression. We have improved in our ability to care for Marfan's patients to the point that there is reason to hope that when you die it will be from something other than a complication of Marfans.
Your questions about Marfans are better answered by your Rheumatologist. I recommend keeping a notebook and when you see your doc ask your top three questions. As you are no doubt aware it is hard to speak to your doctor one on one and that's why we started this site... to try to stand in the gap a little bit at least.
Finally, be aware of the following. The symptoms of clinical depression are disturbed sleep (can't go to sleep, wake up too early etc...), loss of a feeling of happiness even while doing things that make normally make you happy ('anhedonia'), crying, feeling helpless or hopeless, and persistent thoughts of death or suicide. If you have any of these symptoms please see your primary physician immediately. Anxiety is sometimes not recognized by the sufferer as anxiety and when it progresses to panic you may feel chest pain, a feeling of imminent doom ('angor animi'), numbness around the lips and in the fingers and feet... this also is a reason to see your primary care physician.
Please ask any questions you have.
Best,
Doctors in the House
Sunday, February 1, 2009
A Young Person With Chronic Headache
S: A young man has been diagnosed with hemicrania continua. This is a new one on me and after reading about this condition it appears that this young man has been properly diagnosed and treated. A curious fact about this disease is that it responds to indomethacin (a very old-school anti inflammatory drug not too different than aspirin). This young man truly has this disease as in his medical history he states that a whole raft of narcotic and 'muscle relaxing' medicine had been tried but did not work. From my perspective that's a real headache and a debilitating one and it's rare to have a patient with chronic headache who does not state 'the only thing that works for me is that pain shot... you know, the one that starts with 'D'... and could you spice it up with a little phenergan for me?"
Problem. Indomethacin, which is also the drug of choice for treating gout, tends to tear up the stomach and can induce GI bleeding and ulcers. This, in fact, is what's happened here. Unfortunately the effects of indomethacin are systemic and the stomach issues created are not usually preventable by taking antacids or acid blocking medications. Nor are they prevented by a particular diet, nor by taking the medicine with food.
It has been proposed that this young man switch to suppository form but this, unfortunately, is not something he is willing to try. From my perspective a suppository form is unlikely to be any better than the oral form but I could be wrong.
O: A young man with hemicrania continua who can not take indomethacin due to GI problems.
A: Same
P: First, before going to a neurosurgical procedure which has been recommended, I highly recommend biting the lower lip and trying indomethacin suppositories. If they work, your problem is solved and at minimal expense and discomfort. Using a suppository is, understandably, not something folks like to do. If they DO like it then there are other issues. The suppository does not hurt and, a trusted nurse can demonstrate for you in the office just how easy this method of administering medicine can be. I too would shy away from a more invasive procedure at this point but only if I were willing to try the suppository route.
The other options at this point are to seek a second opinion from another headache specialist and to try, instead of the indomethacin, an enteric coated aspirin or baby aspirin a day (remember that the medicines are very closely related). Many headache specialists recommend this for their chronic headache patients as a daily medicine which often decreases the need for the more heavy duty pain relievers. It might be that with a simple baby aspirin a day that added tylenol might have a salutary effect on the headache.
If these options fail it would be at that point that I would go for the more invasive procedure (knowing that my diagnosis was such that it prevented me from living life in a 'normal' fashion). Ending up on the disability rolls would be an unfortunate outcome especially if the reason for doing so were an aversion to taking a suppository.
Problem. Indomethacin, which is also the drug of choice for treating gout, tends to tear up the stomach and can induce GI bleeding and ulcers. This, in fact, is what's happened here. Unfortunately the effects of indomethacin are systemic and the stomach issues created are not usually preventable by taking antacids or acid blocking medications. Nor are they prevented by a particular diet, nor by taking the medicine with food.
It has been proposed that this young man switch to suppository form but this, unfortunately, is not something he is willing to try. From my perspective a suppository form is unlikely to be any better than the oral form but I could be wrong.
O: A young man with hemicrania continua who can not take indomethacin due to GI problems.
A: Same
P: First, before going to a neurosurgical procedure which has been recommended, I highly recommend biting the lower lip and trying indomethacin suppositories. If they work, your problem is solved and at minimal expense and discomfort. Using a suppository is, understandably, not something folks like to do. If they DO like it then there are other issues. The suppository does not hurt and, a trusted nurse can demonstrate for you in the office just how easy this method of administering medicine can be. I too would shy away from a more invasive procedure at this point but only if I were willing to try the suppository route.
The other options at this point are to seek a second opinion from another headache specialist and to try, instead of the indomethacin, an enteric coated aspirin or baby aspirin a day (remember that the medicines are very closely related). Many headache specialists recommend this for their chronic headache patients as a daily medicine which often decreases the need for the more heavy duty pain relievers. It might be that with a simple baby aspirin a day that added tylenol might have a salutary effect on the headache.
If these options fail it would be at that point that I would go for the more invasive procedure (knowing that my diagnosis was such that it prevented me from living life in a 'normal' fashion). Ending up on the disability rolls would be an unfortunate outcome especially if the reason for doing so were an aversion to taking a suppository.
Thursday, January 29, 2009
A Gentleman With Urinary Problems (Our First Case)
To start off our first case I will familiarize you with the way physicians typically write an office note. As opposed to a complete History and Physical Exam (H&P), the S.O.A.P. note format is preferred. This stands for "Subjective" (the patient's complaint in their own words), "Objective" (the physician's exam and pertinent lab data and radiographic findings), "Assessment" (the physician's conclusions about the patient's complaint), and "Plan".So the 'S' in our first case is as follows... A gentleman over sixty years old complains that he has urinary hesitancy, urgency, and sometimes an inability to void. He adds that a prior workup by a specialist revealed that he has 'overflow incontinence' meaning that his bladder will not empty until it is so over-filled with urine that the pressure built up eventually forces urine out, and not at convenient times for the patient.
As one can see from looking at the diagram of the male genito-urinary system above, there are a few problems that come to mind as causative of the problem here and they are...
Neurogenic Bladder results from stress on the bladder walls due to retained urine. Eventually the muscles of the bladder wall and, specifically the detrussor muscle, lose tone and can not be voluntarily controlled due to the chronic stretching. Neurogenic bladder can be self induced but is more likely a result of prostatic hypertrophy. All of us males, probably as a payback for not having to deal with a menstrual cycle or childbirt, WILL get prostatic hypertrophy as we age.
Prostatic Hypertrophy (enlarged prostate due to age related changes or Cancer, and Cancer always needs to be ruled out... definitively done with biopsy but the 'prostatic specific antigen' or PSA blood test is a very good marker of Cancer of the prostate and is relied upon by many urologists to follow a possible Cancerous lesion)
Other mechanical obstruction (such as a pelvic mass... usually seen on CT scan and not suspected in this case)
In fact, the culprit here seems to be a combination of the above.
Objective: In this particular patient a diagnosis of 'hydronephrosis' was also made by CT Scan. This is easy to visualize the following way. If you were to mechanically obstruct urinary outflow the ureters (the tubes taking urine from the kidney to the bladder) would become distended (swollen) due to the pressure. Eventually this backflow pressure also makes the kidneys swell and this is easily seen on a CT Scan or Ultrasound. If not relieved in a timely fashion this can lead to renal failure.
The patient in this case, with the assistance of his primary physician and his urologist, has arrived at a solution for his problems... he intermittently passes a bladder catheter to relieve urinary retention. Of course, this is a bit of a bummer in a similar way that having diabetes is a bummer... having to plan one's day around the necessity of performing intermittent self-catheterizations.
The question in this case is whether there is a solution besides the intermittent self-catheterizations and this is something I can not offer an opinion on without referring to a urologic specialist. I must say that based on the information presented to me this patient is being optimally managed.
Assessment: 60yo plus gentleman with neurogenic bladder hopes for definitive treatment of his condition.
Plan: Unfortunately a little research has revealed that our ability to treat 'neurogenic bladder' or 'neuropathic bladder' in a definitive way is limited. Click here for a discussion of this problem. There are medications such as flomax which can help, but unfortunately for the pateint in this case the maximum benefit has been attained from this medicine.
Experimental surgery to allow voluntary emptying of the bladder has met with mixed results and is still in the development phase. Therefore Intermittent Self-Catheterization is the recommended treatment as it stands today. Should the problem become severe enough there is another option which is to create a urostomy.
This would really be a solution of last resort and comes with it's own problems, mainly having to continue to mechanically empty urine from the urostomy pouch, but might be preferable in some cases to the ISC route.
A final question from this patient has to do with the surgical procedures used to relieve prostatic obstruction of the urethra (the tube draining urine from the bladder through the penis). A good way to visualize this is to view the urethra as a McDonald's straw and the prostate as a small, walnut-sized organ that surrounds the urethra. As the prostate enlarges the urethra is decreased in caliber and it becomes difficult to empty the bladder fully.
This is why men with prostate cancer and BPH (benign prostatic hypertrophy) are continually getting up at night to urinate because they require a certain baseline pressure to be able to get urine flow started and once that pressure is relieved by partial urination the bladder still retains urine. This standing urine is ripe for colonization with bacteria and folks with BPH often suffer from repeat urinary infections and even prostate infections.
Prostate infections (prostatitis) are difficult to diagnose and to treat and when combined with incomplete bladder emptying this condition eventually will compromise kidney function. It is at this point that surgery is often recommended in the form of a Trans-Urethral Radical Prostatectomy (TURP) OR with one of the newer procedures that involve applying microwaves (heat) to the prostate in order to shrink it OR a green light laser which allows for decreasing the obstruction AND, at least as it stands now, may be a much easier and effective treatment for the patient.
Please note that Prostate Cancer is not discussed here as it would make the post too lengthy but the first symptoms of this form of cancer are usually indistinguishable from BPH, so again, cancer must be ruled out in this case.
My feeling about this case is that IF intermittent self-catheterization is relatively easily accomplished then a prostatic procedure is likely to provide minimal to no benefit. I say this because if the prostate were a big player here the catheter would be difficult to get into the bladder. In fact, with trauma patients in the ER, it is often hard to pass a catheter due to enlarged prostate. In extreme cases we will place a suprapubic catheter using ultrasound guidance in the ER to void the bladder.
Questions to ask a urologist are the following: To what extent is the prostate responsible for the urinary obstruction and would a minimally invasive prostate reduction procedure (like a green light laser) provide any benefit? Is there another medicine besides flomax that might help? Are there any experimental treatments being developed to treat neurogenic bladder. And, what about a urostomy?
I hope this was helpful. Questions and comments welcome. Please be aware that any spam posts, off the subject posts, or comments advocating alternative treatments will be deleted.
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