Wednesday, March 30, 2011

the chester sign

When this NP used to work in migrant health care pediatrics, we would commonly see kids walk in the door toting 900 cal. bags of spicy hot cheetos (with GERD producing lime and chili ADDED to the bag)... when parents and kids complaining of uncomfortable gastritis adamantly declined eating these red and orange tinged snacks.... brightly stained fingers would often chip away at such claims. One pediatrician I worked with jokingly called this bright orange evidence "positive chester sign" .... as in

S; c/o abdominal discomfort
HPI; approx 3 weeks with abdominal discomfort, worse after eating and on empty stomach,
ROS; denies V/D but does report occas nausea. No fever/chills. Denies eating any spicy or fast food, including spicy hot cheetos
O; bright orange tinged fingers.......positive chester sign
A; dyspepsia with evidence of CHEETO CONSUMPTION
P; no more quarters for the vending machine... cutting you off of red dye #5

a new article links hyperactivity and artificial food dyes, all the more reason to lay off the cheetos (and the chester sign will give you away if you don't!);

Friday, March 25, 2011

dirty little secret

Afrin... a dirty little over the counter secret that many patients keep to themselves.. use this nasal spray once or twice in a 48 hour period, and sweet vasoconstriction will relieve your drippy faucet of a nose for a few hours... but use it past the 48 hour period, and a flood of rebound nasal congestion will leave you drowning, gasping for more Afrin to stem the tide.

Medical diagnosis; rhinitis medicamentosa (too much afrin use is causing rebound congestion, resulting in your nose to ceasing to be an orifice capable of breathing) 

What to do about this? STOP USING THE AFRIN. Also, start using an appropriate prescription only nasal spray (fluticasone is cheap now, yeah!!!!) and, although debatable, I have found that a short burst of oral steroids (consult epocrates and up to date here folks) can be helpful in transitioning the Afrin lover during the withdrawal period of rebound congestion. It's also important to remind the patient to only use their new nasal spray as directed, as many assume that more of a good thing is an even better thing.... not the case at all.

Addendum; saw a patient today complaining of "I have a loss of flavor in my mouth" (I swear those are his words)... after I pondered for a moment, i said "are you congested" (yes), "do you use afrin" (yes).... ahhh, what a brilliant dignosis.

Thursday, March 24, 2011

stay sexy...

It's official... sex can kill you:

one more reason to stay fit... apparently being sexy before engaging in sexy time can safe your life.

big surprise there.

If you're not going to stay fit, then make sure to have enough sex.... so your ticker isn't caught off guard, kind of like the "weekend warrior" syndrome during Wednesday night business time;

Thank you Flight of the concords for keeping us sexy, or at least, helping non-sexy people somewhat reduce the risk of cardiovascular events by creating a regular schedule for business time;

sign language

As most of my patients are exclusively Spanish speaking... I often play a funny little head game of speaking in Spanish while writing in English simultaneously during each visit... I like to think of it as my mental training to stave off Alzheimer's well before its time. This being said, it's rare that I speak English with a patient, and often find myself translating my common "medical discussions" from Spanish to English in my head as I spout of frequently used patient education, medication instructions, the occasional diabetic threat and the like. 

Yesterday, I had the unique opportunity to examen a patient who spoke no English or Spanish.  This was a lovely Turkish patient, who was complaining of cold symptoms. This patient arrived wearing  hijab with a floor length black non-descript coat, and a dark head covering  and I was immediately conscious of respecting the personal privacy such attire suggested.  At her request, the kind son translated the subjective portion of the visit, but the exam involved slight disrobing, and thus, son was kicked to the waiting room till the diagnostic portion of the visit.  

In community health, it's best to ask patients to bring all their bottles to the visit... resulting in large crumpled plastic bags, totes, and coolers full of random pill bottles which the provider arranges precariously on the side of their desk, attempting to create a med list from nondescript worn labels and foreign medication names ... but hey, it beats "I take a green pill for blood pressure sometimes, and a birth control pill in a pink box" which is the normal "med list" we can otherwise expect.  This patient had brought her pills with her, true to our request... and when she pointed at a bottle of thyroid medication, she then looked me in the eye tenderly, and pointed at my neck and then hers. 

Caveat... this NP is a thyroid cancer survivor, a badge I proudly wear, and truly do not mind the frequent inquiry as to the origin of my thyroidectomy scar (albeit.. if the comment is along the lines of "why did you try to kill yourself like that" or "are you in a cult"... both of which I have heard several times... my answer will certainly be directed at directly embarrassing the ignorantly inquisitive small mind behind such questioning). 

As I pulled open the black fabric of my patient's covering, I noted the same thyroidectomy scar... sisters in experience... we gave each other a hug, and a kiss on the cheek, and embraced for a few moments, before, with a deep sigh, settling into a visit of no words, many gestures, and a deep shared trust. A positive strep test, and some amoxicillin later, she was on her way.... and I was left with the kindness of her gesture and a deep sense of place, satisfaction, and acceptance. 

These are the moments I love my job... when the unspoken language between two people is so audible, it is impossible not to hear and connect to the essence of being human.

Friday, March 11, 2011

the mighty wiki....

In Community health most of our patients don't know what prior diagnoses they have had, let alone what pills they take or how tall they even are, some of this is due to lack of health knowledge/literacy, or cultural implications, but this particular case, I cannot fully explain.... it went a little something like this;

me; do you have any health problems like diabetes or hypertension, or have you ever been in the hospital
patient; yes, I was in the hospital last year for that thing that killed Bernie Mac... well, you know, that "thing"
me; no, I'm not sure what killed Bernie Mac....

a few seconds later, Wikipedia offered the diagnosis; "Mac suffered from sarcoidosis, an inflammatory lung disease that produces tiny lumps of cells in the solid organs, but had said the condition was in remission in 2005. His death on August 9, 2008 was caused by complications from pneumonia"

back to the patient...

me; sarcoidosis? wow, that's pretty serious (incredulous that patient didn't know this diagnosis)
patient; no, the other one
me; (after re-re-reading the wikipedia posting) pneumonia?
patient; yeah, that one... I think

ok.. it's one thing to not know your diagnosis, yet another to define it incorrectly by a diagnosis given to a now dead celebrity.... Pneumonia, now known as the disease formerly known as that which ultimately killed (but did not chronically pose a threat to) Bernie Mac.

Wikipedia caveat; can't say it's the first time wikipedia came through as an accurate clinical resource... it's a great way to look up icd9 codes, beats any iphone ap or online coder I have found!

Tuesday, March 8, 2011

self lovin'... no not that kind

A word about self-care in medicine.... it's more than important, it's a crucial skill that they touched on for about thirty seconds of your last lecture you never attended before the final exam which you probably skipped for a pre-exam nerve calming margarita (or at least that was the plan when I was in school at a fancy shmancy institution in the warmer nether regions of the state).

the first lecture any medical provider is given should be entitled : SELF CARE; "take care of yourself, if you don't.... you will burn out and won't be able to heal the masses... let alone yourself."

ways to make this a reality?

EAT YOUR GREENS; eat well (what you eat becomes your body... is there a better reason?), bring snacks to the clinic, the kind that are high in protein and fiber, and keep a water bottle full and in reach. Watch out for caffeine (my arch nemesis, prior lover and the crack of life... yeah, we have a volitile relationship) and sugar (no siesta time available in exam room five at 2 pm) and the starchy processed junk food that drug reps and staff spread around the clinic in your most stressful and mindless moments.

WORK THAT ASS- exercise (endorphins are like legal speed... and should be fully enjoyed), plus, everyone likes to be fit and look their best. Even little bits of exercise add up to something... for example, my favorite; taking the stairs up to medical records (you will inevitably avoid facing a patient in the awkwardness of the elevator as they attempt to catch your eye and ask a question about a visit you no longer remember in any way)

 FLUORESCENT LIGHTING ISN'T JUST BAD FOR BATHING SUIT SHOPPING- get some air and sunlight ever day; take a walk during lunch, make friends with a local barrista, library or coffee shop (one of my most favorite NPs of all time used to take a walk around a mostly Mexican migrant farming town with during lunch by herself, she admitted to me one day that she like to "pretend she was out of the country" ... which I think is pure genius, and have repeated myself too many times to count. Tomorrow, I will be going to.... hmmmmm..... details pending).

TURN AND BURN- when you leave the clinic, as much as possible, LEAVE it there (it will still be there in the morning) ... this means physically, mentally, emotionally... leave it... it won't walk away. And, save your family ALL the gory details... they only THINK they want to hear them all. This is why we all need a colleague to have a drink with after work as needed (especially you women's health folks... been there.. and the conversation is less than delicious at the dinner table).
         Caveat here; huge appreciation to my friends and current partner who are always there to let me spout medical gobbeldygook after an emotional day... regardless of how much they may care about the details, a support network of people who love you is key to being a complete clinician.. and in this arena, I am blessed fully.

VOCATION vs. VACATION; ok... yes, you are an NP, a nurse, a podiatrist.. whatever. Yes, there is such a thing as identifying with a vocation.. but, it's important not to lose yourself. Limit the time you spend reading articles if you are tempted to spend every waking second on up to date at night in bed, next to your snoring partner, face illuminated by the laptop (you know you've been there, just looking up one more cause of end stage kidney disease or one more "derm quiz")... stay up on the facts, but don't overdo it... admin time at work exists for a reason, as do copious to do/to learn/to experience lists....  Take trips and vacations frequently, especially if you are lucky enough to live in a place where you can head to beach, snow, dessert, mountains, or redwood forests within a 5 hour drive (do it).

Want to heal others? keep yourself in tip top shape... not just the cerebral type... your life, and loved ones, and ultimately... patients... will be all the better for it.

Monday, March 7, 2011

the straight dope

 Although this NP takes chronic pain seriously (like one patient who was a subway attendant and was beat up on the subway landing by thugs, or another who was shot in the back in Vietnam.... and the list goes on) my office will not become the local ghetto candy shop if you know what I mean..... gotta be careful with your "rep" in these parts, because word gets out fast, and before you know it, if you could have a quarter for ever prescription with the prefix "oxy"... let's just say that I would be retiring in style....

But seriously... we have created a system where patients with legitimate pain concerns cannot access the help that they need (PT, OT, accupuncture, chiropractic.... and the list goes on) and therefore, become addicts to pain medication, and need higher and higher doses (and methadone) as their narcotic receptors quickly adjust to levels of opiates strong enough to tranquilize a charging rhino.

The secret to good practice... consistent limits which patients are well aware of... trust me, those with legitimate concerns will follow up on time, and you will soon weed out the "seekers" or "street merchants" from the "legits"....

No Narcotic refills in triage... no exceptions, same story every time.
Most of the NP triage frequent narcotic refill fliers get the picture after one or two or twelve reiterations of this same policy... but some have become extra savvy..... take mr "Smith"

me (in waiting room); Mr "Smith" I notice you are here for a refill, does that refill request contain a narcotic medication
Mr Smith; no, it's for my blood pressure
me; excellent, that is a refill I can consider, come back to the office with me and let's discuss
Mr Smith (now in office); so... I'm out of my oxycontin and my blood pressure is really high because I'm anxious
me; *shakes head, and points at door*... mr Smith, you know our policy hasn't changed, anything else I can do for you today
Mr Smith; *gets up, opens door, escorts self out of clinic.

sigh... well, at least there was no yelling or calling of security this time..... now if I can just find a way for him to make it to his follow-up appointments, that would truly be dope.