Posts Tagged ‘CRP’

Six clinical triumphs and a tornado

March 17, 2017

I had me a wonderful day

I was keeping the blindness at bay

And I helped stop the shakes

Oh, the difference it makes!

To start steroids without a delay.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, and short jobs in western Iowa and Alaska, I am working in Clarinda, Iowa. Any identifiable patient information has been included with permission.

I can’t write about particular patients but I can write about clinical trends.

Sometimes I suspect Parkinson’s in the first 60 seconds after I meet a patient. I note a shuffling gait with arms that don’t swing, a face with limited movement, and a quiet voice lacking in music.  After the patient finishes their concerns,  I ask about shrinking handwriting size and loss of sense of smell.  Then, if the patient lacks the characteristic resting tremor, I’ll hold the patient’s hand.  If I feel the muscles between the thumb and forefinger quivering, I strongly suspect the disease.

No single sign or symptom serves as a gold standard. Without a lab test for Parkinson’s, the diagnosis frequently relies on response to the medication Sinemet, (levodopa and carbidopa).

Parkinson’s always progresses, but the rate varies. No matter what stage I find the patient in, I tell them that we have no medication that will slow disease progression, but we have a whole sequence of drugs for the symptoms.  Most elect to try the meds, a few don’t.

I love seeing a person in the hour or two after their first Sinemet dose, especially if I find the family close at hand. It really deserves the term, awakening, the title of the Oliver Sachs book and Robin Williams movie about the development of the drug.

I have picked up more than one case per week here.

I’m also finding an inordinate number of people with polymyalgia rheumatica (PMR), also called giant cell arteritis or temporal arteritis. For unknown reasons, worse with advancing age, occasionally a person’s body will attack the arterial lining with very large immune cells.  As a result, people feel terrible, lose strength in their shoulders and hips, and get severe morning stiffness lasting more than an hour.  The symptoms can sneak up over the course of months, or ambush over the course of days.  I ask if their jaw gets tired while chewing.  I feel the arteries over the temples; once in a while I feel hot, ropey spots on the scalp, where the blood vessel pulses .  We use two non-specific blood tests, the C-reactive protein (CRP) and the erythrocyte sedimentation rate (sed rate or ESR), which help make the diagnosis.  The conclusive test is the temporal artery biopsy, but only if it’s positive, which it never is.

Blindness ranks as the most feared complication of the untreated PMR; the artery that supplies the retina can clot off. Thus if I have strong suspicion I start steroid therapy promptly.  A quick response helps make the diagnosis.

Last Tuesday I had the wonderful experience of seeing more than one Parkinson’s patient and more than one PMR patient in their initial positive response to therapy.   Bethany picked me up at the hospital, and in the time it took for me to walk out the front door and get into the car the sky darkened so fast that the street lights came on.  As we drove to the gym I started to recount my day full of successes, but halfway there our phones interrupted with the announcement of a tornado warning.  We continued on, but the noise of the hail drowned out my words.  Three blocks later we arrived at the gym just as the tornado sirens started.

We sat on a bench inside and watched the vacant pool while I finished recounting my 6 clinical triumphs in one day.

Let’s see what happens.

July 27, 2013

A matter of prognostic projection

When it comes to a diagnostic question

My pain management skills

Involve very few pills

And no longer my Enbrel injection

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In 2010, I danced back from the brink of burnout and traveled for a year doing temporary medical assignments from Barrow, Alaska to New Zealand’s South Island.  I’m now working at a Community Health Center part-time, which has come to mean 54 hours a week.

During my senior year of medical school I arranged to get credit for an elective rotation in acupuncture in January of 1979.  I studied under a very smart non-Asian internist for a month, and learned the vocabulary and the rudiments.

Before I had passed any Boards or actually obtained a license, I did acupuncture on a friend in a time crunch.  I applied a needle in each shin, close to the knee (the name of the point is Su Zan Li, but its nickname means three villages).  He responded well, and worked with tremendous efficiency for the next 9 days, turning out top-notch work.  The bottom dropped out of his energy three days later, and he slept for the next two days.

In retrospect, I had precipitated a hypomanic episode; his bipolarity would not be diagnosed for many years.  Nor did I realize the enormity of the power of those two needles for decades.

High-quality research with acupuncture showed mixed results.  A study published in a major journal demonstrated very good results in treatment of the most severe alcoholics (regretfully, the study didn’t detail exactly where needles went nor how they were placed).  Another, published in JAMA, showed acupuncture and sham acupuncture equivalent in the treatment of migraine.  Many docs point to that study and assert acupuncture has no validity; I look at the same data and conclude that you don’t have to be much of an acupuncturist to treat migraine; put a half-dozen needles anywhere you want and not very deep, on a regular basis and at the end of a year the patient will have half the migraines he/she used to.

I went to my acupuncturist today for a session because I’ve been off Enbrel for three weeks.  My sacroiliac joints haven’t fused despite my age, leading my rheumatologist to question the diagnosis of ankylosing spondylitis.  He would like to see if my sed rate (ESR) and my C-reactive protein (CRP) go up in the absence of therapy.

I can hope for a misdiagnosis, or for news that my disease has burnt itself out, but as the days go by the pain in my spine grows.  I’m now relying on the pain management skills I developed between 1967 and 2000, when I got my first injection.

I can do a lot of things to bring down the level of pain a notch or two; I can’t do anything to make the pain go away completely.    When I walked away from the acupuncturist/chiropractor’s office the pain between my shoulder blades had faded by about two-thirds, and I could sneeze without grunting.

Now I have to work on my sleep pattern.

Chocolate, tornado, lemonade, ear wax, and a supervisory visit

May 3, 2011

Don’t even try to refute,

For this there is no dispute

     Could I get any closer?

     I tell you, No Sir!

Happiness is a shorter commute

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  On sabbatical to avoid burnout, while my non-compete clause ticks away I’m having adventures, visiting family and friends, and working in out-of-the-way places.  After a six-week assignment in Barrow, Alaska, I’m working on the North Island of New Zealand.

I started the day at leisure with a seven-step commute to my office.  I sat down promptly at 8:00 AM and started to review lab work.

In the quiet of the morning, early, before the first patient arrived, I found an alarming erythrocyte sedimentation rate (ESR) with the highest C-reactive protein (CRP) I’ve ever seen; both markers of inflammation throughout the body, I prescribed prednisone.  I don’t prescribe that medication often, and always in the context of getting a specialist’s opinion.

I can’t talk about patients and their medical problems without permission, but I can talk about myself and about medicine.  Yet diseases don’t come to me, people come to me; none of them perfect, each with flaws, quirks, a terrific back story and a family.  Every person who seeks my advice has a unique smell, voice, accent, style of dress and body language.

If a person presents with an ear wax problem, and I take the wax out with a simple instrument called an ear curette, I’ll tell them how to keep the wax problem at bay.  I make sure they’ve never had a hole in their ear drum and I instruct them to start with body temperature water and put in enough white vinegar that it smells like vinegar but not so much it feels cooler.  Then, I say, use a bulb suction syringe to rinse the ears out about once a week.

I saw another person today with appendicitis, making three since I arrived.  At least, I hope I saw the first case of appendicitis I’ve ever seen in a person who had enjoyed their lunch.  I worry that my patient has something worse.

I saw a person with a single distended vein where I’ve never seen one before.

I made referrals the general surgeon, ophthalmologist, urologist, neurologist, and orthopedist.

At mid-morning, I took a tea break.  While the fifteen minute hiatus comes built into my schedule, most mornings I use it to catch up.  Today I walked back through the apartment, picked a lemon from the tree, came back in, made hot lemonade and sipped it while I talked with Bethany, nibbling on some exquisite dark chocolate macadamia nut bark.

When noon came round we lunched while we watched the shocking, driving rain outside.  The first thunder we’ve heard since we arrived made us stop and listen.

The rain continued for the afternoon drive to Wellsford.

In accordance with the Medical Council of New Zealand rules, any doctor new to the system requires supervision their first year.  In this case my supervisor is the clinical director, and we met in the early afternoon.

I enjoyed the interview. 

A reasonable clinical pace.  I told people on asthma medication to quit smoking.   I gave others with high cholesterol levels instructions about diet and exercise.

Driving back to Matakana in the rain, we learned that the same storm that gave our afternoon’s deluge spawned a tornado, so rare in New Zealand that rating came only with difficulty.