Posts Tagged ‘ear infection’

A straightforward ear infection, and the work up of vasculitis

November 19, 2016

Tell me how can I choose?

The labs will come slowly as news

I won’t be so brash

As to diagnose a rash

That shows as many a bruise. 

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. A winter in Nome, Alaska, assignments in rural Iowa, a summer with a bike tour in Michigan, and Urgent Care in suburban Pennsylvania stretched into the fall. 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, I am back on the job in western Iowa. Any identifiable patient information has been included with permission.

Friday morning arrived and the sweetness of yesterday, with 15 patients before lunch and no computer, lingered.
The first patient of the day, an adult with ear infections, gave me permission to write more than I have. Most people who come to the doc with cold symptoms expect an antibiotic, though studies show a good explanation of why an antibiotic runs more risks than no treatment satisfies the majority. Still the explanation takes more time than writing the prescription.
Current wisdom holds that a physician can justify an antibiotic in the presence of fever, more than 10 days of symptoms, or “second sickening,” where a patient started to improve and then worsens.
I see adults with ear infections so rarely, and I spend so much time gently coaxing patients away from antibiotics, that finding not one, but two bright red ear drums in a single patient gave a great start to the day.

The second patient came in with a rash.  I said, “I write a blog.  I won’t say gender, age, name or diagnosis, but I’d like to write about vasculitis and the steps a doctor has to go through,” and the patient agreed.

When I look at a rash, I want to know if it blanches, that is, loses its color under pressure.  And I want to know if I can feel it.  Tiny bruises, petechiae, that cannot be felt, herald serious disease.  I went to the Internet to find what labs to run.  In the three years since I last saw a case of vasculitis, the work-up has changed, but not much.  I printed off a page, handed it to my nurse, gave her a thousand apologies, and asked her to enter the orders into the Electronic Medical Record.

Then I settled in to read about treatment.  We always like to have a firm diagnosis before we start administering medication, and the firm diagnosis can’t happen until the lab results come back.  A lot of those probably won’t arrive before Thanksgiving.  After that, urgency of treatment depends on symptoms.

It took the nurse as long to enter the long list of lab tests into the computer as it did for me to read the monograph.  I thanked her profusely.

I read the authoritative monograph, and shook my head when it said that 72% of cases of vasculitis will not be conclusively diagnosed.

Last century, at another clinic in another city, a young man came in with a sore throat in the middle of a strep epidemic.  I love a slam-dunk diagnosis I can do something about, but as I exited the room, he asked, “What’s this rash?  I was just sitting here and I noticed it,”  and he pointed at his ankle.  With outside temps hovering in the negative double digits, he wore no socks.  Those tiny purple bruises on his lower legs prompted an investigation leading to a hospitalization, and uncovered a heartbreaking story of drama, irony, hunger, homelessness, love, betrayal, and chemical dependency.

Some things don’t show up on a lab test.

 

 

 

 

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A nose full of jelly bean, an ear full of wax, and parasitology vies with heart failure in the morning

February 23, 2011

A toddler will try, I suppose,

To stick jelly beans up in the nose

      With patients in stacks

     We take out ear wax,

While outside the arctic wind blows.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  Avoiding burnout, I’m taking a sabbatical while my one-year non-compete clause winds down, having adventures, visiting family and friends, and working in out-of-the-way places.  Currently I’m on assignment at the hospital in Barrow, Alaska, the northernmost point in the United States.

Long before dawn (the sun rose about ten today), with the mercury firmly at -28 F (-33 C), the physicians of Barrow sat down together in the hospital’s Commons Room.

We start clinic days with a conference, an hour discussion of patients who need to be brought to the group’s attention.  Sometimes the debate runs hot.  No two docs have the same range of skills; we all come away from the discussion better physicians.

The hour, for the last week, now features a five-minute starter from the Case Manager, giving us updates on the patients sent to Alaska Native Medical Center (ANMC) for hospitalization. 

We don’t talk about drama and irony nor contrast and meaning, though we talk about the impact of illness and injury on people’s lives. 

We focus on diabetes and smoking, emphysema (which we call COPD or chronic obstructive pulmonary disease) and steroids, heart disease and the interplay of factors that bring a person to illness.  Occasionally we’ll talk about tragedy and trauma and domestic abuse.

Narcotics seeking behavior comes up a lot, but as a group we’ve evolved a way to deal with the problem.  Part of the solution includes the doctors communicating with each other.

One doc gave an erudite rundown on congestive heart failure, renal physiology, and hypertension.  He did it as casually as giving directions to the gas station.  An in-depth round table on practical parasitology followed 

Morning appointments follow morning conference.

My last patient before noon survived burning, stabbing, shooting, being run over by a riding lawn mower, and falling from a roof and bouncing (and gave me permission to use more information than I’m including ).  After all that trauma, his lifestyle choices threaten his life more than anything else that has happened.  I called a specialist in another city, and, in the spirit of full transparency, included the patient in the conversation by leaving the speaker phone on. 

 The specialist said a lot of things he wouldn’t have if he’d known the patient were listening, like using the phrase, “stupid idiot,” but he also gave a good if emotional rundown of the physiology in the case.  I watched the patient’s face, he seemed neither offended nor surprised.  I respect him as a man of remarkable emotional and physical resilience, whose intelligence has not been ruined by schooling.  But I disagree with a lot of his choices. 

Afternoons, the clinic opens to walk-ins with no appointments necessary or available.

Ears, nose, and throat problems dominated the afternoon.  One patient left cured after ear wax removal.  Four others had ear infections.

The mother of a young girl gave her OK to post the following: the child inserted a jelly bean into the nose.  Toddlers imitate reflexively though their first response to a command is No.  I held one side of the mother’s nose shut, with a tissue guarding my hand, and had her blow through the other nostril.  Given the opportunity, the kid did the same thing, and the jelly bean, its colorful sugar coat dissolved, shot onto the paper.

I don’t often get the chance to cure patients before they leave.

Application of medical first principles on a Tuesday in Keosauqua

December 21, 2010

Why do doctors go gray?

Is it all work and no play?

     Life can be a ball,

     Though you’re working on call,

Just don’t give in to dismay.

When I’m on call, nights or weekends, I get a lot of calls from people who have self-diagnosed an antibiotic deficiency and want a prescription called in.  Pain with urination, sore throat, and cough comprise the most frequent complaints.

I would like to say I don’t ever yield to the request, but on rare occasions I do.  I weigh the risk to the patient of treatment with an exam versus the risk of treatment without an exam.  Most of the time I’m pretty rigid, but flexibility sets in during extreme weather.  Last year a blizzard descended on Sioux City when I had Christmas weekend on call.  On a day when it took three hours to get from my garage to the street, I said “Yes” a lot.

Most sore throats do not benefit from penicillin.  Most pain with urination is not urinary tract infection.  Most earaches do not come from ear infections.

Today I saw four patients with painful urination, abrupt onset, accompanied by blood in the urine.  One had a urine infection.

I work very little to write out a prescription for three days of antibiotics; I work a great deal more explaining why the patient shouldn’t take antibiotics.

Of the last nine patients with pain in the ear, one had an actual ear infection.

Three other patients, all smokers with emphysema, came in short of breath today; they all left with prescriptions for antibiotics and inhalers.  One got a prescription for prednisone (a steroid).

On six occasions today I added up the costs of peoples’ bad habits.  “OK,” I’d say, “How much are you paying a pack for Marlboros/a bottle for Mountain Dew/a cup of coffee/a pack of generics/a case of beer?”  I got out my calculator and said, “Dang!  Eight hundred dollars/twelve hundred dollars/nine thousand dollars a year!  They must pay you well!  I’m a doctor and I couldn’t afford that.”

People who work with livestock in general and horses in particular don’t complain much, and if they do, I’d better listen.  I applied that principle twice today.

Three folks with mental health histories were in today; their complex medical problems took time.  I considered the principle that craziness doesn’t protect from physical illness.  I have a lot of lab results pending.

Four patients let drop the fact that a close relative had died in the last six months.  I listened and I sympathized.  I remembered the ten months after my mother died, when penicillin injections kept me going during a succession of eleven culture-proven strep throats.

Depressed patients get sick, and sick patients get depressed.