Posts Tagged ‘PMR’

Finishing early=playing hookey

March 22, 2017

The morning went just a bit slow

And I left with an hour to go                                              

But with the time I had freed

I got in some read

And enlarged the stuff that I know

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.

Last night Bethany and I had the chance to tell my story to a housemate. Coming up to my 60th birthday I knew if I didn’t slow down I’d burn out.  But I had a one-year, 30 mile non-compete clause.  That’s when I went to Barrow, Alaska, the northernmost place in the US.

Bethany recounted the time I called her to say that I had put in 63 hours that week, but I had time for the gym, playing my sax, participating in a jazz group, recreational reading and writing, socializing and watching TV. I initially attributed the extra time to commute reduction and other factors inherent in living in a small community, but then I applied the same criteria to what I’d been doing in private practice and came up with a conservative estimate of 84 hours a week, not counting obstetrics work.

Nowadays, any work week shorter than 60 hours feels like vacation. And when I walk into the clinic on Mondays, my steps bounce and I grin because I love the work.

I love it passionately up to about 50 hours, and after that my enjoyment starts to decay.

And I think my patients can tell when I get excited about a diagnosis. And when the patient makes my day, I tell them so.

Since I got here I’ve been able to radically help about a dozen patients with either Parkinson’s (involving tremor and stiffness) or PMR, polymyalgia rheumatic (an inflammation of the arteries).

But as influenza season wanes, so does the patient flow. This morning I had no inpatients at all.  Of my two scheduled morning patients, the first one showed on time at 9:00 and the second at 9:30.

I used the hours to read up on PMR . It overlaps with giant cell arteritis (GCA) and temporal arteritis (TA).  Because it comes in clusters, some authorities think it might be viral, and, indeed, if a biopsy of the temporal artery (which runs from right in front of the ear up into the scalp on the side of the head) shows TA, 3 times out of 4 it has the chickenpox virus in it.

Bethany met me for lunch.

In the afternoon I did some more work on my Canada license. I read up on Parkinson’s disease.  I saw 4 patients and finished their documentations.  Throughout the clinic, calm and low patient flow prevailed.  I got permission to leave at 430PM.  Bethany picked me up outside the front entrance, with a stiff March breeze blowing.  She took one look at me.  “Feel like you’re playing hookey?”  she asked.

I nodded. I had only worked 9 hours.

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.