Month: March 2017

Painful Encounters, Part 1

Posted on by writenp

I just completed the new mandated continuing education for prescribers on controlled substances in New York State. It’s part of a nationwide effort to stem the opioid abuse problem in this country, which is growing exponentially. The program was very well executed with many suggestions on how to prevent opioid abuse while still treating a patient’s chronic pain. There was also information on state-specific guidelines on prescribing, many of which have become more stringent in light of the opioid epidemic. A month ago, I also completed a similar program for the state of Massachusetts where I also hold a license, and this was through Massachusetts General Hospital. This presentation featured re-enactments of typical patient encounters. They brought back some painful memories.

It was probably my second week at the community health center. A new patient (in this particular scenario it’s always a new patient), a clean-cut while male in his late 20’s, sat on the exam table. I had noticed that he had walked in stiffly past my office door, lagging behind the medical assistant and holding the small of his back. He was with his girlfriend. He said he was visiting from Florida and his back was acting up. He had been in an MVA (car accident) 5 years ago which “broke my back” and resulted in excruciating back pain which came and went. His girlfriend held an envelope which contained an xray film. His last name was written on the corner with marker. He was disappointed when I informed him we didn’t have a light table to read the xray.

His vital signs and reflexes were normal. His lower back appeared normal without bruising or redness or swelling, but was hypersensitive to the touch. He denied fever or urinary symptoms which could signal a kidney infection. He denied loss of bowel or bladder function – a red flag which would indicate an emergent condition called cauda equina syndrome, requiring quick surgical intervention. He denied prior use of IV drugs which would make him more susceptible to a bone infection called osteomyelitis.

He did say that the pain radiated down both legs suggesting sciatica. Every motion I instructed him to do hurt – bending forward, backward, twisting. Any manipulation of his leg while he was supine was painful. Even pushing down on his head while he was sitting was painful.

He said surgery was suggested for his condition, described as “many herniated discs” but he didn’t have insurance. His doctor in Florida gave him Vicodin – the generic didn’t work. Yes he tried physical therapy but it made the condition worse. He was extremely polite and kept calling me “ma’am.”

I held up my hand and began my spiel about how opioids were not the most effective drugs for pain management. I talked about how NSAID/acetaminophen in combination had more efficacy. Suggested we start such a regimen in addition to a muscle relaxant for 5 nights. I talked about alternative therapies such as heating packs or topical lidocaine. I encouraged him to speak with our advocate to start the process of acquiring insurance so that he could get his problem re-evaluated by orthopedics and perhaps start physical therapy again. I spoke about referral to a pain management doctor if all else failed.

He listened politely and then asked, “So you can’t give me any Vicodin?” I told him I was not comfortable doing that. “Well they told me you could help me when I made the appointment.” His voice started getting louder. His girlfriend started to look anxious. “Let’s get out of here, baby” she whispered. She was too thin.

“I’m not f-ing paying for this appointment.” He continued, almost shouting. “I wanted to see a real doctor.”

“They told you I was a nurse practitioner when you made the appointment. Do you still want your prescription for the muscle relaxant? If so, which pharmacy?” I kept my tone level and neutral.

He reluctantly named one and I sent it off. I got up and said I would bring back the instructions for taking the ibuprofen and acetaminophen in rotation and a referral to our patient advocate.

When I returned to the exam room a few minutes later, it was empty. The exam table paper appeared to give one last rustle in the abandoned room, like tumbleweed. 30 minutes spent on a visit allotted 15 and I still had to write the note.

The Dreaded UTI

Posted on by writenp

You notice in retrospect that you’ve been peeing more than usual. You tell yourself you’ve just been drinking more water lately. Then you notice a little twinge in your lower abdomen (what we call the supra-pubic region). You begin to suspect (okay, reluctantly admit) you are getting a urinary tract infection (UTI). (Note, this post is about UTIs in women.)

What to do? It depends a bit on your age, but everyone should drink lots of water, at least 20 oz. an hour. Recently the long-held belief that cranberry juice has a bacteriostatic effect and can nip a UTI in the bud has been disputed due to lack of scientific evidence. But it doesn’t do any harm so I do start drinking a cup of pure cranberry juice (not sweetened cocktail) an hour.

Women up to perimenopause (so teens to 40-ish) should see a health care provider if the symptoms persist more than a day, or worsen. The reason is that an annoying UTI can more easily turn into a serious kidney infection (pyelonephritis) if left untreated, and is especially common in younger women. Symptoms of pyelonephritis include lower back pain (bilateral or one-sided), pelvic pain, fever and chills. Any of these symptoms require prompt medical attention. It is very important that a urine sample is collected. Your provider will do a quick “dipstick” test that can indicate if you have an infection, and then, send your urine specimen out to the lab for a culture and sensitivities test. This second step is vital because UTIs can be caused by a variety of bacteria that require different antibiotics. (This is the reason I rarely will prescribe an antibiotic for a UTI over the phone. It’s is in the patient’s best interest to come in, if only to submit a urine sample.) Also if your infection is just getting started, the dipstick might be negative or inconclusive but the culture will usually demonstrate an infection if you have one.

Seeing a health care provider is important because the physical exam dictates the care. If I see a young women with all the symptoms of a UTI, including suprapubic tenderness, I will rule out pelvic inflammatory disease (PID) with a quick pelvic exam and send some tests out for STIs (sexually transmitted infections) like chlamydia and gonorrhea which can mimic the symptoms of a UTI. (I always do a pregnancy test too and a positive result will dictate further treatment.) I am going to treat her for a UTI, regardless of what the dipstick says. And if the pelvic exam is suspicious, I will treat for those STIs separately as well while we await lab results. It’s called treating empirically. If I suspect a possible kidney infection, I’ll use a certain type of antibiotic called a fluoroquinolone. If not, I’ll use a medication called nitrofurantoin because of the problem of bacterial resistance to some commonly-used drugs. If the culture and sensitivities test I ordered indicates a different antibiotic is needed, I will call the patient and change it. I always tell my patients to call if they are not much better in three days or if they feel worse, and to go to the ER if the symptoms of a kidney infection develop.

For women entering perimenopause, or if they are menopausal or post-menopausal, fluctuation in estrogen can make them more susceptible to cystitis which is inflammation of the bladder. Cystitis may or may not be caused by a bacterial infection. These women can try the water and cranberry juice for a few days as long as the symptoms don’t worsen and there is no fever or back pain involved. Ibuprofen also helps with the inflammation. It’s never a mistake however, to go to your health care provider at the first sign of a UTI at any age.

There are some things all women can do to prevent UTIs:

  • Keep hydrated and don’t hold urine in when you feel the need to urinate. (‘Holding it’ for too long can definitely cause a UTI.)
  • Wipe from front to back after a bowel movement
  • Urinate ASAP before and after sexual intercourse.

Hope this helps the next time you have an “uh oh” moment.

An Exercise Prescription

Posted on by writenp

As a health care provider, I often advise my patients to exercise. It does not make me popular. People who aren’t regularly exercising have their reasons. “No time” is a big one, and I get that. But there are ways to work in 15 minutes at a time throughout the day if you can’t devote a half hour to it.

When I promote exercise, I’m not usually focusing on a patient’s need to lose weight. I’m thinking about keeping his heart healthy, her body (especially muscles and bones) in good enough shape to support her in living an active, independent life well into old age. I’m also focused on his mental health.

When a patient comes to me with depression. I always prescribe exercise, in addition to therapy and medication (if warranted).  Regular exercise, even just brisk walking, changes your brain chemistry. The endorphins released when exercising treat depression and anxiety in the most natural way possible.

Exercise is not one size fits all. You have to find something you enjoy doing enough to incorporate into your day at least five times a week. Walking is a great place to start, gradually increasing distance and speed as tolerated. Take time to observe your environment and how it stimulates your senses.  Appreciate the whirring of insects, the birdsong, the laughter of children playing, snippets of overheard conversation.  Enjoy the cool clean air, the fragrances of flowers or evergreens,  or the energy and bustle of the city.

If you have  heart issues, always check with your provider before embarking on any exercise program, and also report back if you are having trouble when walking, including leg pains, shortness of breath, and extreme fatigue. Chest pain when exercising is a red flag which requires prompt medical attention.

People often ask me which is best – cardio or weight training. First, depending on how you work out, weight training is also a cardio exercise because it elevates your heart rate. You should be doing both.  As we age, we lose bone strength and muscle mass. Strength training helps build muscle and strengthen bone. Cardio machines, running, spinning, boot-camp type classes all serve to exercise your heart muscle, making it more efficient and stronger. Your large muscles, mostly in your legs, also benefit.

Pilates and yoga build core strength and, yoga especially, promotes balance. Having good balance is important to prevent falls and maintain mobility. One of the first tests we do during a “Welcome to Medicare” exam is time how long it takes for a person to get up from a chair, walk a few steps and sit down again. It is easy to tell who is going to do well just by observing the patient walking with me to the exam room. The people who exercise regularly ace this part and often get competitive, wanting to know what’s the usual time period (we aim for under 8 seconds), and wanting to do it again to improve their time.