Month: April 2017

Skin Stuff: or, Yellow Salve Revisited

Posted on by writenp

This is one of my more clinical posts, addressing common skin disorders. If you are interested, feel free to suggest more topics in the comments section.

Cold Sores

As a small child, I developed what our local GP called impetigo on my lips. My mother put this yellow salve on it. I still remember its slightly sweet taste and grainy consistency. I couldn’t stop licking it off.  Salve – it’s such a medieval-sounding name. I’ve not sure if she got it by RX or if it was something the pharmacist just whipped up.  As I remember, it did nothing but dry out the lesions which took about a week to go away. (If you look online for yellow salve, it seems to be making a comeback as an alternative treatment, but I’m not sure it’s targeted towards cold sores or even whether it is indeed the same yellow salve.) Trouble was, this wasn’t impetigo, it was herpes labialis, or your common cold sore.  Kids can develop this in infancy, often by being kissed by someone infected, or contact with the lesions of a playmate. It’s caused by a virus related to chicken pox and shingles, hence the blisters, and has cycles of dormancy and recurrence. It can be brought on by illness, i.e., a cold, stress, or too much sun. If you’ve had it, you become hypervigilant about the first sign of a tingle, the harbinger or “prodrome,” as we say in the biz, of an outbreak.  Best way to diagnose it is through a viral culture. If the clinical presentation is not obvious, I do both a bacterial and viral culture and see what grows out. Treatment has come a long way, and if begun at that first tingle, goes a long way towards stopping a full-blown outbreak which can be very painful, disfiguring, and embarrassing.

For adults, I prescribe valacyclovir (generic Valtrex), the huge 1000 mg lozenge-shaped pills. Take two of them at the first sign and then another two 12 hours later.  So four should treat an outbreak, which is a good thing because they are very expensive, over $10 per pill. Insurers prefer the cheaper anti-viral, acyclovir, which does not work nearly as well.   I also recommend OTC Abreva (www.abreva.com), a cream that can be applied as often as you like. Since it is white, you might want to save this for when you are not out in public.  You can also buy an OTC clear lysine gel which you can use when you are out and about.  Why would you want these extra measures?  If you are already a cold sore sufferer, you know. Those lesions hurt and are unsightly, and you just want to do everything you can to make them go away.   Health care providers are not immune to this desire to overtreat their own outbreaks.  A dermatologist once told me she herself used a topical steroid cream to reduce inflammation.  This is controversial because a steroid can decrease immunological response. Her point was that a lot of the pain and swelling is caused by inflammation and the steroid addressed that.  If you are unlucky enough to suffer from cold sores, make sure you have your provider write you a script for the 1000 mg valacyclovir pills, maybe eight, with a lot of refills. And always carry two pills around with you.

Preventing Skin Cancer and the Problem of Vitamin D

What I (often) tell my kids about skin care is wear sunscreen every day, at least 30 SPF, limit exposure from 12-3pm, wear a hat and sunglasses when in bright sun, and get a yearly full body check by a dermatologist.  Some posit that this kind of vigilance against skin cancer – a good thing – has led to a widespread Vitamin D deficiency – a bad thing.

Vitamin D is a fat-soluble nutrient essential for calcium absorption, bone health, heart health and especially important for those with autoimmune diseases.  It has been advised to get at least 10 minutes of unprotected sunlight daily so your body can make vitamin D.  This is controversial because of the association of sun exposure with skin cancer. Medicine is seldom black and white. We don’t know how much sunlight is safe, and most dermatologists will tell you, no amount is safe.  I always advise it’s best to get your vitamins through food in most cases, although that’s difficult with vitamin D. Web MD lists food sources of vitamin D: http://www.webmd.com/osteoporosis/features/the-truth-about-vitamin-d-vitamin-d-food-sources), some of which include fortified foods (where the vitamin is added). For a while, most primary care providers were checking vitamin D levels as part of regular screening blood work. You might recall lots of people were deemed deficient and were advised to take megadoses for a period of time. (I was shown to be mildly deficient but chose not to do this. Not a fan of megadoses of anything.)  Now the USPSTF (United States Preventative Services Task Force) recommends against this screening, citing there is not enough information to assess benefits vs harm in testing of adults without symptoms.

Acne

When teens are just breaking out a little bit, simple solutions are the best.  I tell them: don’t overwash, and use a mild cleanser like Cetaphil (www.cetaphil.com). Don’t scrub or use harsh astringents. First try benzoyl peroxide cream (Clearasil: www.clearasil.com) applied to the zits at night. Takes about six weeks to see results, so be patient.  Next step is adding a prescription antibiotic cream, like clindamycin, and mixing the two together. There are premixed creams such as Duac and Benzaclin but insurers are getting less inclined to pay for them.  Some people do well with Differin (www.differin.com) which is a retinoid, similar in the way it works to Accutane or Retin A, but milder, and with fewer side effects. Now you can buy it over the counter. After topical creams, providers try six-week courses of oral antibiotics such as doxycycline, minocycline, or azithromycin. These can work well, but like all antibiotics, they have potential side effects. If the RX topical treatments are not working after six weeks, I recommend seeing a dermatologist.

Diaper Rash

Diaper dermatitis happens to all babies at one time or another, usually after a bout of diarrhea.  At home, treatment is frequent diaper changes, using a diaper balm, allowing the area to air-dry when feasible.  Sometimes, though, the rash is severe, beefy-red, causing obvious discomfort. This is when your child should be seen by a provider. Often, when it gets this severe, there is a fungal component. Usually I can see the rash is deep red, with small affected areas in addition to the main one, called “satellite lesions”.  I prescribe the anti-fungal nystatin cream, and sometimes a steroid cream as well if there is particular discomfort. I advise using the nystatin after each diaper change for 3 days, cleaning with warm water instead of wipes, exposing the diaper area to air as much as is possible.  Not too often, but sometimes, the problem is a bacterial infection, the impetigo I mentioned in the beginning of this post.  In the diaper area, it can manifest with rather large blisters and is called bullous impetigo (which can also appear in other places).  The treatment is antibiotics, usually oral if a large area is affected.

Eczema

Eczema or atopic dermatitis, usually starts in infancy, manifesting as rough dry, reddish patches which can be itchy. It can be mild or severe and is an allergic response to the environment or food and linked to other allergic disorders, such as asthma.  Severe cases are very itchy and can result in secondary bacterial infections from scratching.  Steroid creams are used to treat the outbreak but prevention is best and here’s why: steroids can adversely change the appearance and texture of the skin, making it thinner and at times, darker, which can be permanent, if used for more than two weeks, twice a day.  At times parents need to be educated about this because the steroid cream works so well, they want to use it all the time to keep their child comfortable. If the steroids aren’t helping, there are newer topical meds, such as Elidel and others in this class, approved for children over two years old. At this point, though, I advise having the child seen by a dermatologist. There have been some safety concerns about these newer drugs, including a possible link to certain cancers, but nothing has been proven at this point.

For prevention, I advise only using mild unscented soap, such as Dove for sensitive skin (www.Dove.com), every other day, washing with only water on the days in between. Moisturizing is key. A&D ointment works very well, but some people dislike the rather medicinal smell; others actually prefer it because it makes it seem more like a healing medication. Also good is Aquaphor (www.aquaphorUS.com) or plain old petroleum jelly, which is basically the same thing. The good news is you can use these ointments as much as you want (or can stand, since they can be messy). A little goes a long way. The problem with scented baby oils or lotions is that the scent itself can cause an allergic reaction. Also important is using a detergent for bedding, towels and clothing that is free of perfume and dyes and not using dryer sheets, which can cause a reaction to predisposed people.  If you notice you or your child has an outbreak following a certain food, cut it out. You can get allergy testing down the road but most allergists prefer to wait until children are aged three or older.

There are plenty more skin conditions that could be addressed, but I will stop here. If you have any skin topics you’d like me to cover (or any other clinical topics), put your suggestions for future topics in the comments section below.  No promises, though, and please, no personal medical queries – see your own provider for that.  If you prefer more “Tales From the Clinic” patient stories,  let me know that too.

 

Teeth Don’t Lie, or If It Walks Like a Duck…

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It was at the end of the day.  Encounters like this one always happen at the end of the day. You’re tired, your staff is tired, and you’re behind schedule. Welcome to any day of the week at 4pm at a community health center.

I had scanned my schedule as I finished my note on the last patient.  A new patient visit popped up.  A women age 43 with an unfamiliar (for this particular clinic), Nordic-sounding name.  Okay, I thought, maybe someone visiting here and not wanting to go to the emergency room. This was before there was an Urgent Care Center on almost every block. And it was always very difficult to get into a private practice for what is likely to be a one-time visit. The complaint written on the schedule was “teeth falling out.”

Oh.  Or uh-oh. Or at least, hmmmmm.  When I think of missing dentition in a relatively young person, I think homelessness/mental illness.  Or meth.  I dutifully checked Uptodate (www.uptodate.com) to see if I was missing something, like some rare auto-immune disorder. I wasn’t.

Sooo. I walked into the exam room ready for anything.  I encountered a tall, blond women, gowned and sitting on the exam table, shuffling a lot of papers.  Never a good sign. The part about the papers, I mean. I smiled and introduced myself and I asked why she was there.  Sometimes, with our bilingual front desk staff, things can get lost in translation.  For many of the staff, English is their second language and certain physical complaints can be hard to translate.  It was a hopeful thought and I decided to stick with it until I heard otherwise.

“I was at the emergency room all night,” she said, as she thrust the papers towards me.  She had a faint, Germanic-sounding accent.  In fact, she slightly resembled the model Heidi Klum. “They said I had vasculitis.”  She moved the hem of her exam robe to expose a reddish rash going down her thigh.

“Well, what did they give you?” I asked.

“It’s all there,” she responded with a touch of impatience. She tossed her blond hair, a habit from youth, I guessed, but her hair was straggly and dull,  rendering the movement ineffective.

I explained that these reports often fail to contain the information that will be most helpful to me: a diagnosis, test results and medication prescribed.  Often it is page after page of instructions and disclaimers with the important stuff hopelessly buried within, if present at all.

“They gave me this,” she said as she handed me a prescription bottle from her purse. “But I know it’s a steroid and I don’t want to take it.”

“Okay,” I said. “Have you had a bad reaction to steroids before?” It was relatively common to get palpitations, anxiety or insomnia while taking this kind of medication.

“No, it’s not that.  I just prefer to do things naturally.  I don’t like medication.  And besides, the people at the ER didn’t help me with my main problem.”

“Which is?”

“My teeth are starting to fall out.”

Here we go, I thought. “Let’s start at the beginning, is that alright? I just want get your basic medical history. I positioned the computer so I could enter the information while we still talked face-to-face.

The history she gave me was totally unremarkable.  According to her she was the picture of perfect health. She took no medication.  Her teeth just started to become loose about 4 weeks ago.  She made it a point to tell me she lived, not in the town the clinic was in, but one town over – a very upscale suburb. She also mentioned her two children who were excelling at the high school. One had just gotten into an Ivy League college, in fact.

She dug in her purse and I thought it was for her phone to show me a photo but she took out a laminated newspaper clipping with well-worm edges.  “That’s me,” she said proudly. “I was a model in my country. “

“Very nice,” I murmured. It was indeed her, about 20 years ago, and she’d been beautiful. She was handsome, as they say, even now. “Let’s get started on the exam.” I suggested.

I couldn’t really tell what the rash was, but vasculitis seemed a long shot. I thought it was a simple, uninfected contact dermatitis, which could be treated with an OTC steroid cream.  But now I went on to the part I was dreading, the oral exam.  She complained of no pain when I palpated her jaw and cheekbones. She had no swelling or bruising. I did notice her complexion was a little rough and there was one unusual scab right in front of her ear.  When she opened her mouth, it was clear she was missing a few of her back bottom molars, and when I shined a light inside, the top ones too. She wiggled a canine tooth for me like an excited kindergartener. The disconcerting sight gave me goosebumps.

“See, nurse, this is what I’m talking about.” I nodded and completed the rest of the exam. Other than her skin and teeth, nothing seemed amiss.

I excused myself and conferred with a colleague, who agreed that I had to do a tox screen.

“What’s weird is that she’s not asking for anything, no requests for opioids.” I mused.

When I went back in the exam room, I told her I was stumped. I recommended we start with some basic blood work.  I told her we needed to do a urine test as well, to test for drugs.

“But I told you, I don’t even like medication. I certainly don’t take drugs.” She made a point of holding my gaze directly, her clear blue eyes telegraphing her sincerity.

“I understand,” I responded, “But please humor me. Use of methamphetamine is a major cause of teeth falling out.  I would not be doing my job if we didn’t rule that out first “  I also wondered if they had done that at the ER.  If so, I was sure that particular tidbit would not be included in the papers she handed me.

“I will call you with the results,” I told her.

“Don’t I need a follow-up appointment?” she asked, which kind of surprised me.

“Well, you can certainly make one if you wish, but until we get the results, I’m not sure how productive it will be. We may need to refer you to a specialist.”

I went on to the next patient and my medical assistant went in to draw blood and hand her a urine specimen cup.

My last patient was an 8 year old with strep throat. Easy peasy and she was a sweetheart to boot. I was about to sit down at my desk to finish charting when my medical assistant informed me my prior patient was still here because she couldn’t pee.  She was drinking water when I entered the room. My patience was wearing a little thin. “Look,” I said, “We really need to do this test. We can’t continue to take care of you and get to the bottom of this if we don’t.” She regarded me coldly as she took the last swig from the bottle.

“Very well,” she retorted.

By the time I left that day, I had no idea if she submitted the specimen, but it turned out she had.  The next morning the urine test was back.  Positive for methamphetamines.  I called several times, leaving discreet messages asking her to call me but she didn’t.

They informed me at the front desk that she had indeed made another appointment.  She told them this time she wanted to see a doctor, “not a nurse!”, and she wanted a male doctor.  I doubted that she’d show.

I was wrong. I guess her charms were lost on me. Because the doctor, even though I had told him about the tox screen, was driven to find out what was wrong with “this poor women”.  He said she told him that she was taking her child’s Ritalin to concentrate and that’s why her tox screen was positive.

“But I asked her about medication.  She denied taking any.”

“Well, I guess she didn’t feel comfortable with you,” my colleague suggested. And  I guessed  that old modeling photo still had a certain juju.

“And she hasn’t requested any opioids?” I could not help asking.

“Oh, no,”  he responded. “She’s very anti-drug.”

It made me wonder why she came to the clinic in the first place.  Was it for the attention? Was she mentally ill?  A borderline personality disorder, maybe?  But it wasn’t my problem anymore, and there were always more patients to see.

I did ask my colleague a few months later what progress he had made in her case.

“Oh, she just stopped coming.” He admitted sheepishly, and a little regretfully.

“And her teeth?”

“Kept falling out. I referred her to a dentist but not sure if she went. She was going through a divorce and there were insurance problems and money was tight.”

I began to question myself. Maybe I was getting too hard. Could it have been really advanced periodontal disease?  Was it all from stress?  But how and why did she know the exact thing to say that would explain away her positive urine screen?

About six months later, another colleague drew my attention to an article in the local paper. “Isn’t this that women with the teeth?” It was. Her bone structure prevailed even in the mug shot.  Heidi Klum on a very bad day.  She was found sleeping in her car in that exclusive suburb.  Also found was her stash of methamphetamine.  It was sad.  I wondered if the children she told me about were real, and how they were faring in the midst of all this. I asked one of our social workers to look into it.

It continued to be a mystery to me.  Was that first visit a cry for help?  Or did she think stopping her teeth from falling out would prevent her life from falling apart?

©2017 by Eileen Healy Carlsen. All rights reserved.

To Test or Not to Test: of PSAs and Pap Smears

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The United States Task Force on Preventative Services (USTFPS) creates guidelines for providers to help them determine which preventative tests to do when, for which patients and if at all. We in community health rely on this task force perhaps more than other providers due to its global perspective. Basically their mandate is to decide, through a rigorous review of the research, whether certain tests or counseling interactions actually save lives in the long run, whether the benefits outweigh potential harm, and whether they are cost-effective. You can find out more at https://www.uspreventiveservicestaskforce.org/.

To make things more complicated, there are other specialty physician organizations with their own guidelines and the recommendations are often conflicting.  So what to do and how to decide?

If you have a good relationship with your health care provider, that is the best place to start. Discuss your risk factors for certain diseases, your age and state of health, your family history and your state of mind when it comes to medical tests and results. Personally, I am as conservative with tests as I am with prescribing medication.  There are potential downsides to every medical intervention, even tests.

Many people are surprised about this last notion.  They believe testing is good and want every test available, all for the assurance that they are healthy. But tests can have false positives – meaning they might indicate you have a condition when you don’t and thus lead to further testing or unnecessary interventions.  False negatives happen too, when the test says you’re fine but you are not.  Your provider will be able to tell you the false negative and false positive rates of most tests, as well as potential side effects, to help you make an informed decision.

An example is the PSA test, which is a blood test for a protein called prostate specific antigen, which is elevated in men with prostate cancer.  It can also be elevated in men who ride bicycles a lot, or who have an enlarged prostate, or have had a recent infection. Before 2012, we routinely tested men 50 and over, and younger men with family histories, risk factors or symptoms. If the PSA number was above a certain range, the test was repeated and if still high, they were referred to a urologist for a prostate biopsy.

Biopsies are never pleasant but prostate biopsies are particularly unpleasant given the location of the gland. Urologists try to take samples from many locations on the prostate, often guided by ultrasound or MRI, to find the cancer cells. Sometimes they do.  And sometimes they don’t.  As you can imagine, this is anxiety-provoking either way.  To compound the dilemma, many prostate cancers are very slow-growing and may not require treatment. But currently it is impossible to ascertain this definitively so depending on their age, most men are advised to, or want to, get treated.

Because of all this, in 2012 the USTFPS recommended against screening most men. A new guideline that came out just this week amended this slightly, recommending discussing screening with men aged 55-69, and then making an individualized decision.  I think that’s what most of us were doing anyway. A lot of times a man in his 50s would come in for a physical (pushed by his wife or girlfriend), and ask for the PSA test. We would discuss it and he would decide against it and with his permission, I would offer to talk with his significant other as well. Lots of times this would be a relief. The “man on a mission” did not want to go home, as it were “empty-handed,” having failed to get the test she requested.

Now on to the Pap smear, the screening test for cervical cancer. We actually call it a Pap test now because it is no longer a “smear” collected on a slide and preserved with a fixative.  It is liquid-based, collected with two tools usually: a small plastic “spatula” and a small brush. It is a better test because it requires fewer cells (so less repeat Pap tests for an inadequate sample), it can be done on days of light menstruation, and it can also be used to test for HPV, the human papilloma virus.  This is huge because HPV, a sexually-transmitted virus, is the cause of most cervical cancers, and the presence or absence of HPV in an abnormal Pap test guides our treatment and follow-up.  HPV can occur without symptoms and there is no cure or treatment for the virus itself.  Sometimes it manifests as genital warts “the HPV you can see,” and these can be treated, but eliminating the warts does not eliminate the virus.

The efficacy of this liquid test along with the ability to test for HPV is the reason behind the latest USTFPS guidelines on Pap tests: basically less is more, and later is better. This is welcome news to women, who never look forward to getting this test.

Now we don’t do Pap tests on women younger than 21, regardless of sexual activity. (We do of course test for sexually transmitted infections (STIs) and give safe-sex and contraceptive advice.)  This is because most young women have a low-risk strain of the HPV virus, which clears on its own. Before the guidelines, we were getting lots of abnormal pap smears for women under 21 which required other, more invasive tests and interventions, all of which could have been prevented by waiting. The jury is still out on how the new generation of women vaccinated against HPV will influence future guidelines.

Currently we test every 3 years from 21 until age 30. At age 30, women have the option of having the Pap test every 5 years along with an HPV test, or every 3 years without. Women older than 65 don’t need further testing if they have had regular screening in the past and do not have risk factors. This has taken a lot of getting used to, both for providers and patients. Women, as much as they dread the test, wonder if it’s okay to wait that long, is it safe? Rigorous research has proven that it is.  Some providers were still testing every year and some women wanted the assurance. As insurance companies adjusted their re-imbursement to the guidelines, this has changed. Go to this link for the particulars: https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/cervical-cancer-screening?ds=1&s=cervical cancer

The bottom line though (no pun intended) is that medicine is both art and science and patients are individuals.  There is no “one-size-fits-all.”  If I have a women who wants the test even though it isn’t due yet and is not warranted clinically by the presence of symptoms or past personal or family history, we will discuss it.  Sometimes, I find out she thinks the Pap tests for all STIs and she has had a recent risky sexual encounter.  Lots to discuss including other STI testing and possibly emergency contraception in that case.  Other times there is a nebulous family history, “my great aunt died of cancer ‘down there,” or she is worried after a friend had a bad diagnosis.  As a provider, I value my patients’ mental health as much as the physical.  In some cases, I will do the test to ease anxiety, after discussing cost in case her insurance won’t pay.

The takeaway message to this rather long post is that medical tests are complicated, imperfect, at times invaluable tools to maintaining good health.  Team up with your provider to get informed, be conservative and make sure you understand what you are getting into.

Healthy Thoughts: What This Blog is All About

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There are a lot of health-related blogs out there, so what makes this one different?  Imagine if you will that you have a close relative or friend who is a nurse practitioner.  You would probably feel free to ask her or him anything about your current state of health as a matter of course. Off the cuff, spur of the moment,  things you might not ask your doctor because of embarrassment or time constraints or fear of seeming silly.

My patients often tell me nurse practitioners are easy to talk to because they listen. And I do make it a point to give my full attention when a patient is describing symptoms or as we say in the biz – complaints. That word may have a negative connotation outside of health care but it’s a simple way to describe what brought you in to see a health care provider.

Even nurse practitioners have restricted time-slots (alas!) so there are questions that you might not get to ask during an office visit. Unless you have a relative or friend who’s an NP. Then you can send emails to that person with the subject line “eye” or “kidney” or “weird symptoms.” And you will get answers.

Now before you get the wrong idea – this blog is not going to be a forum for your specific health questions.  Rather, I will discuss all the kinds of questions patients, relatives, friends, and yes, even strangers, have asked me about their health. Chances are, some of these topics will speak to you personally.  I will share with you my health practices — what I do to stay healthy, what I advise my family to do, as well as share my thoughts about health care today, including how to utilize the system to optimize your health. My goal is to improve health through knowledge, from a nurse practitioner’s perspective.

But that is not my only motivation.  The URL for the website is www.mynursepractitionerwrites.com because, well. I was a writer before I was a nurse practitioner.  And sometimes, certain patient encounters resonate with me, becoming almost lyrical in the truths they reveal about both the patient and provider. It happens when the humanity of each person comes through despite the trappings, time constraints and mechanisms of modern-day healthcare.  It’s the reason  I renamed my site, “Tales From the Clinic.”  Some of the content is clinical, for sure, and some of it reflects the meaning I find in patient stories.

Please take a look at the menu bar to find content that interests you, and if you find it helpful, or just fun to read, please subscribe to my blog at the bottom of the menu drop-down. Thank you.

© 2016-2020 Eileen Healy Carlsen, FNP-BC (board certified nurse practitioner in Family Health)

A Bad Diagnosis

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Sometimes it’s in an email, with a worrying subject line. I’ve found the most worrying subject line is just someone’s name. Other times it’s a phone call, the seriousness of which is immediately revealed in the tone of the caller’s voice. There are times when it just comes up in a random run-in with a friend or acquaintance. A bad diagnosis.

It doesn’t have to be life or death but it has consumed this person’s every waking thought. And of course, they’ve been on the internet, reading everything from “survivor” blogs, alternative health sites and mainstream sites such as WebMd.com and Mayoclinic.com. It’s made them crazy, confused and panicky.

Many times, off the top of my head, I can’t give them an immediate answer. It’s out of my field of expertise.  Or I just want to make sure I am aware of the latest developments in that particular field. I tell them to take a deep breath, that they have some time to make a decision, no matter how serious the issue.  Yes, they should get a second opinion, and they should check with their insurance company about how to go about that.

If the diagnosis is cancer, I tell them to check if they’ll be able to go to the top cancer center in their area (and I tell them the name of the center) for treatment or at least for that second opinion.

No matter the diagnosis, a lot of research needs to be done before that second-opinion visit. I am happy to do this for them but for many people, knowledge bestows a measure of control. So usually we do the research together. Not only is it vital to understand the diagnosis, but being as well-informed as possible will maximize the benefits of that second-opinion visit. They will know where the gray areas lie (and there are always gray areas), the latest promising but perhaps controversial treatments being researched, and the ramifications of not treating. The last is always a very important question to ask – what if I decide to do nothing?

In terms of research, I recommend http://www.webmd.com and http://www.mayoclinic.org/ for very preliminary understanding. Beyond that, it’s best to go to the source most health care providers use, including myself. It’s non-biased and has the very latest research. In the past, it was extremely expensive for an individual. Providers have access through their electronic medical record software or as a standalone through a group practice subscription. There is a free basic patient information option and you can start there, but for the kind of research I recommend, you will need to subscribe. Luckily, now you can subscribe for a week for $20.00 or a month for $53. http://www.uptodate.com/home/uptodate-subscription-options-patients  (Note: I currently have no affiliation or financial dealings with any of the websites mentioned.)

Then it’s always a waiting game, and that’s the worst part. For the appointment, for new tests, for test results. I don’t make decisions for anyone but I hope my input helps them make the best decisions possible with the current state of knowledge. And that’s really all anyone can do.

Painful Encounters, Part 2

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“Foot pain” was the reason listed for the appointment. A new patient, male, age 31. I had now been in the clinic long enough to prepare myself mentally for just about anything. A year ago a young women with the same complaint, also a new patient, had presented with an infected foot wound open to the bone emitting an odor so strong, that when she took off her shoe it made the medical assistant have to leave the room in a hurry. Turned out she had spina bifida, and got this often. Her decreased lack of sensation and frequent hospitalizations made her blasé. As we waited for the ambulance, I asked “Why didn’t you just go to the ER?” “I didn’t think it was that bad, and I don’t have my insurance yet.” She was later transported to a trauma center where she remained on IV antibiotics for 3 weeks.

The man was tall and thin with longish straight brown hair. He was wearing a gray tank top and jeans and the prison tattoo on his upper arm was displayed for all to see.  I took that as a conversation starter and made a guess. “Were you recently incarcerated?” It was a universal term, no matter a person’s first language or education level.

“Yes, got out two days ago.” I suppressed the urge to ask what he had been in for.

“Have you had a TB and HIV test?” I asked. It was pretty standard.

“Yeah, all that, I was negative.”

“We can test you again 6 weeks from now to be sure.”

“Yeah, okay whatever, but that’s not why I’m here.”

“So tell me,” I encouraged.

“Five years ago, I was working as a roofer and fell off a roof. Broke both my feet. Was in casts, the whole deal.” He grimaced at the memory. “But the docs said I needed surgery to really repair things and I didn’t have insurance.”

“Are you in pain?”

“All the time. That’s why I’m here.”

Now was the time to ask about why he had been in jail.

He looked sheepish. “Um, narcotics, a little dealing. It was all because of my foot, though.”

I was surprised at his honesty.

“Let’s do an exam first and then we’ll talk.”

He was meek as a lamb.

The exam was pretty normal. The soles of his feet were painful to the touch but there was nothing really to see. He had full range of motion, good pulses.

I took a complete family history and got ready to order some blood tests. “Oh, no, doc, I hate needles,” said the man with the crude prison tattoo.

We compromised. A urine test this time, including a tox screen and a return in two weeks for blood work and a complete physical exam. I gave him a prescription for high dose naproxen for his pain, with the appropriate caveats.

Surprisingly, he came back and became a model patient. He said he was not using and his tox screen was negative. He was depressed, not surprisingly, and I started treating that with medication. We were helping him with insurance so that he could see a specialist for his foot pain. I continued to write him scripts for the naproxen since he was having no ill effects and his labs were normal. This was during the early days of electronic prescribing and not all pharmacies were equipped for this. He told me his wasn’t and I gave him paper scripts.

Six months went by. The clinic was always swamped so it took me a while to realize he was coming less frequently. I placed a call to ask him to come in to monitor his depression meds. Left a message but no response. Next time I called, the phone was not in service. I sent a letter to the last known address. And then forgot about him.

Until two years later, when I noticed he was on my schedule again. The complaint this time was “medication check.”

After the initial greeting, I asked where he’d been, thinking he’d moved.

He had been in jail again. This time, I asked straight out.

He seemed to wrestle with how to respond. “You’re not gonna like it,” he finally said. I was sure I wasn’t. And waited.

“Prescription tampering. Well, not really, but those scripts you wrote for that medication—“

“The naproxen?”

He nodded, and added “And the other.”

“The medication for depression?” I thought I couldn’t be surprised anymore but I was. Shocked actually.

“But wouldn’t I have been notified?”

“Well, there were drugs in the car, they cared more about that. And I was never able to use any of the doctored-up prescriptions – guess my forgery skills weren’t up to par. And the way you wrote them made it hard.“ He chuckled a bit until he noticed my stony-faced expression.

“So what brings you here today?” I finally managed a neutral tone.

“Well this time, I do want help to see the bone doctor. What I told you about my feet – that was true. And um — nurse?” (patients always struggled as to what to call me.)

“Yes.”

“I’m sorry. I know you really tried to help me and I took advantage and screwed up.”

What do you say to that? I just nodded and began the exam.