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Sat Feb 27, 2016, 02:16 AM

I felt like Dr. House in clinic today. Bear with me.

I have a patient who has been experiencing fainting episodes for about 18 months. The VA is convinced it is due to injuries the patient sustained sixteen years before the symptoms presented. Doesn't make a lot of sense. A prior report by a neurologist states the evidence obtained from CT imaging doesn't correspond to the clinical symptoms.

I've looked everything over, and the other day, I had a brainstorm: has he ever been evaluated for narcolepsy? Today, I obtained a new history from the patient, trying to suss out if he has risk factors for narcolepsy. I've started a workup for that diagnosis. If my diagnosis is correct, we can start treating him. If I'm wrong, at least we've ruled another condition out. My patient was happy that at least someone is exerting a little brain-power on the problem...

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Reply I felt like Dr. House in clinic today. Bear with me. (Original post)
Aristus Feb 2016 OP
artislife Feb 2016 #1
Wounded Bear Feb 2016 #5
LiberalElite Feb 2016 #6
KT2000 Feb 2016 #2
Aristus Feb 2016 #4
Baobab Feb 2016 #15
In_The_Wind Feb 2016 #3
Aristus Feb 2016 #8
elleng Feb 2016 #7
Aristus Feb 2016 #9
elleng Feb 2016 #10
3catwoman3 Feb 2016 #11
Baobab Feb 2016 #14
greymouse Feb 2016 #12
Baobab Feb 2016 #13
Baobab Feb 2016 #16
Recursion Feb 2016 #17
Paula Sims Feb 2016 #18

Response to Aristus (Original post)

Sat Feb 27, 2016, 02:18 AM

1. Good job.

 

I loved Dr. House's brain.

He would have been hell to live with but he would be the doctor for me.

Good luck in healing your patient. Having someone who is really trying to help means the world.

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Response to artislife (Reply #1)

Sat Feb 27, 2016, 12:03 PM

5. I'm not so sure...

After all, it seems almost all of his patients need to have a near death experience before he miraculously cures them. Not sure this old man would survive.


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Response to Wounded Bear (Reply #5)

Sat Feb 27, 2016, 12:56 PM

6. I loved that show - but

there was a routine to it. (Maybe that's true of all of TV series.) One time it seemed like they had figured out someone's illness - but there was still at least a half hour left in the program. I thought, no, it's too soon. They don't know what's wrong yet - there has to be fluids suddenly gushing out of multiple locations first.

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Response to Aristus (Original post)

Sat Feb 27, 2016, 03:09 AM

2. be sure to ask about

environmental exposures. People who develop sensitivities to chemicals in the environment have been known to pass out when exposed to problematic chemicals including molds. Sometimes these patients are diagnosed with narcolelpsy.

US Dept of Health & Human Services in conjunction with other agencies once had a booklet about Taking an Exposure History.
just a few sources of concern:
formaldehyde
herbicides and pesticides
solvents
carbon monoxide
car exhaust
living near a toxic site
use of chemicals in the home for cleaning and hobbies
workplace exposures

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Response to KT2000 (Reply #2)

Sat Feb 27, 2016, 11:38 AM

4. Thanks!

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Response to KT2000 (Reply #2)

Sun Feb 28, 2016, 04:23 AM

15. YES, that is what I was wondering too..

Clean air is so important

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Response to Aristus (Original post)

Sat Feb 27, 2016, 04:20 AM

3. Go get 'em Tank!




BTW, IMO, House is a great show.

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Response to In_The_Wind (Reply #3)

Sat Feb 27, 2016, 02:23 PM

8. I will!...

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Response to Aristus (Original post)

Sat Feb 27, 2016, 02:21 PM

7. Nice,

and I'm sure you were more pleasant than House!!!

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Response to elleng (Reply #7)

Sat Feb 27, 2016, 02:24 PM

9. He's a really nice guy.

And his wife, who accompanies him to every clinic visit, is very sweet. They are both staunch Bernie Sanders supporters, so politically, we're sympatico...


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Response to Aristus (Reply #9)

Sat Feb 27, 2016, 02:26 PM

10. Even NICER!

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Response to Aristus (Original post)

Sat Feb 27, 2016, 02:29 PM

11. Being a primary health care provider...

...provider is like the box of chocolates from the Forest Gump movie - when you walk into an exam room, you never know what you are going to get.

I work in a private pediatric practice, as the only nurse practitioner among 9 docs. We see patients from birth thru college, which requires quite a broad knowledge base. Happily for us, unlike your situation, Aristus, we seldom have patients at risk of dying. Those who are in those sad circumstances are generally under the care of subspecialists for a hematology-oncology diagnosis or degenerative neuro disorder

That said, we do see quite a number of patients with multiple concerns - some real, some imagined, some simple, some complex. Visits are scheduled every 20 minutes, which is adequate for a straight forward problem like an earache or sore throat. I cannot begin to count the number of times an appointment will be made for something that sounds simple when you see the stated reason on the schedule, only to walk in and find that the parent/patient has thought of at least 3 other "issues," usually presented with the, "By the way, as long as we're here..." phrase. Or, they make an appointment for one child, and then ask if you would please take a "quick peek" at the 2 siblings they brought along, hoping you will do it for free. "It'll only take a second." Nothing only takes a second, if you are going to do it well.

Just yesterday afternoon, I went in to see a 17 yr old girl, whose mom had made an appointment for the stated reason of 'cold symptoms.' The young lady was 17, and by herself, with mom planning to show up a bit later. The patient got there late. I walked in, and was presented with the following list entitles "my issues":

1. losing hair
2. losing weight
3. sore throat
4. diaphragm hurts when she takes a deep breath
5. IT band problem for a few months
6. 2 episodes of numbness and tingling in her legs
7. elbow sensitivity
8. long term problem with a knee that required surgery a while back - no record from her orthopedist
9. nausea for over a year
10. lump in right breast
11. lump in left armpit
12. often feels cold

WTF!!! The alleged cold symptoms weren't even on her list.

With that many problems, you can't even take a decent history in 20 minutes, let alone perform a decent exam and devise a plan. No freaking way. We dealt with problems 1, 2, 10, 11 and 12 with orders for thyroid levels, and ultrasounds of the lumps, both of which were small and and had classic benign characteristics. She already had an appointment scheduled in 2 weeks with a chiropractor for the knee problem. I suggested she also tell that person about the elbow, IT band and numbness concerns, and offered her the contact information for our favorite orthopedic specialist should she not be satisfied with the chiropractor. Her GI complaints were evaluated quite thoroughly by one of my colleagues last summer. Probably time for her to go to a GI specialist.

I probably spent at least 40 minutes with her. For some mysterious reason, this type of patient usually has an appointment late on a Friday afternoon, when we are often running behind because that is just how things go on Fridays in a pediatric office - everybody want to come in on Friday to get something their kid has had all week fixed right now, because there is a game/party/ dance performance/ family gathering, etc on Saturday.

Once I got home, I spent about an hour documenting this encounter in the electronic medical record. I find EMRs very cumbersome and time consuming - it takes at least as long to document what I do as it does to do what I do, and I routinely take home 1-2 hours of record keeping at the end of what can be 9-10 hours at the office. I still, for the most part, enjoy the interactions with families, and the challenge of helping parents learn what they need to know to take safe and confident care of their children, but I thoroughly detest the electronic documentation and how it has changed how we do our jobs - more secretary than clinician much of the time.

I have been a nurse practitioner for almost 40 years. I used to think I would dread retirement. Since the advent of EMR, I am now looking forward to it.

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Response to 3catwoman3 (Reply #11)

Sun Feb 28, 2016, 04:19 AM

14. I used to be one of those patients, and I had several of those symptoms

I am much much better now and even when I have health issues now try to avoid going to the doctor, and actually have some observations about that kind of situation which might be helpful.

You may notice that I am an extremely avid supporter of single payer health care. I am that way because I see the health insurance industry as being out of control and their co-enabling relationship with the political establishment as moving into crime against humanity territory. The olitical establishment isnt trustworthy either.

here is what I know I 'had'. It turned out that the attic of my apartment building had been involved in a fire around 25-30 years earlier that had never been cleaned out in terms of black carbon/soot/whatever, and additionally it had been spray insulated with some kind of cellulose that was filled with toxic black mold. It was off the charts bad.

The mold was invisible, for most of the time I was there (9 years) did not smell, and it was literally one of the most toxic things we know of, well around the 60th most toxic things we know of, and it was basically like a chemotherapy drug.

I have long lists of scrawled symptoms. Its a hell of a story. I learned a great deal. But please understand from the patients point of view, they dont want to be there. Doctors should lay it on the line with patients and try to come up with something that works for both of you that allows you to conserve your time and resources SO YOU CAN GIVE HER WHATEVER TESTS SHE REALLY NEEDS. She may just get better, but it may be something too.

Do her ears ever ring, loud?

I know from experience that the situation I described because it suppresses the immune system results in people in that situation getting some new infection every year or two and it just piles on top of the other ones. Common community acquired infections that remain invisible (but the person is miserable and really sick) and they dont become symptomatic until he person starts to get better, paradoxically. And their immune system starts getting better then they will start having different symptoms and in the case of mold then they start realizing where the mold exposure is coming from. In my case, an out of style powdered cholesterol drug was the key for me getting better. Initially my doctors thought I was losing my mind when I gave them my theory of what was going on but it turned out to be completely right.

It was like something out of a movie.

I have only seen one other person who had the same experience and it was actually written up in the New York Times, and reading it I realized they had gone through the exact same thing. Same labs and everything. This head of this family was doing some secret job and they gave him a house to live in with is family on an army base, and it was moldy and he became convinced that the government was trying to poison him, which is - as strange as this may sound, completely understandable to me in that situation because thats what this stuff did.

It may have had some neurotrophic effects on something, but it also impacted some part of my short term memory in not a good way. And I also completely lost my sense of smell for three years,

I could go on and on about it.

I need to write this experience up and collect all those notes I took.. Its now many years later and its only now that I feel better enough to do that project without getting - I dont know, too wrapped up in it again.

Moldy buildings produce LSD like alkaloids when it grows on moldy latex paint.

Tell your patient to take antioxidants,like NAC and alpha lipoic acid, and perhaps acetyl-l-carnitine...they are just things everybody can benefit from. They help a great many things. Resveratrol might help her joints, taken buccally.. (in the cheek) its around 20 times stronger..

HTH, YMMV

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Response to Aristus (Original post)

Sat Feb 27, 2016, 09:44 PM

12. Think Like A Doctor

Sounds like a candidate for the NYTimes column.

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Response to Aristus (Original post)

Sun Feb 28, 2016, 03:46 AM

13. With the caveat that it might not help, YMMV.

Last edited Sun Feb 28, 2016, 10:57 AM - Edit history (1)

glycine in the evening may improve their sleep quality.

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Response to Aristus (Original post)

Sun Feb 28, 2016, 04:36 AM

16. I like the image of the mad scientist..

Last edited Sun Feb 28, 2016, 10:52 AM - Edit history (1)

Back in the day, more than 20 years ago while I was trying to go to school and support myself with three jobs, I needed to work on weekends, so for a long time I mixed up amino acid laced smoothies for club-goers. So I have a lot of experience as a mad scientist, and can pull the mad scientist act off well.

I was lucky because I already had a lot of knowledge from my circle of friends who would feed me information in the form of printouts from scientific journals and the UC Library system catalogue for scientific and medical journals. Now of course those references would be to PubMed IDs.

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Response to Aristus (Original post)

Sun Feb 28, 2016, 06:23 AM

17. House would treat him for narcolepsy before confirming and see if he got better (nt)

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Response to Aristus (Original post)

Mon Feb 29, 2016, 07:20 PM

18. on behalf of those of us with rare diseases, THANK YOU!!

Thank you for not giving up. I have Ehlers danlos (types1 & 3) and lipedema.

That said, have you ruled out POTs or hypokalemia? POTS is easy to test for. I'm 51 and just began having serious symptoms about a year ago.

Good luck and thank you for thinking outside of the box.

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