Wednesday, December 9, 2009

Questions to Prepare for a PCP Visit Regarding Back Pain

If you are visiting your Primary Care Physician about back pain, make sure your visit covers as many possibilities as you can. Filling out this form in advance and taking it with you will help;

Allergies: _________________________ Medications currently taking: __________________________________________________________________
Are you pregnant? When was your last period?

When did the pain start- (acute <6 weeks chronic > 3 months acute on chronic etc.

What happened?
Injury/trauma/overuse twisting lifting bending etc.
Have you had this kind of pain before-
If you have, is there anything different about this pain-
Describe the severity of the discomfort on a scale of 1-10 10 being the worst pain imaginable, how bad is it at its;
On average
How long does it usually stay at the different levels etc;

What does it feel like- quality – sharp or dull, burning, ache, stabbing, cramping/spasms, shock like etc –

Where is the pain area / size of pain- Draw a picture and put “x”s where it hurts and “o”s where it might radiate
Does the pain move around or radiate anywhere or stay in one area-
Is it only in the center? Across the back? Down one leg R or L ? or both and how far down the leg does it go?

Constant- Intermittent-
Change as time progresses since started- getting better worse or the same
Timing issues that affect pain-
Menses or part of cycle- no association
Having bowel movement or bearing down- when was your last BM?
Taking a deep breath
Standing, walking or bouncing/ hopping
Does it hurt when you push on the area where you are feeling discomfort?

Things that make better- positions or activities
Things that make it worse- moving in certain positions etc.

Any weakness in your legs, feet or ankles?
Back pain triage questions page 2

Does your foot slap or flop when you walk?

Associated other signs or symptoms?

Fever chills night sweats weight loss fatigue nausea vomiting diarrhea

Black or bloody stool

Does it wake you from sleep?
Does it keep you awake like a “nagging can’t get comfortable toothache”?

Any bloody or discolored urine?

Any “saddle numbness” in the crotch groin inner thighs?

Pulsatile/heart beat pulsing or tearing nature of the pain?

What if anything have you taken for the pain so far-
Have you recently been taking regular NSAID medications like Advil (Ibuprofen), Aleve (naproxen), aspirin or Rx meds for arthritis or Prednisone/Medrol steroids?

If so what and how many (dose in mg. etc.) and how often are you taking them?

Recent (last 2-3 months) antibiotics or infection like pneumonia urinary tract infection

Previous tests to evaluate pain- Cat Scans, Ultrasounds, Colonoscopy or upper endoscopy Upper or Lower GI tests etc.

What things can you not do now that affect your life due to the pain?
(Could you go to the market and pickup a gallon of milk without needing a shopping cart? Etc.)

History of Present Illness Questionnaire - For Your PCP

Make the most out of a visit with your primary care physician by filling out this form and taking it with you when you go;

Where exactly do you feel the ache- make an outline of the front and back of a person and mark “x”s where you feel the sharpest strongest pain and “o”s where it radiates or if it moves around etc.

Describe the quality of the pain; sharp dull cramping stabbing burning pressure pulling etc and how it changes etc;

Describe the severity of the discomfort, how bad is it at its worst best on average and how long does it usually stay at the different levels etc;

Describe the timing of the pain- day or night? wakes from sleep? constant intermittent? etc;

Describe any factors that seem to modify the pain- make it better or worse and specify if they make it better or worse; eating pooping peeing drinking exertion rest certain activities postures etc;

What if any treatments have you tried so far? Include physical modalities like physical therapy acupuncture etc, over the counter treatments or Rx treatments. Have any of them helped, what hasn’t worked in the past?

What diagnostic tests (specific blood test, X ray, Cat Scan MRI, Stress Test, internal scope procedure or surgical tests etc.) have been done so far to evaluate the problem? Who ordered or did the tests? When were they done and what if anything did they show?

Describe any associated signs or symptoms- fever chills nausea sweats weight loss dizziness shortness of breath belly cramps etc. that seem to come on along with the pain if you have noticed any.

Monday, December 7, 2009

Swine Flu Blues… Part Two 12/7/09

I just got this interesting Email from my State Health Dept. about the scarce H1N1 vaccine.

See my comments in italics;

The Pennsylvania Department of Health has received information from across the commonwealth that indicates many of the individuals in the Centers for Disease Control and Prevention’s (CDC) five priority groups have received the H1N1 vaccine. As a result, the Pennsylvania Department of Health will soon be expanding availability of H1N1 vaccine to any individual who wishes to receive it, even though we will continue to actively encourage persons in the five priority groups to receive it if they have not yet been vaccinated.

Interesting!!! Where are you (The PA Dept of Health) getting your information/ reports?

We just had our family practice department meeting 12/1/09 at our local hospital. Only a small percentage of the primary care doctors had themselves received a dose of the vaccine, primarily from occupational health at the affiliated hospital. There has been no vaccine available for their “at risk” family members, office staff or the vast majority of their patients.

Most of the physician practices that requested and registered for the vaccine months ago (about half the offices) have not received any vaccine, or notification of when or whether they will get any vaccine from the State distribution center PASIIS. When I called PASIIS earlier this week I was told that they did not know if or when I might receive any of the vaccine that I ordered for my practice months ago. I was only told that I would likely get an email from the distributor about 3 days prior to receiving a shipment if my practice was selected to get a supply of the vaccine.

In reality only one family practice office (that I know of) in my county got any vaccine. It just so happens that they are one of the two practices in the county that is designated by the State to do influenza nasal culture surveillance of patients with Flu like illness. Our local State funded Community Health Center had H1N1 vaccine available only for their indigent patients. The Chester County Department of Health has some vaccine from time to time.

I am a Board member of the Chester County Department of Health myself, but was unable to arrange a vaccine for myself or my at risk family members. When I called last week I was told to call back periodically to see when more vaccine became available. Due to scarcity, it would then be distributed on a first call when in stock, first scheduled protocol.

Unfortunately, most of my at risk patients didn’t have the time or knowledge to contact them and register on their web site or call to schedule an appointment to get the vaccine. Currently, due to the scarcity of vaccine allotments from the State and limited staffing, they are scheduling appointments for H1N1 vaccine in 5-6 weeks, well into the New Year.

A patient of mine is the Principal of a large elementary and middle school in my county. She is totally frustrated that after working diligently with the County and State Health Departments for months, that her board denied distributing H1N1 at their facilities due to “liability concerns.” She assumes that few if any of the at risk pupils have or will ever get a dose of H1N1 vaccine.

So, it is very interesting to hear from the powers that be in the State Health Department that so “many of the high risk candidates state wide have received vaccine” that those facilities who currently have vaccine can give their doses to whomever asks for it regardless of risk.

I can only surmise that the “information received from across the commonwealth” has come from employees of County and State run distribution centers that don’t cater to the same patient populations as community based physician practices. I am also sure that demand has been low within these State and County run facilities due to the non consumer friendly manner in which the vaccines have been distributed.

So, Happy Holidays to my at risk children, wife, at risk office staff and all of my at risk patients. We are not and likely won’t get the H1N1 vaccine in 2009 nor likely in 2010. I got my vaccine dose at my hospital's occupational health department as a good doctor should but have no access to vaccine for all those others I care for at risk.

The Department will be taking this step because we anticipate significant increases in the amount of vaccine allocated to Pennsylvania in the coming weeks. However, before the offer of vaccine is extended beyond the five ACIP priority groups, the Department of Health thinks it is important to assure that health care facilities and other providers are provided the opportunity to complete vaccination of their priority populations.

If you are a certified provider and have not yet received H1N1 vaccine, or sufficient doses to complete your program, please provide us with the number of doses you still require to assure vaccination of your patients in the five priority groups. To do this, you do not need to formally place an order for additional vaccine.

If you have completed your vaccination activities among the priority groups and still have remaining doses, the Department suggests that you now begin to use these doses to vaccinate persons outside of the priority groups.

Please contact the Department of Health by email at with the name of the facility, which ACIP priority group served, contact person and phone number, and number of doses needed.

When the community based doctor’s offices that placed our orders for the H1N1 vaccine a few months ago, we estimated or exactly counted the number of our patients who were in the at risk categories and based our order based on these numbers. We assumed we would get priority shipment of vaccine. Since the allocation of vaccine has been seemingly political or random at best, it is very difficult to know how many of our patients received vaccination at their schools, at State and County health centers etc.

Sunday, December 6, 2009

Altitude Sickness - Prepare to Get High

There's not much you can do to prevent this problem -- though there are ways you can ease its effects. Being at a high elevation is stressful to your body. The concentration of oxygen is 21% at both sea level and at higher altitudes, but the decreasing air pressure at higher elevations means you get significantly fewer oxygen molecules per breath once you go over about 8,000 feet.

Before your trip, make an effort to hit the gym more often, or do a few extra laps at the track. This can minimize the dizziness, fatigue, shortness of breath, nausea, and headaches that signal altitude sickness. Fitness at sea level doesn't guarantee an easier time when you're 2 miles high. But being in good shape makes it more likely that your lungs will be able to cope.

Ease the body's transition to higher altitudes once your trip begins. If you're going higher than 8,000 feet, take it slow. When you arrive, try to let your body acclimate for a day or two. When hiking up to 15,000 feet or more, spread out your ascent over a period of two or three days to give your body more time to adapt. And once on your trip, watch what you eat and drink. You'll want your respiratory system operating at full capacity, so avoid alcohol and any drugs that might interfere with your breathing, such as sleeping medications.

If your symptoms are severe, a prescription drug called Diamox/acetazolamide 250mg 2-4x a day # 10 may help. It works by stimulating your breathing, so that you take faster and deeper breaths. Ideally the first dose can be taken 24-48 hours before ascent at the twice a day schedule. Alternatively, It can be taken on a plane several hours before arrival or at the airport before departure. Then, it can be taken 2-4x a day for up to the first two days (48 hours) at altitude.

However, Diamox is a powerful medication, so it's best to avoid it if you can. Side effects include increased urination and tingling of the fingers and toes; it may also make carbonated drinks taste flat. People with allergies to sulfa drugs should not take Diamox. As always, discuss any allergies with your doctor before you start any new medications. Also discuss if you are pregnant or may become pregnant.

If your symptoms become more pronounced and include severe shortness of breath, mental disorientation, or disturbed balance, return to a lower altitude immediately. The air up there just isn't for everyone.

Sleeping with your head elevated and avoid over eating though your appetite will likely be quite supressd once at altitude. Spend the first day and night after arriving at altitude resting and taking it easy to help acclimate.

Have medication in case you get a migraine headache or nausea and vomiting just in case as well. Triptans for migraine if OK with your doctor and a Phenergan/promethazine Suppository 25mg #6 1-2 per rectum every 6 hours as needed prescription might really help you out in a pinch.

Thanks to John West MD PhD for his input

Thursday, December 3, 2009

Treatable Dementias

Although this article is filled with med-speak (sorry patients and friends), it is one I wrote about an issue I am passionate about.

Diagnosis and treatment of some of these diseases that lead to impaired cognition and thinking will slow down or in some cases reverse dementia symptoms to a varying degree. If you or someone you are close with is exhibiting signs of loss of memory and becoming functionally impaired, consider sharing this list with their primary care doctor (if it isn't me)  in the evaluation of potentially treatable conditions that may prevent further irreversible brain damage. Most of these conditions are rare but they should be considered by your doctors at the same time that a diagnosis of Alzheimer’s type dementia is entertained and treated. Treatments for Alzheimer’s type dementia generally will not result in further aggravating these secondary causes of dementia, so it is OK to start treatment for this most common type of dementia while evaluating and investigating for these other more rare causes.

1)      Mass lesions: tumors, and hematomas seen by getting a CAT SCAN of the head or MRI- usually large or in critical areas causing easily seen changes by the time they cause dementia.
2)      Hydrocephalus: Normal Pressure Hydrocephalus (NPH) other communication and obstructive causes.
3)      Infections: Syphilis, parasites, AIDS, Lyme disease can cause slow onset dementias
4)      Demyelinating diseases: MS, and MS imitators (especially collagen vascular diseases)
5)      Metabolic disorders:
-          Acquired- the usual suspects- Vitamin B12 deficiency, advanced liver kidney glucose and electrolyte imbalances, hypothyroid disorder ( basic chem. 20, CBC, TSH, B12, SED Rate etc blood tests)
-          Inherited: Wilson’s Disease, etc- rare
6)      Pseudodementia (especially depression)
7)      Other neurodegenerative conditions- treated like Alzheimer’s disease
8)      Vascular dementias: treated with cholesterol, blood pressure and blood sugar control in diabetics
-          Cortical: multiple medium to large strokes- significant rapid step like losses of function- classic vascular dementia
-          Sub cortical; True Binswanger’s disease asn other disorders of leukoariasis- (“UBOsis” on MRI) – diffuse small vessel arterial disease
-          CADASIL (cerebral autosomal-dominant arteriopathy with sub cortical infarcts and leukoencephalopathy); the notch3 gene mutation
9)      Collagen-vascular diseases
- Rheumatoid arthritis, Systemic Lupus, Systemic Scleroderma, Polymyositis/Dermatomyositis, Polyarteritis nodosa, etc.

Mini mental screening 30 point test;
21-26 mild, < 20 moderate < 1-10 severe
Cerefolin NAC for pre dementia Mild Cognitive Impairment

Wednesday, December 2, 2009

Electronic Medical Records - The Trouble with Tribbles

Electronic medical records (EMRs) are slowly transforming the delivery of healthcare. EMRs are intended to securely keep track of a patient's entire medical history in a computerized format. By keeping these records electronically, they are easily accessible; have the potential to help identify the most cost effective treatments; and can make navigating through the healthcare system much safer and more efficient.

The potential benefits of EMRs, such as substantial healthcare savings and the ability to share a patient's health information to avoid unnecessary testing and prevent medication errors, sounds appealing to most physicians yet many healthcare providers remain hesitant to implement an EMR system.

One of the challenges of implementation is cost. Although financial incentives are being offered by the Medicare Program and President Obama's Stimulus Package, there are still significant expenses involved for physicians with the purchase of software, infrastructure, installation, and maintenance. Indirect costs are also realized in training staff on data management and entry. "Medical decision making" data entry, in particular, is very time consuming and by far the most expensive aspect of converting to electronic records.  There are huge amounts of older patient data stored at insurance companies, hospitals, pharmacies, and laboratories that need to be cultivated, shared, and checked for accuracy by the patient with the help of a skilled clinician in order to have a complete patient profile.

Incorrect information can lead to a cascade of inefficiencies.  If a patient is wrongly identified as having an allergic reaction to X-ray dye, for example, a red flag alert comes up on the chart anytime the patient goes to a medical facility. If an emergency situation arises where the best test requires the use of X-ray dye, hours are wasted trying to identify the truth and avoid liability. Currently, even if identified, there are few mechanisms available to correct this misinformation in organizational computer systems.

An experienced primary care provider who knows the patient well and has all medical information flowing through their office is the obvious entity to input and screen new information important for medical decisions. Primary care shoulders the largest burden of "raw" data vetting and, therefore, the cost of implementing an EMR. Unfortunately, these are the same practices that are the least financially capable of absorbing these expenses.

Another challenge of physician office based EMRs is the inability to collaborate back and forth with local labs, hospitals, and other doctor's offices. Any interconnected central repository that could communicate effectively in a standard medical decision based format is still many years away from being a reality. The potential is real, but it will need strong leadership and national standards to achieve this lofty goals.

Currently, less than 30 percent of physicians have installed an EMR system. So, if a physician seems slow in adopting health information technology, show some compassion.