tag:blogger.com,1999:blog-56812599805895663042024-02-07T23:30:03.399-05:00Doctor Murdoch - Personal PhysicianAnonymoushttp://www.blogger.com/profile/00508849128984146799noreply@blogger.comBlogger23125tag:blogger.com,1999:blog-5681259980589566304.post-44221196163712450712018-03-13T17:30:00.000-04:002018-03-13T17:56:28.425-04:00Celiac Disease and Osteoporosis<br />
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<span style="background-color: transparent; font-family: "calibri"; font-size: 11pt; font-style: normal; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"><b><span style="color: #0b5394;">The Pearl</span></b></span></h2>
<div dir="ltr" style="line-height: 1.295; margin-bottom: 8pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "calibri"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre;">If you are diagnosed with Celiac Disease and osteoporosis, the Celiac Disease should be treated first, </span><br />
<span style="background-color: transparent; color: black; font-family: "calibri"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre;">through a strict gluten restricted diet for at least 3 months. Your physician should be sure that you have a </span><br />
<span style="background-color: transparent; color: black; font-family: "calibri"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre;">restored normal level of vitamin D (which can be measured by a vitamin D 25-OH blood test) before </span><br />
<span style="background-color: transparent; color: black; font-family: "calibri"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre;">considering starting treatment of your osteoporosis. </span></div>
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<span style="background-color: transparent; color: black; font-family: "calibri"; font-size: 11pt; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"><i><b>Why?</b> </i></span><span style="background-color: transparent; color: black; font-family: "calibri"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre;"> Because the medications we use to treat osteoporosis; Forteo, a bisphosphonate like Boniva, </span><br />
<span style="background-color: transparent; color: black; font-family: "calibri"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre;">Fosamax, and Reclast, or a Rank Ligand monoclonal antibody like Prolia, can lead to severe even life </span><br />
<span style="background-color: transparent; color: black; font-family: "calibri"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre;">threatening low levels of circulating blood calcium (hypocalcemia). This can cause seizures, </span><br />
<span style="background-color: transparent; color: black; font-family: "calibri"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre;">muscle spasms, and cardiac arrhythmias that are potentially fatal. </span></div>
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<span style="background-color: transparent; color: black; font-family: "calibri"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre;"><br /></span></div>
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<span style="color: #0b5394; font-family: "calibri";"><span style="background-color: white; font-size: 14.666666984558105px; white-space: pre-wrap;"><b>More Explanation</b></span></span></h2>
<div dir="ltr" style="line-height: 1.295; margin-bottom: 8pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "calibri"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre;">Celiac Disease is a condition that is associated with an immune overstimulation process that starts in the </span><br />
<span style="background-color: transparent; color: black; font-family: "calibri"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre;">small intestine lining in response to a specific type of gluten. Gluten is a common plant protein storage </span><br />
<span style="background-color: transparent; color: black; font-family: "calibri"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre;">molecule, but the particular gluten molecule produced by Wheat, Barley, and Rye are problematic for a </span><br />
<span style="background-color: transparent; color: black; font-family: "calibri"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre;">small subset of genetically predisposed persons. </span></div>
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<b><span style="font-family: "calibri"; font-size: 11pt; vertical-align: baseline; white-space: pre-wrap;"><i>How common is this?</i></span><span style="font-family: "calibri"; font-size: 11pt; vertical-align: baseline; white-space: pre-wrap;"> </span></b><span style="font-family: "calibri"; font-size: 11pt; vertical-align: baseline; white-space: pre-wrap;"> Forty percent of the population carries one or both susceptibility genes, yet less that one in a hundred persons develop Celiac Disease. In this subset, grain glutens result in inflammation throughout the body, but especially inside the lining of the small intestine. This “enteropathy” and inflammation can lead to many other problems throughout all the bodies systems. </span></div>
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<span style="background-color: transparent; color: black; font-family: "calibri"; font-size: 11pt; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"><b><i>Why is celiac disease related to osteoporosis?</i></b></span><span style="background-color: transparent; color: black; font-family: "calibri"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre;"> Inflammation excess itself can lead to damage to the </span><br />
<span style="background-color: transparent; color: black; font-family: "calibri"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre;">skeletal bones through remodeling imbalances, where not enough new bone is laid down and too much </span><br />
<span style="background-color: transparent; color: black; font-family: "calibri"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre;">existing bone is resorbed back into the blood stream from existing bone. Add to this the malabsorption of </span><br />
<span style="background-color: transparent; color: black; font-family: "calibri"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre;">nutrients vitamins and minerals, and you have a perfect storm of risk for those who are suffering from </span><br />
<span style="background-color: transparent; color: black; font-family: "calibri"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre;">Celiac Disease in developing osteoporosis.</span></div>
<div dir="ltr" style="line-height: 1.295; margin-bottom: 8pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "calibri"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre;">Calcium absorption is reduced, and an acquired lactose intolerance from Celiac Disease leads to a lower </span><br />
<span style="background-color: transparent; color: black; font-family: "calibri"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre;">threshold of a person to tolerate dairy products. Vitamin D is poorly absorbed from the diet through the </span><br />
<span style="background-color: transparent; color: black; font-family: "calibri"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre;">inflamed intestine, and, if a person with Celiac Disease feels unwell, they are less likely to exercise or spend time outdoors in natural sunlight to make vitamin D in their skin. </span></div>
<span id="docs-internal-guid-d2a630f3-213b-1fb3-40a8-bcbdc523f7d1"></span><br />
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<span style="background-color: transparent; color: black; font-family: "calibri"; font-size: 11pt; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"><b><i>What else should I know?</i></b></span><span style="background-color: transparent; color: black; font-family: "calibri"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre;"> Dental maturation and enamel, our tooth protective coatings, are reduced </span><br />
<span style="background-color: transparent; color: black; font-family: "calibri"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre;">and often secondary teeth are slow or late to develop. </span></div>
<div dir="ltr" style="line-height: 1.295; margin-bottom: 8pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "calibri"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre;">Over years and decades, even in those without obvious intestinal symptoms of Celiac Disease that might </span><br />
<span style="background-color: transparent; color: black; font-family: "calibri"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre;">otherwise lead to a timely diagnosis, bone does not fully calcify and mature, and the bones natural </span><br />
<span style="background-color: transparent; color: black; font-family: "calibri"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre;">remodeling process is in constant imbalance. Cancellous spongy bone which provides the interior bone </span><br />
<span style="background-color: transparent; color: black; font-family: "calibri"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre;">scaffolding to provide bone strength and resiliency to the outer cortical bone becomes more fragile and </span><br />
<span style="background-color: transparent; color: black; font-family: "calibri"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre;">brittle and less supportive. </span><span style="background-color: transparent; color: black; font-family: "calibri"; font-size: 11pt; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"><i><b>Premature or severe osteoporosis and or fracture may be the first sign that you may have Celiac Disease. </b></i></span></div>
<div dir="ltr" style="line-height: 1.295; margin-bottom: 8pt; margin-top: 0pt;">
<span style="background-color: transparent; color: black; font-family: "calibri"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre;">In the setting of active intestinal inflammation, dietary calcium is poorly absorbed. The body requires a </span><br />
<span style="background-color: transparent; color: black; font-family: "calibri"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre;">very specific and narrow range of calcium to constantly circulate to support cells throughout the body in </span><br />
<span style="background-color: transparent; color: black; font-family: "calibri"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre;">particular nerve, muscle and cardiac/heart cells. Most treatments for osteoporosis stop the body from </span><br />
<span style="background-color: transparent; color: black; font-family: "calibri"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre;">recruiting the bone cells, the osteoclasts, from breaking down existing bone and releasing calcium back </span><br />
<span style="background-color: transparent; color: black; font-family: "calibri"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre;">into the circulation. In common osteoporosis, this leads to beneficial balance of bone remodeling, where </span><br />
<span style="background-color: transparent; color: black; font-family: "calibri"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre;">osteoblasts create new bone and calcium deposits, while inhibiting the activity of the osteoclasts that will </span><br />
<span style="background-color: transparent; color: black; font-family: "calibri"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre;">now greatly reduce their break down the bone and release of calcium stored there. If, however, your </span><br />
<span style="background-color: transparent; color: black; font-family: "calibri"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre;">calcium levels drop, the body automatically absorbs more calcium from the intestines and increases the </span><br />
<span style="background-color: transparent; color: black; font-family: "calibri"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre;">osteoclast activity to breakdown and release stored calcium form the bones into the blood stream. If the </span><br />
<span style="background-color: transparent; color: black; font-family: "calibri"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre;">intestinal inflammation limits intestinal calcium absorption in Celiac Disease, and the osteoporosis </span><br />
<span style="background-color: transparent; color: black; font-family: "calibri"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre;">medications prevent the bone from releasing calcium back into the bloodstream by their very mechanism,</span><br />
<span style="background-color: transparent; color: black; font-family: "calibri"; font-size: 11pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre;">it could spell a recipe for disaster. </span></div>
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Anonymoushttp://www.blogger.com/profile/00508849128984146799noreply@blogger.com0tag:blogger.com,1999:blog-5681259980589566304.post-20039490232189379862013-06-08T16:04:00.001-04:002013-06-08T17:20:04.871-04:00Maximizing Your Healthcare Visits<div class="separator" style="clear: both; text-align: center;">
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In a perfect world, your physician would evaluate all of these things in a single visit. An empowered patient needs to team with their doctor to maximize the completeness of each visit. </div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEguDdTcQxx0BcL-fo-1pnyDTo1yn1pnE7V5WrbWtoTMwcmc1LieTnctP8aZChN4bnfECkVKPh_e_gxs24glH2v36SYRcPzrrlQkEGWv4nD7tbUTgPb041WoMwaFO4Q85dfoMoEzbj_AA8U/s1600/Doctors+Mind-Map+of+an+office+visit.jpeg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEguDdTcQxx0BcL-fo-1pnyDTo1yn1pnE7V5WrbWtoTMwcmc1LieTnctP8aZChN4bnfECkVKPh_e_gxs24glH2v36SYRcPzrrlQkEGWv4nD7tbUTgPb041WoMwaFO4Q85dfoMoEzbj_AA8U/s1600/Doctors+Mind-Map+of+an+office+visit.jpeg" height="492" width="640" /></a></div>
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<span style="font-family: Times, Times New Roman, serif;">Thanks to Rob Lambert, M.D. for the mind map</span></div>
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<span style="font-family: Times, Times New Roman, serif;">Things
that <i><b>you</b> </i>can do to maximize your
visit<o:p></o:p></span></div>
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<span style="font-family: Times, Times New Roman, serif;">Winslow W. Murdoch, M.D.</span></div>
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<span style="font-family: Times, Times New Roman, serif;">Realize that you and your doctor have a limited amount of time to spend on goal setting and problem solving. Evaluating a given problem may take several visits and be done in a sequential way. Many conditions evolve over time, so even the best and brightest doctor and patient may not come up with the correct diagnosis or treatment plan at the first or even third visit. Keeping track of the "story" helps clarify and focus both parties. You will immeasurably help your doctor by relating your story in a way that they are trained to make a diagnosis. See my "History of Present Illness" Questionnaire at the end of this segment.</span></div>
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<span style="font-family: Times, Times New Roman, serif;">Other valuable tools include; </span></div>
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<span style="font-family: Times, Times New Roman, serif;"><span style="text-indent: -27.75pt;"> </span><span style="text-indent: -27.75pt;">Keep a “personal health notebook,” or password protected computer file, where you write down any routine
questions you have for the doctor and take the notebook with you when you go to
your appointment.</span></span></div>
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<span style="font-family: Times, Times New Roman, serif;"><br /></span></div>
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<span style="font-family: Times, Times New Roman, serif;">Better yet, type your notes and ask your doctor’s office if you can
send/share the list via secure email or a patient portal prior to your visit.</span></div>
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<span style="font-family: Times, Times New Roman, serif;"><br /></span></div>
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<span style="font-family: Times, Times New Roman, serif;">If appropriate, Include some blood pressure readings, and make sure to note your range (highest and lowest) as well as average results
of home or community acquired blood pressure results.</span></div>
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<span style="font-family: Times, Times New Roman, serif;"><br /></span></div>
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<span style="font-family: Times, Times New Roman, serif;">Record your weight if this is pertinent to your medical history as
well.</span></div>
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<span style="font-family: Times, Times New Roman, serif;"><br /></span></div>
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<span style="font-family: Times, Times New Roman, serif;">If you have diabetes, and
are monitoring fasting or after meal blood glucose levels, include the ranges
(high and low fasting and after meal readings) and a guesstimate of averages of
the fasting and after meal numbers.</span></div>
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<span style="font-family: Times, Times New Roman, serif;"><br /></span></div>
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<span style="font-family: Times, Times New Roman, serif;">Keep a written record of your medical history and bring it to the
doctor’s office. They will really
appreciate it. They can copy it and put
it in your chart and you should take your copy back home with you.</span></div>
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<span style="font-family: Times, Times New Roman, serif;">Ideally, note all of your medication, food, and environmental allergies, all of your medications (see below) and each substantial medical or other problem on your list. </span></div>
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<span style="font-family: Times, Times New Roman, serif;">It is also very helpful if you are aware of how the problem is controlled and note this after the listed problem; </span></div>
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<span style="font-family: Times, Times New Roman, serif;">Well, not so well, or not at all well, etc.</span></div>
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<span style="font-family: Times, Times New Roman, serif;">Please, always bring a list of
current medications to every visit. The list should include things you take as
needed every once and a while, as well as <i>any
and all</i> vitamins, minerals and supplements.
Be sure to write the dosage and how often you take the medication and
supplements. If this is too hard to do,
bring a bag with all our medications and supplements with you. Prior to the
appointment, call the office and ask if you can arrive 30-60 minutes early
(depending on the size of your bag!) and have a clinical assistant to go
through your bag and make a list before your doctor’s appointment.</span></div>
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<span style="font-family: Times, Times New Roman, serif;">If you are presenting with a
new problem or concern, or a significant worsening of an existing problem, ask
if you can complete or at least review a triage sheet or questionnaire ahead of
your appointment. We maintain a list of these for the more common and serious
problems that we encounter on a daily or weekly basis. In addition, with new acute, or
complex chronic problems we often ask our patients to review and or complete a
“History of Present Illness” form that improves the accuracy of the visit
immensely. </span></div>
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<span style="font-family: Times, Times New Roman, serif;"><br /></span></div>
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<span style="font-family: Times, Times New Roman, serif;">Write down the names and
telephone #s of any specialists you have and take the notebook with you when
you go to see <i>them.</i> </span></div>
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<span style="font-family: Times, Times New Roman, serif;">If you have been hospitalized, gone to the emergency department or urgent care, or to another doctors office or had any lab, radiology or other studies done since you saw your doctor last, call ahead and make sure that your doctor has received results or communication from these outside sources prior to your visit.</span></div>
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History of Present Illness Questionnaire; pg 1 of 3- (in
context of personal and family history) <o:p></o:p><br />
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Name: Date:<o:p></o:p></div>
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When did the problem start?
Describe the onset of the process.<o:p></o:p></div>
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Have you had the problem before? If so, was there a diagnosis made? Was it
exactly the same- what is different now? <o:p></o:p></div>
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If there is pain, discomfort or an unusual feeling, where
exactly do you feel it- see diagram on last page- mark “x”s where you feel the sharpest strongest pain and
“o”s where it radiates or if it moves around etc.<o:p></o:p></div>
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Describe the quality of the pain or unusual feeling; sharp
dull cramping stabbing burning pressure squeezing pulling spasm etc and how it
changes etc;<o:p></o:p></div>
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Describe the severity of the pain or unusual feeling, how uncomfortable
is it (on a scale of 1-10, where 10 is the worst imaginable pain- screaming
with a hot poker in the eye) at its <b>worst, best, on average</b> and how long does it usually stay at the
different levels etc;<o:p></o:p></div>
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Describe the timing of the problem/pain- day or night? Wakes
from sleep? Keeps up all night like a tooth ache, constant intermittent? etc;<o:p></o:p></div>
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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 (walking running hopping up and
down, postures (laying standing sitting bending twisting), sex, taking a deep
breath, bearing down, leaning forward, pushing on certain areas etc;<o:p></o:p></div>
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Describe how if any activities you are unable to do because
of the problem/pain- any disabilities due to the pain?<o:p></o:p></div>
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What if any treatments have you tried so far? Include
physical modalities like Heat Ice Rest Physical therapy acupuncture etc, over
the counter treatments or Rx treatments. Have any of them helped, what hasn’t
worked in the past?<o:p></o:p></div>
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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?<o:p></o:p></div>
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Describe any associated signs or symptoms- fever chills
nausea sweats weight loss dizziness shortness of breath belly cramps skin
changes, swelling redness heat over area etc. that seem to come on along with
the problem if you have noticed any. <o:p></o:p></div>
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<o:p> Draw a diagram of your body that best describes your problems in a schematic way if it applies</o:p></div>
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<span style="font-family: Arial, sans-serif;"><a href="http://images.google.com/imgres?imgurl=http://bestpractice.bmj.com/best-practice/images/bp/694-3-iline_default.gif&imgrefurl=http://bestpractice.bmj.com/best-practice/monograph/694/diagnosis/step-by-step.html&usg=__qfAwO-prNje4hn9FDZkDDGL2Ylo=&h=363&w=353&sz=24&hl=en&start=12&itbs=1&tbnid=T9rvSeogK-JgUM:&tbnh=121&tbnw=118&prev=/images%3Fq%3Dpain%2Bdiagram%26gbv%3D2%26hl%3Den"><span style="color: blue; text-decoration: none; text-underline: none;"><!--[if gte vml 1]><v:shapetype
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href="http://images.google.com/imgres?imgurl=http://bestpractice.bmj.com/best-practice/images/bp/694-3-iline_default.gif&imgrefurl=http://bestpractice.bmj.com/best-practice/monograph/694/diagnosis/step-by-step.html&usg=__qfAwO-prNje4hn9FDZkDDGL2Ylo=&h=363&w=353&sz=24&hl=en&start=12&itbs=1&tbnid=T9rvSeogK-JgUM:&tbnh=121&tbnw=118&prev=/images%3Fq%3Dpain%2Bdiagram%26gbv%3D2%26hl%3Den"
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Form copyright Winslow W. Murdoch, MD</div>
Anonymoushttp://www.blogger.com/profile/00508849128984146799noreply@blogger.com0tag:blogger.com,1999:blog-5681259980589566304.post-4223908479096616412012-06-20T11:35:00.000-04:002013-06-08T17:46:02.239-04:00<span style="font-size: large;"><b>Transitions in Care, a Primary Care Perspective to Reduce Hospital Readmissions</b></span><br />
<br />
Local hospital readmission data mirrors national data. Twenty percent of hospitalized patients are readmitted within 12 days of discharge, 30% within 30 days. Hospital reimbursement has changed to global, not fee for service payment. Hospitals need to create effective ways to prevent readmission. Readmissions also portend poorer outcomes. Therefore, it is our task, to work collaboratively in this process.<br />
<br />
Currently, most patients have no contact with their primary care physician while hospitalized or at the skilled care facility. At discharge, the patient or caregiver is given a few pieces of paper with confusing instructions and a handful of new prescriptions (several are for medications that they already have, and therefore fill none), or a medication sheet is faxed to the skilled care facility with the admission (from the hospitalist who knows little about the patient) and the patient is wished good luck. <br />
Effective factors proven to reduce readmission rates include; <br />
A primary care follow-up visit within a week of discharge, with transportation arranged if it cannot be done by family.<br />
Demonstration that the patient and or caregivers are fully informed and can show understanding by “teach back” techniques as to medication regimen as well as “red flags” indicating deterioration and when to call for help. <br />
Regular daily phone or direct visit contact with someone (Primary care doctor or delegate, nurse, disease manager, or trained member from a community resource) for several days after care transition to home or skilled facility.<br />
Medication adjudication as well as making sure that transition medications are available, affordable, preauthorized, as well as delivered. <br />
Identify frequent fliers arriving in the ER, and provide proactive actions to prevent readmission.<br />
Historically, the health care system has relegated most of this as the often uncompensated responsibility of the primary care provider. <br />
<br />
Now the reality;<br />
The average primary care provider has 2,000 patients and sees 20 patients a day. The average patient comes in 3x a year. So, the doctor can provide 4,200 visits a year. Yet their panel of 2,000 patients will request 6,000 office visits a year. <br />
Add to this the frail elderly patients with some anxiety or cognitive impairment, typically on 10 prescription medicines, with 8 chronic medical conditions (4 of which are co-managed by specialists), who come in with 2 acute problems. These at risk patients need visits 6-10 times a year and each requires significantly more time than 20 minutes. The disconnect gets exponentially wider. <br />
Even before the post hospital visit, as the patient arrives home or in an unfamiliar skilled care facility, the primary care provider gets the call after hours, weekends etc. We are tasked by the patient or concerned family to discuss conditions and prognosis, and review medication changes. <br />
Next, the post hospital office visit is predictably a schedule wrecker, should the provider take ownership of the process. The typical complex patient takes 90+ minutes, which cannot be pre planned for in the 15 minute same day access slot. Often, the discharge summary is not available and must be faxed at the time of the visit. The visit agenda; review all the exams, consultations, labs, diagnostic studies and interventions provided during the stay, assess ability to acquire, take, refill, or pre authorize medications, assess social supports, evaluate emotional linguistic or intellectual barriers to compliance, assess access to transportation, nutritional status, fall risk, the patient or caregivers knowledge of red flags of early deterioration and the medication regimen through the “teach back” process, discuss and document advance directives and care goals, help coordinate follow up labs/diagnositc testing, specialist visits, review, fill out and sign numerous pages of home visiting nurse, PT/OT/Nutritional assessments and correct conflicting medication lists by each agency, and do a physical exam, all in the allotted 15 minutes. <br />
<br />
No surprise then, that the default response to an urgent request of a complex patient for an acute visit or a “red flag” post discharge concern becomes “go to the ER.” <br />
<br />
We need to create a system wide team approach and work collaboratively. Each player needs to be sensitive to the roll and needs of their downstream teammates, and if possible, do as much of the processes as can be done at the time they are interacting with the patient. We need to either off load the downstream expectations of primary care or find ways to vastly improve the resources available to the primary care player’s role in transitions. <br />
<br />
Perhaps resolutions through organized medical societies, hospital, and skilled facility associations can put pressure on the payers and Medicare/Medicaid to consider adequate payment or savings to be shared with community based primary care, thereby supporting involvement in admissions and transitions to and from hospital and skilled care facilities even without face to face contact with the patient. Anonymoushttp://www.blogger.com/profile/00508849128984146799noreply@blogger.com0tag:blogger.com,1999:blog-5681259980589566304.post-40636598452239302312011-04-28T18:46:00.000-04:002011-04-28T18:46:06.950-04:00Tips for Managing AnxietyTips for Managing Anxiety <br />
<br />
Contributed by <br />
Dr Emma Mellon, PhD <br />
<br />
It helps to remember that anxiety affects almost 40 million Americans annually. It’s a very American complaint.<br />
• Anxiety is an emotion, and most of the time, does not respond to logic or self-criticism. <br />
• Accept that you’re feeling anxious. You can’t move beyond something if you deny you’re feeling it.<br />
• Breathe. Deeply and slowly. Our bodies are designed to manage anxiety if we give them the chance.<br />
• Breathe again, deeply and slowly. Follow the breath in and out for 10 breaths. Concentrate on your breath as if you’ve never felt breathing before.<br />
• Get back in touch with the present moment. Use your senses to steady yourself and anchor yourself in the here and now. See, hear, feel, touch, listen. Breathe.<br />
• Take a time out. Do something completely unrelated. Stretch, walk, yawn (very, very relaxing!), sing, play a game of Free Cell. And yes, breathe.<br />
• As you begin to settle again into a calmer body-mind, decide if you need to attend to the anxiety producer right now. Decide what resources you need – people, information, time, etc. – to handle the source of the anxiety. <br />
<br />
<br />
Come to your senses<br />
<br />
Look. Listen. Smell. Touch. Taste. <br />
<br />
Our senses are built-in tools for managing anxious feelings. Before or after an anxiety- producing encounter, take time to use your senses to refresh yourself, and anchor yourself in the here and now. <br />
<br />
I suspect we use the sense of taste more frequently than the other senses in an effort to quell our anxieties. Chocolate, Potato chips. Mmmm. The temporary solutions.<br />
<br />
Less problematic foods work, too, since the result comes less from the sugar and salt, and more from the act of consciously focused attention. Taste something. Concentrate on the experience.<br />
<br />
Look around. Notice shapes and colors, movement and stillness. Notice the difference you feel when you look at yellow, as opposed to grey. <br />
<br />
Listen, really listen to your favorite artist, or to rain, or silence, or you own footstep. Allow sound to come to you.<br />
<br />
Touch and notice texture, temperature, and the quality of surface. Hold and ice cube in your hand. Touch denim or a steering wheel. <br />
<br />
Smell. Take a deep breath and focus on a scent. Lavender can be very soothing, but you may have your own favorites: cinnamon, grass, leather.<br />
<br />
By exercising your senses, you are returning to the solid present and to the supportive system of your physical body which has intelligences for soothing and calming beyond the capabilities of the rational intellect.Anonymoushttp://www.blogger.com/profile/00508849128984146799noreply@blogger.com0tag:blogger.com,1999:blog-5681259980589566304.post-8851398884139157552011-03-24T21:30:00.000-04:002011-03-24T21:30:40.207-04:00Texting & Tweeting Shorthand for Seniors and Middle Aged Doctors Like MeATD: At The Doctor's<br />
<br />
BFF: Best Friend Fell<br />
<br />
BTW: Bring The Wheelchair<br />
<br />
BYOT: Bring Your Own Teeth<br />
<br />
CBM: Covered By Medicare<br />
<br />
CUATSC: See You At The Senior Center<br />
<br />
FWBB: Friend With Beta Blockers<br />
<br />
FWIW: Forgot Where I Was<br />
<br />
FYI: Found Your Insulin<br />
<br />
GGPBL: Gotta Go, Pacemaker Battery Low!<br />
<br />
GHA: Got Heartburn Again<br />
<br />
IMHO: Is My Hearing-Aid On?<br />
<br />
LMDO: Laughing My Dentures Out<br />
<br />
LOL: Living On Lipitor<br />
<br />
LWO: Lawrence Welk's On<br />
<br />
OMMR: On My Massage Recliner<br />
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ROFL... CGU: Rolling On The Floor Laughing... And can't Get Up<br />
<br />
TTYL: Talk To You Louder<br />
<br />
WAITT: Who Am I Talking To?<br />
<br />
WTP: Where's The Prunes?<br />
<br />
WWNO: Walker Wheels Need Oil<br />
<br />
LMGA: Lost My Glasses Again<br />
<br />
GGLKI =Gotta Go, Laxative Kicking InAnonymoushttp://www.blogger.com/profile/00508849128984146799noreply@blogger.com0tag:blogger.com,1999:blog-5681259980589566304.post-32937446178036502002011-01-20T20:00:00.004-05:002011-01-20T20:03:51.775-05:00New Year's Resolutions<object width="340" height="160"><param name="movie" value="http://www.mainlinehealth.org/vid/swf/pbPlayer.swf"></param><param name="allowFullScreen" value="true"></param><param name="allowscriptaccess" value="always"></param><param name="FlashVars" value="video=http://www.mainlinehealth.org/vid/uploads/murdoch(4).flv&vidicon=http://www.mainlinehealth.org/vid/icons/large/8c6cb323d63e4052a5e8029aa848bcf2.jpg&autostart=true&playerURL=http://www.mainlinehealth.org/vid/swf/pbPlayer.swf&captionsURL=http://www.mainlinehealth.org/vid/captions/&captionsEnabled=false&siteURL=http://www.mainlinehealth.org/OTH/Page.asp?PageID=OTH005506"</param><embed src="http://www.mainlinehealth.org/vid/swf/pbPlayer.swf" width="340" height="160" allowScriptAccess="sameDomain" allowFullScreen="true" type="application/x-shockwave-flash" pluginspage="http://www.adobe.com/go/getflashplayer" FlashVars="video=http://www.mainlinehealth.org/vid/uploads/murdoch(4).flv&vidicon=http://www.mainlinehealth.org/vid/icons/large/8c6cb323d63e4052a5e8029aa848bcf2.jpg&autostart=true&playerURL=http://www.mainlinehealth.org/vid/swf/pbPlayer.swf&captionsURL=http://www.mainlinehealth.org/vid/captions/&captionsEnabled=false&siteURL=http://www.mainlinehealth.org/OTH/Page.asp?PageID=OTH005506" /></object>Anonymoushttp://www.blogger.com/profile/00508849128984146799noreply@blogger.com0tag:blogger.com,1999:blog-5681259980589566304.post-63797519199207530932010-10-17T17:25:00.000-04:002010-10-17T17:25:10.163-04:00When High Blood Pressure Is Hard To Control......Resistant Hypertension<br />
<br />
The average person with high blood pressure is on 2.3 medications. Up to 30% of this population has “resistant hypertension,” defined as blood pressure that is above goal despite the use of three or more appropriate blood pressure medications at maximal doses, with one being a diuretic or “water pill.” <br />
<br />
Causes <br />
Obesity, excess salt intake, excessive alcohol use, having diabetes, being over 75, having left ventricular hypertrophy (thickened walls of the heart on EKG or heart ultrasound), obstructive sleep apnea (loud snoring and daytime drowsiness) or chronic kidney disease all contribute. Medications like Non Steroidal Anti Inflammatory Drugs (high doses of aspirin, ibuprofen, or naproxen), stimulant compounds (for ADHD, decongestants, and diet drugs), oral contraceptives, herbal preparations containing ephedra, and some injected anemia treatments can elevate blood pressures.<br />
<br />
Falsely elevated readings occur when the cuff is too small for a patient's arm girth, by not getting a resting value, by poor compliance with medications, or by anxiety. Some older patients have heavily calcified arteries, and it is best to also check the pulse at the wrist when evaluating the real blood pressure.<br />
<br />
Those who are resistant to control should be screened for secondary forms of hypertension, including kidney disease, kidney artery narrowing, and primary aldosteronism (an excess stress hormone). Less common causes of resistance include Cushing's syndrome, pheochromocytoma, hyperparathyroidism, intracranial tumors, and aortic coarctation (ask your doctor to consider these).<br />
<br />
Evaluation <br />
Blood pressure should be measured repeatedly with a proper-size cuff using good technique. Make sure that you are taking all medications as directed. Drugs that may interfere with blood pressure control should be discontinued, if possible. <br />
<br />
A physical exam should look for damage in the retina (back of the eye), arterial blockages/narrowing, features of Cushing's syndrome, and a blood pressure checked in both arms. If you are anxious, blood pressure readings at home or work, or ambulatory blood pressure monitoring, should be considered.<br />
<br />
Lab evaluation to look for secondary causes should now be considered to include basic labs and urine testing, first morning aldosterone/renin stress hormone levels, activities and ratios. Also, a 24-hour urine test can be obtained if there is a history of severe spikes in pressure with sweating and headache. Imaging tests for kidney artery narrowing can be considered in young patients with severe hypertension, and in older patients with vascular disease. In most cases, no secondary cause is found because the cause is often multifactorial.<br />
<br />
Treatment <br />
Lifestyle modification with a low-salt, high-fiber, low-fat diet; weight loss; moderation of alcohol intake; and exercise should be encouraged. Treatment of sleep apnea should be started. Medication regimens should be simplified, making compliance easier.<br />
<br />
Blood pressure can often be improved by increasing the dose or changing to a more potent diuretic. In patients with chronic kidney disease, the use of a strong diuretic used twice a day can help. Adding diuretics like spironolactone or amiloride may have additional benefit. <br />
<br />
If blood pressure remains elevated despite the above, referral to a hypertension specialist is recommended.Anonymoushttp://www.blogger.com/profile/00508849128984146799noreply@blogger.com0tag:blogger.com,1999:blog-5681259980589566304.post-4748286163878309752010-09-04T15:39:00.000-04:002010-09-04T15:39:02.443-04:00Nocturnal Leg Cramps<meta content="" name="Title"></meta> <meta content="" name="Keywords"></meta> <meta content="text/html; charset=utf-8" http-equiv="Content-Type"></meta> <meta content="Word.Document" name="ProgId"></meta> <meta content="Microsoft Word 2008" name="Generator"></meta> <meta content="Microsoft Word 2008" name="Originator"></meta> <link href="file://localhost/Users/dbmurdoch/Library/Caches/TemporaryItems/msoclip/0clip_filelist.xml" rel="File-List"></link> <style>
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<div class="MsoNormal"></div><div class="MsoNormal">There are no FDA approved treatments for leg cramps and the non prescription and prescription treatment options are more from individual experiences and not from large trials proving effectiveness or safety. </div><div class="MsoNormal"><br />
</div><div class="MsoNormal">That said, here are some options- trial and succeed but you may need a few trials…</div><div class="MsoNormal"><br />
</div><div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">1)<span style="font: 7pt "Times New Roman";"> </span>Nighttime leg stretches of the most prone muscle groups- gentle stretch tension not bouncing- hold for count of twenty and repeat 3-5 x</div><div class="MsoNormal"><br />
</div><div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">2)<span style="font: 7pt "Times New Roman";"> </span>B complex- B 50 3x a day- over the counter</div><div class="MsoNormal"><br />
</div><div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">3)<span style="font: 7pt "Times New Roman";"> </span>Magnesium supplements if OK with your doctor Slo Mag or Mag Ox are over the counter 1 1-2x a day- </div><div class="MsoNormal"><br />
</div><div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">4)<span style="font: 7pt "Times New Roman";"> </span>Consider trial of a week or two or three off Statin cholesterol medication if you are taking them</div><div class="MsoNormal"><br />
</div><div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">5)<span style="font: 7pt "Times New Roman";"> </span>Diltiazem immediate release 30mg at bedtime</div><div class="MsoNormal"><br />
</div><div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">6)<span style="font: 7pt "Times New Roman";"> </span>Escalating doses of gabapentin from 100mg up to 600mg as a bedtime dose- may take a few weeks to improve symptoms</div><div class="MsoNormal"><br />
</div><div class="MsoNormal" style="margin-left: 0.5in; text-indent: -0.25in;">7)<span style="font: 7pt "Times New Roman";"> </span>Quinine has been used with mixed success (if any, but some patients swear by it) for many decades. It has recently been given a black box warning as it carries a 1 in 110—1 in 200 chance of severe blood clotting, bleeding and or bone marrow toxicity risk which could prove disabling or fatal. It is an option as a short term (1-2 months to see if it helps) trial only when all else has failed and the symptoms are so severe that the patient is willing to take a risk similar to base jumping (parachuting from cliffs and tall buildings), an extreme sport, to get relief.</div><div class="MsoListParagraph"><br />
</div>Anonymoushttp://www.blogger.com/profile/00508849128984146799noreply@blogger.com0tag:blogger.com,1999:blog-5681259980589566304.post-61958882421144955652010-03-13T17:13:00.001-05:002010-03-13T17:21:23.209-05:00About Kidney Stones<meta content="" name="Title"></meta> <meta content="" name="Keywords"></meta> <meta content="text/html; charset=utf-8" http-equiv="Content-Type"></meta> <meta content="Word.Document" name="ProgId"></meta> <meta content="Microsoft Word 2008" name="Generator"></meta> <meta content="Microsoft Word 2008" name="Originator"></meta> <link href="file://localhost/Users/dbmurdoch/Library/Caches/TemporaryItems/msoclip/0/clip_filelist.xml" rel="File-List"></link> <style>
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</style> <![endif]--> <!--StartFragment--> <div class="MsoNormal">What are kidney stones? </div><div class="MsoNormal"><br />
</div><div class="MsoNormal">A kidney stone is a hard gravel-like mass in the kidney, ureter tube from the kidney to the bladder or in the urethra tube that passes urine out of the body. Kidney stones are usually made of mineral salts (most commonly calcium but sometimes uric acid, the gout chemical).</div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><br />
</div><div class="MsoNormal">What should I know and do for kidney stones?</div><div class="MsoNormal"><br />
</div><div class="MsoNormal">Symptoms include:</div><div class="MsoNormal"><br />
</div><div class="MsoNormal">Pain that usually begins suddenly and commonly comes in waves of intensity </div><div class="MsoNormal">Pain that is in the back or flank and seems to move to the lower abdomen, groin or legs</div><div class="MsoNormal">Dark or bloody urine</div><div class="MsoNormal">Take medication exactly as directed. </div><div class="MsoNormal">Do not drive while taking these pain medicines. </div><div class="MsoNormal">Drink at least 2-3 quarts of fluids a day (water is best) to flush out the particle(s). Reverse osmosis filtered water for drinking water has much less mineral content and might be helpful for long term use.</div><div class="MsoNormal">Strong Narcotic pain medications as well as Ibuprofen if approved by your doctor help manage pain. </div><div class="MsoNormal">Also, at a recent Urologic conference studies were presented that found Medical expulsive therapy with off label use of (non FDA approved use for kidney stones) steroids, nifedipine calcium channel blocker, Flomax (tamsulosin), (as well as considering a low dose Viagra type medication) as a potential powerful tools to reduce acute painful stones working their way down when the stones are smaller than 10mm and certainly if 3-5mm.</div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><br />
</div><div class="MsoNormal">What should I do if I think I have kidney stones?</div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><br />
</div><div class="MsoNormal">Strain your urine so that you can catch the stone if and when it passes. Cheesecloth works well for this, as does any porous clothing material. If you do catch the stone or little chunks of sand or gravel, take them to your doctor so it can be analyzed. Your doctor may suggest a diet change based on the type of stones you have.</div><div class="MsoNormal"><br />
</div><div class="MsoNormal">You should have at least an x ray called the KUB as well as routine lab work and a urine analysis and culture with the onset of likely kidney stone. Cat scan without contrast via stone protocol is now the best study to confirm a stone and assess position size and degree of urine tube blockage. The only downside is the cost and the modestly higher radiation dose especially in those with a history of multiple stones so sometimes a simple KUB and ultrasound can be done instead.</div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><br />
</div><div class="MsoNormal">If you are female or have more than one stone or an infection related stone a more thorough investigation including a 24 hour urine test are in order. Also, if you don’t pass a stone within 10-14 days, you should seek help from a urologist as early permanent kidney damage starts to occur when the urine tube is blocked by a stone within 14 days and if fully blocked, a kidney will become non functional by 6 weeks from onset. </div><div class="MsoNormal"><br />
</div><div class="MsoNormal">Stones <4mm have greater than an 80% chance of passing on their own within the 10 day wait period. Stones 4-6mm have about a 60% chance of passing on their own. Stones 6-8mm have a 40% chance of passing and stones >8mm should be referred to an urologist immediately for removal. </div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><br />
</div><div class="MsoNormal">To help prevent formation of kidney stones:</div><div class="MsoNormal"><br />
</div><div class="MsoNormal">If you have more than one kidney stone, especially if you have a family history of stones, you are more likely to have kidney stones again. But you can take steps to help prevent them:</div><div class="MsoNormal"><br />
</div><div class="MsoNormal">Exercise on a regular basis at least 3 times a week</div><div class="MsoNormal"><br />
</div><div class="MsoNormal">Follow diet instructions provided by your doctor</div><div class="MsoNormal"><br />
</div><div class="MsoNormal">Drink more fluids. Try to drink enough water to keep your urine clear, about 8 to 10 glasses of water per day. Slowly increase how much you drink, perhaps adding one more glass of water a day until you are drinking 8 to 10 glasses a day. This slow increase will give your body time to adjust to the extra fluids. You are drinking enough water when your urine is clear or light yellow. If it is dark yellow, you are not drinking enough fluids. If you have kidney, heart, or liver disease and have fluid restrictions, talk with your doctor before increasing how much you drink. </div><div class="MsoNormal"><br />
</div><div class="MsoNormal">Change your diet. This may be helpful, but it depends on what is causing your kidney stones. Your doctor may do more tests before deciding whether changing your diet will help reduce your risk of developing another stone. The results of these tests may suggest that it could be helpful to do one or more of the following: </div><div class="MsoNormal">Increasing how much fiber you eat. Fiber includes oat bran, beans, whole wheat breads, wheat cereals, cabbage, and carrots. </div><div class="MsoNormal">Eating less beef, pork, and poultry. </div><div class="MsoNormal">Eating a moderate or high amount of calcium-rich foods, such as dairy products. Getting your recommended amounts of calcium, combined with a diet low in sodium and protein, may decrease your risk of kidney stones.<a href="http://www.webmd.com/kidney-stones/kidney-stones-references#ug3117"><span style="color: windowtext; text-decoration: none;">7</span></a> In older people and younger women, one study indicates that eating more calcium-rich foods reduces the risk of kidney stones.<a href="http://www.webmd.com/kidney-stones/kidney-stones-references#ug3116"><span style="color: windowtext; text-decoration: none;">8</span></a> </div><div class="MsoNormal">Avoiding foods that are high in oxalate such as dark green vegetables, nuts, and chocolate. </div><div class="MsoNormal">Not adding salt when you cook or eat. Try removing the salt shaker from your table.</div><div class="MsoNormal"><br />
</div><div class="MsoNormal">Medicine</div><div class="MsoNormal"><br />
</div><div class="MsoNormal">If you get more kidney stones despite drinking more fluids and making changes to your diet, your doctor may give you medicine to help dissolve your stones or to prevent new ones from forming. You may also receive medicine if you have a disease that increases your risk of forming kidney stones. Which medicine you take depends on the type of stone you may have.</div><div class="MsoNormal"><br />
</div><div class="MsoNormal">Medicine to prevent calcium stones</div><div class="MsoNormal"><br />
</div><div class="MsoNormal">About 80% of kidney stones are calcium stones.<span> </span>Calcium stones that have already formed cannot be dissolved by changing your diet or taking medicines. There are medicines that may keep calcium stones from getting bigger or may prevent new calcium stones from forming:</div><div class="MsoNormal">Thiazides (such as hydrochlorothiazide, chlorthalidone). </div><div class="MsoNormal">Potassium citrate (Urocit-K). </div><div class="MsoNormal">Orthophosphate (Neutra-Phos). </div><div class="MsoNormal">Cholestyramine (Questran). </div><div class="MsoNormal"><br />
</div><div class="MsoNormal">When and why should I follow up with the doctor?</div><div class="MsoNormal"><br />
</div><div class="MsoNormal">If you have nausea or vomiting and can not keep fluids down.</div><div class="MsoNormal">If you develop more intense pain in the back or abdomen</div><div class="MsoNormal">If you notice blood in your urine or your urine is dark</div><div class="MsoNormal">If you have difficulty passing you urine</div><div class="MsoNormal">If you develop fever or chills</div><div class="MsoNormal"><br />
</div><div class="MsoNormal">Make sure that even if your pain has subsided or that you have passed what you think was the stone that you call your doctor’s office and let your doctor know. Also, find out if any further testing for follow- up is needed. Commonly a CAT scan or an Ultrasound is performed to make sure that there is no hidden blockage of the ureter tube which may lead to painless loss of a kidney over 4-6 weeks time. Lastly depending on the type of stone, the number of stones you have or have had and the size of your stones, your doctor may want you to follow-up for a more detailed evaluation, blood work and 24 hour urine analysis for stone forming tendencies that may have a stronger genetic component and put you at increased future risk of recurrent stones and other seemingly unrelated health problems.</div><div class="MsoNormal"><br />
</div><div class="MsoNormal">Note- high amounts of protein in the diet and high amounts of sodium in the diet force an increase in urinary calcium which then binds to the usually excreted urinary oxalate from dietary sources such as fruits and vegetables and can increase stone risk.</div><div class="MsoNormal"><br />
</div><div class="MsoNormal">Note on pain medications containing Tylenol/acetaminophen:</div><div class="MsoNormal"><br />
</div><div class="MsoNormal">Take medications as directed, never more. Realize that there is acetaminophen in most prescription pain medications, and severe or permanent liver damage can result from prolonged use and after taking higher doses than recommended of this medicine. </div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><br />
</div><!--EndFragment--> <span style="font-family: Cambria;"><o:p></o:p></span></div>Anonymoushttp://www.blogger.com/profile/00508849128984146799noreply@blogger.com0tag:blogger.com,1999:blog-5681259980589566304.post-79289200422093215332010-03-07T09:47:00.000-05:002010-03-07T09:47:55.797-05:00Alternative Headache TherapyTreating the different forms of headache and chronic pain syndromes often requires an individualized approach, utilizing a team of specific professionals to achieve lasting success. Several treatment trials may be required until lasting success is achieved. Using conventional prescription medications until the right nutritional and lifestyle approach is firmly established should be considered in order to decrease suffering and disability. Also, we sometimes need to treat depression or anxiety first in order to remove roadblocks to lifestyle change.<br />
<br />
Treatment of these conditions results in gradual and delayed improvement. Once an adequate response has occurred, we can start to eliminate several of the supplements as long as your diet and lifestyle are back on a healthy track.<br />
<br />
To reduce Pain immediately try laying down in a dark quiet room. Put a cold moist towel over your forehead. Massage your scalp using a lot of pressure. Put pressure on your temples.<br />
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Don’t smoke. If you do, quit.<br />
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Avoid excess alcohol (especially red wine). If you drink more than two alcohol-containing beverages a few times a week or if you binge not infrequently, cut down.<br />
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Avoid caffeine/stimulants. If you drink coffee, tea, sodas, chocolate, cocoa, carob, or take supplements with caffeine, Kola nut, guarana, Ma Huang, or ephedra/sudoephedrine in over the counter diet supplements or decongestant medications, you will need to slowly wean off of these over a few weeks.<br />
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Avoid regular use of pain medications (Excedrin/ibuprofen/Tylenol etc) more than three or four times a week, or combination headache medications like Esgic or Fiorinal on a regular basis.<br />
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Avoid strong odors, bright lights and loud noises. These can all be migraine triggers as can stress, weather change, fatigue, eyestrain, menstruation, loud noises, over exertion, and fatigue.<br />
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Avoid certain foods or food additives Some of these items may be triggers. Try to find out which if any seem to be associated with headache shortly after ingestion; Aged, canned cured, or processed meat (bologna, game, ham, herring, hot dogs, pepperoni, sausage), artificial sweeteners- Aspartamine/Nutrasweet, Avocados, Beans (pea pods, snow peas, pole, broad, lima, Italian, navy, pinto, garbanzo, and lentils), Brewer’s yeast (fresh yeast coffee cake, donuts, sourdough bread), Canned soup or bouillon cubes, most Cheeses especially aged cheese, Cultured dairy like buttermilk and sour cream, Figs, citrus fruits, Meat tenderizer (MSG), Nuts and peanut butter, Onions except for flavoring, Papaya, Passion fruit, Pickled salty or marinated foods (olives, pickles, sauerkraut, soy sauce, seasoned salt), Raisins, and Red plums.<br />
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Avoid missing meals or fasting. If you are overweight, moderate weight loss of five to ten pounds, at a level of a pound or two a week may provide benefit.<br />
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Be aware of symptoms that precede migraine such as fatigue, yawning, excitability, high energy, visual disturbances (flashes sparks, wavey lines, blind spots, and nasal congestion.<br />
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Consider early abortive treatments with Tryptan Rx medication, or Excedrin Migraine as indicated by your doctor. Realize that early treatment might prevent a full blown disabling migraine from blossoming.<br />
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Consider preventive or prophylactic treatments if you need headache medication more than 2 days a week or you are functioning poorly due to any aspect of the migraine spell on a fairly regular basis, you should consider preventive therapies. There are a few FDA approved medicines and a myriad of off label prescription medications in an array of categories such as blood pressure lowering, antidepressant and seizure prevention medications that if taken daily can lessen the severity and or reduce the frequency of migraine headaches.<br />
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Exercise- moderate levels such as a brisk walk outside for thirty minutes five times a week or swimming is very helpful, especially during daylight hours. Advance to include resistance training, stretching, and more intense aerobic exercise as time and tolerance permit. Start with a physical therapist or trainer to avoid injury.<br />
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Maintain consistent sleep/awake hours. Schedules that vary often induce headaches.<br />
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*Magnesium Slo Mag (over the counter), or Mag Ox 400 mg, one pill two times a day.<br />
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Calcium 1,200-1,500 mg per day with Zinc/vitamin D<br />
Calcium citrate with meals two to three times a day- Citrical, Oscal-D, Cal/Mag/Zinc, or nonfat dairy sources, especially from yogurt three to four servings day as well as green leafy vegetables.<br />
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B Complex or multivitamin with Bs-Centrum silver, etc…<br />
<br />
*Take omega 3 fatty acids or Essential Fatty Acids (4-6 grams a day is the suggested range). This ideally it should come from actual fish (salmon, sardines, cod, or small mackerel), walnuts or fresh flaxseed oil has some omega 3 fat but its biological effects may vary. Extracted fish oil capsules are generally distilled and not likely to carry many impurities such as mercury or pesticides etc. Some brands that have less fishy aftertaste are Fisol and Omega Synergy that (can be bought by ordering it on the web at; www.designsforhealth.com or by calling 1-800-847-8302). These can additionally be kept in the freezer further reducing aftertaste issues if present.<br />
<br />
<br />
*Vitamin B2 (riboflavin) may help when taken in higher than the 2mg/day RDA dose. Doses of (200mg 2x a day = 400mg a day) have proven helpful at decreasing headaches over time in many people. It usually takes about 3 months to start working.<br />
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*Feverfew (Tanacetum parthenium) containing greater then 0.2% parthenolide 50-100mg a day has proven to reduce migraines, and prevent recurrent attacks as a maintenance treatment where conventional treatments have been inadequate.<br />
<br />
“MigreLief” combines Magnesium, B2/Riboflavin and Feverfew) 1 tablet twice a day $17 to $25 a month http://www.migrelief.com/FAQ.html <br />
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*Butterbur Petasites Hybridus in extract form known as Petadolex 150mg a day- as published in “Neurology” reduced the frequency of migraines by almost 50%– costs $40- $50 a month.- may cause upset stomach or burping – may also help in asthma and allergies<br />
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*Co-Enzyme Q10 100mg as a gel 3 x a day may reduce headache frequency by a third- worth a try for a month or two. If you find a good source it should only cost $40 a month but can be very expensive.<br />
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Sinus Buster capascin hot pepper nasal spray can help with chronic sinus congestion, sinus and migraine headache control as well as per noted from the Princeton Longevity Center 11/07,<br />
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Acupuncture has proved quite helpful for both acute treatment of pain symptoms as well as the maintenance of more chronic arthritic or inflammatory problems.<br />
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Less well proven approaches that some patients have reported success with include:<br />
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Evaluating for unfavorable bacterial overgrowth in the intestinal tract and removing, replacing, and repopulating and retaining a healthy balance of intestinal flora with probiotic supplements may also play a role in treating more serious inflammatory conditions.<br />
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Detoxification with a combination medical foods and elimination diets may also help achieve a reduction in the inflammatory process causing arthritis and chronic pain. It may also help to detoxify one’s system further reducing inflammation.<br />
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Fatigue- American Ginseng for, 200-2,000 mg per day as needed.<br />
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Insomnia- Chamomile tea and Valerian capsules at bedtime.Anonymoushttp://www.blogger.com/profile/00508849128984146799noreply@blogger.com0tag:blogger.com,1999:blog-5681259980589566304.post-40789310408491536352010-03-04T06:51:00.000-05:002010-03-04T06:51:49.619-05:00Domestic Violence: Protecting Yourself and Your Children<!--StartFragment--> <br />
<h3><span class="Apple-style-span" style="font-weight: normal;">It is much more common than you think.</span></h3><h3>What is domestic violence?</h3>Domestic violence is abuse by a caregiver, a parent, a spouse or an intimate partner. It can take many forms. Here are some types of abuse: Physical abuse is the use of physical force; sexual abuse means any forced sexual activity; emotional abuse includes threats, constant criticism and put-downs. Controlling access to money and controlling activities are other abusive behaviors. <br />
<h3><a href="" name="What_should_I_know_about_domestic_violen"></a>What should I know about domestic violence?</h3>Violence against a partner or a child is a crime in all states. Each year, at least 2 million women are abused in this country. Abuse happens to people of all races, ages, incomes and religions.<br />
People who are hurt by their partners or parents do not cause the abuse. Alcohol and drugs do not cause abuse, although they can make the violence worse. Abuse can begin, continue and increase during pregnancy. <br />
<h3><a href="" name="What_can_I_do_if_my_children_or_I_am_abu"></a>What can I do if my children or I am abused?</h3>First, make sure you and your children are safe. Go to a safe place, such as the home of a friend or a relative or an emergency shelter. Take your children with you. Call the police if you think you can't leave home safely or if you want to bring charges against your abuser.<br />
If possible, take house keys, money and important papers with you. Do not use drugs or alcohol at this time because you need to be alert in a crisis. The staff members at emergency shelters can help you file for a court order of protection. <br />
<h3><a href="" name="What_are_other_ways_I_can_get_help_if_I_"></a>What are other ways I can get help if I am abused?</h3>Talk to your doctor, who can treat any medical problem, provide support and make referrals. Call an emergency shelter and ask about counseling and support groups for you and your children. Nurses, social workers and other health care professionals can also help you. <br />
<h3><a href="" name=""></a>Other Organizations</h3><div class="MsoNormal">Domestic violence center W. Chester 610 431 1430</div><div class="MsoNormal">Crime victims center Inc <a href="http://www.cvcofcc.org/">www.cvcofcc.org</a><span style="mso-spacerun: yes;"> </span>610 692 7420</div><div class="MsoNormal">Crime victims center of Chester Co. Sexual assault 610 692 7273 </div><div class="MsoNormal">Chester Co Legal aid services 610 436 4510 </div>National Coalition Against Domestic Violence<br />
<a href="http://www.ncadv.org/">http://www.ncadv.org</a> <br />
National Domestic Violence Hotline<br />
<a href="http://www.ndvh.org/">http://www.ndvh.org</a> <br />
800-799-7233<br />
<!--EndFragment-->Anonymoushttp://www.blogger.com/profile/00508849128984146799noreply@blogger.com0tag:blogger.com,1999:blog-5681259980589566304.post-73831257675467915062010-02-28T09:38:00.001-05:002010-02-28T19:33:10.217-05:00Patient Centered Medical HomeThis video depicts the patient centered medical home, which was modeled on concierge practice. Watching it will give you an overview of what my practice team does every day for our patients.<br />
<br />
<object height="344" width="425"><param name="movie" value="http://www.youtube.com/v/c5CW-Tun8Is&hl=en_US&fs=1&"></param><param name="allowFullScreen" value="true"></param><param name="allowscriptaccess" value="always"></param><embed src="http://www.youtube.com/v/c5CW-Tun8Is&hl=en_US&fs=1&" type="application/x-shockwave-flash" allowscriptaccess="always" allowfullscreen="true" width="425" height="344"></embed></object>Anonymoushttp://www.blogger.com/profile/00508849128984146799noreply@blogger.com0tag:blogger.com,1999:blog-5681259980589566304.post-68697583390539870732010-02-15T20:29:00.003-05:002010-02-28T21:23:02.215-05:00ALLI - Weight Loss Medication Option<div align="center" class="MsoBodyText" style="text-align: center;"><b><span class="Apple-style-span" style="font-size: small;">Orlistat or Prescription Xenical (over the counter <a href="http://www.amazon.com/Weight-Loss-Orlistat-Capsules-120-Count-Refill/dp/B000OWLNBY/ref=sr_1_1?ie=UTF8&s=hpc&qid=1267409757&sr=8-1">ALLI</a>)</span><span class="Apple-style-span" style="font-size: small;"><o:p></o:p></span></b></div><div align="center" class="MsoBodyText" style="text-align: center;"><b><span class="Apple-style-span" style="font-size: small;"> </span></b><b><span class="Apple-style-span" style="font-size: small;">How it works</span><span class="Apple-style-span" style="font-size: small;"><o:p></o:p></span></b></div><div align="center" class="MsoBodyText" style="text-align: center;"><span class="Apple-style-span" style="font-size: small;"><br />
</span></div><div class="MsoBodyText"><span class="Apple-style-span" style="font-size: small;"><a href="http://www.amazon.com/Weight-Loss-Orlistat-Capsules-120-Count-Refill/dp/B000OWLNBY/ref=sr_1_1?ie=UTF8&s=hpc&qid=1267409974&sr=1-1">Orlistat </a>(Xenical), a novel drug was FDA approved in 1999 for use in those with obesity. It is different than over the counter “fat blockers” which are often soluble fibers (commonly found in psyllium –Metamucil-, beans, fruits and vegetables, especially prunes), chitins, or soap like substances. These may soak up variable amounts of fat or form fat globules in the stomach or a test tube, but the digestive process usually breaks these down later. </span><span class="Apple-style-span" style="font-size: small;"><o:p></o:p></span></div><div class="MsoBodyText"><span class="Apple-style-span" style="font-size: small;"><br />
</span></div><div class="MsoBodyText"><span class="Apple-style-span" style="font-size: small;">This new drug actually chemically binds and inactivates the enzyme that is produced in stomach and pancreatic juices called lipase. Lipase works by cleaving off the fatty fingers from the comb-like dietary fats, breaking the dietary fats down into an absorbable form. By dulling this lipase enzyme, absorption of fat is decreased by over thirty percent. This non-irritating fat passes through the small intestine undigested, and passes in the stool. </span><span class="Apple-style-span" style="font-size: small;"><o:p></o:p></span></div><div class="MsoBodyText"><span class="Apple-style-span" style="font-size: small;"><br />
</span></div><div class="MsoBodyText"><span class="Apple-style-span" style="font-size: small;">There is no significant absorption of Xenical into the blood stream. The medication appears to be harmlessly passed in the stool as well. There are almost no known significant drug-to-drug interactions, making it a safer alternative for those with other medical problems. </span><span class="Apple-style-span" style="font-size: small;"><o:p></o:p></span></div><div class="MsoBodyText"><span class="Apple-style-span" style="font-size: small;"><br />
</span></div><div class="MsoBodyText"><span class="Apple-style-span" style="font-size: small;">More is not better. The standard dose of one pill with each fat containing meal seems to give maximum fat blocking benefit. Conversely, if one eats a nonfat or very low fat meal (for instance bran cereal with skim milk, fruit and a multivitamin for breakfast), there is no weight loss benefit in taking the medication at this time. Xenical should be taken an hour before or up to an hour after eating a fat containing meal.</span><span class="Apple-style-span" style="font-size: small;"><o:p></o:p></span></div><div class="MsoBodyText"><span class="Apple-style-span" style="font-size: small;"><br />
</span></div><div align="center" class="MsoBodyText" style="text-align: center;"><b><span class="Apple-style-span" style="font-size: small;">Cost saving tip</span><span class="Apple-style-span" style="font-size: small;"><o:p></o:p></span></b></div><div class="MsoBodyText"><span class="Apple-style-span" style="font-size: small;">One can save significantly on the cost of this medication by avoiding fat in one or two meals a day, therefore only needing the Xenical once or twice, not three times a day. Fruit, fiber cereal, skim milk and a multivitamin for breakfast, low fat turkey or other healthy choice sandwich (with fat free cheese or mayo) and a V-8 for lunch, and a regular dinner with a Xenical is a cost effective way to save calories and money with this weight loss program. It is best to keep a small store of medication in a wallet or purse compartment for those unexpected meal times. </span><span class="Apple-style-span" style="font-size: small;"><o:p></o:p></span></div><div class="MsoBodyText"><span class="Apple-style-span" style="font-size: small;"><br />
</span></div><div align="center" class="MsoBodyText" style="text-align: center;"><b><span class="Apple-style-span" style="font-size: small;">Side effects</span><span class="Apple-style-span" style="font-size: small;"><o:p></o:p></span></b></div><div class="MsoBodyText"><span class="Apple-style-span" style="font-size: small;">Based on the mechanism of action, there are expected but largely avoidable side effects. These side effects can also be looked at as a major benefit to this weight loss program as it trains the user not to binge on high fat foods or else pay the consequences. Bright orange or brown oily drops are often found floating in the toilet water for several days after a high fat meal. Initially, increased frequencies of BMs are common. At times, a small amount of relatively odorless orange or brown oil may slip out when passing gas, so one needs to be watchful for hygiene, and avoid gas forming foods or take beano to help lessen potentially embarrassing events. Patients on Xenical may need to do periodic “Xenical checks” after passing gas, using a restroom to test wipe. These side effects are generally short lived in the first weeks of starting Orlistat, but may continue for months or recur after a high fat meal. You rapidly become more attuned to throwing out scraps and not finishing the high fat items leftover by the kids or at restaurants. Even so, only about five percent of people tested on the medication stopped it due to side effects. </span><span class="Apple-style-span" style="font-size: small;"><o:p></o:p></span></div><div class="MsoBodyText"><span class="Apple-style-span" style="font-size: small;"><br />
</span></div><div class="MsoBodyText"><span class="Apple-style-span" style="font-size: small;">Theoretically, Xenical may inhibit the absorption of fat-soluble vitamins in our diet. One should therefore take a multivitamin at bedtime or at a time several hours separate from the Xenical to ensure proper nutrition. </span><span class="Apple-style-span" style="font-size: small;"><o:p></o:p></span></div><div class="MsoBodyText"><span class="Apple-style-span" style="font-size: small;"><br />
</span></div><div align="center" class="MsoBodyText" style="text-align: center;"><b><span class="Apple-style-span" style="font-size: small;">Avoiding side effects</span><span class="Apple-style-span" style="font-size: small;"><o:p></o:p></span></b></div><div class="MsoBodyText"><span class="Apple-style-span" style="font-size: small;">One can avoid side effects and improve the weight loss potential from Xenical by decreasing fat and increasing fiber intake. Studies have shown that side effects can be lowered by fifty percent in those on high fiber diets. Before starting Xenical, I suggest you get used to a high fiber diet first. The average American diet has 10-12 grams of fiber per day. We really need 20-30 grams a day. It may take two or three weeks for your intestines to adjust to this high level of fiber. </span><u><span class="Apple-style-span" style="font-size: small;">Only after you have adjusted to a high fiber diet should you start your Xenical treatment program.</span><span class="Apple-style-span" style="font-size: small;"><o:p></o:p></span></u></div><div class="MsoBodyText"><span class="Apple-style-span" style="font-size: small;"><br />
</span></div><div class="MsoBodyText"><span class="Apple-style-span" style="font-size: small;">Whole grain foods as well as beans, fruits and vegetables (and lots of them) are good sources of fiber. Lettuce is not. Cereals (if you can tolerate fat free milk or milk substitutes) such as </span><b><u><span class="Apple-style-span" style="font-size: small;"><a href="http://www.amazon.com/FIBER-ONE-Cereal-Lovers-Bundle/dp/B002SZXUOI/ref=sr_1_9?ie=UTF8&s=hpc&qid=1267410088&sr=1-9">Fiber One</a> or All Bran</span></u></b><span class="Apple-style-span" style="font-size: small;"> (extra fiber or bran buds) are excellent sources of high fiber. Kashi “Go Lean” cereal tends to cause gas but can be tried. You can sprinkle some of your preferred cereal on top of the fiber for flavor. I also suggest adding fruit (other than starchy bananas) for flavor and nutritional value. Other options for those on the go are the Metamucil fiber bars or Citrucel or Fibercon tablets with plenty of water, or you can add the new tasteless powdered soluble “</span><a href="http://www.amazon.com/Benefiber-Natural-Fiber-Supplement-25-6oz-Servings/dp/B000MM2RZM/ref=sr_1_1?ie=UTF8&s=hpc&qid=1267409911&sr=1-1"><b><u><span class="Apple-style-span" style="font-size: small;">Benefiber</span></u></b></a><span class="Apple-style-span" style="font-size: small;">” to your food and drink. Have a bowl of fiber cereal if you are feeling the urge to nibble, or before or after dinner if you are feeling hungry. For variety, try a piece of fruit and lots of water as a chaser to take the edge off your hunger.</span><span class="Apple-style-span" style="font-size: small;"><o:p></o:p></span></div><div class="MsoBodyText"><span class="Apple-style-span" style="font-size: small;"><br />
</span></div><div class="MsoBodyText"><span class="Apple-style-span" style="font-size: small;">Also, you should </span><u><span class="Apple-style-span" style="font-size: small;">avoid the Olestra</span></u><span class="Apple-style-span" style="font-size: small;"> (non-absorbable fat) snack products recently made available. These also increase the delivery of non-absorbed fat through the intestinal tract and increase the risk of side effects on Xenical. </span><span class="Apple-style-span" style="font-size: small;"><o:p></o:p></span></div><div class="MsoBodyText"><span class="Apple-style-span" style="font-size: small;"><br />
</span></div><div align="center" class="MsoBodyText" style="text-align: center;"><b><span class="Apple-style-span" style="font-size: small;">Collateral benefits</span></b><span class="Apple-style-span" style="font-size: small;"><o:p></o:p></span></div><div class="MsoBodyText"><span class="Apple-style-span" style="font-size: small;">Due to its mode of action, Xenical lowers cholesterol, blood sugar in diabetics, and blood pressure in hypertensive patients to a modest degree. It also may help those suffering from constipation. It also discourages people from eating high fat meals and hopefully helps them make healthier food choices incorporating more fruits and vegetables into the diet.</span><o:p></o:p></div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><br />
</div>Anonymoushttp://www.blogger.com/profile/00508849128984146799noreply@blogger.com1tag:blogger.com,1999:blog-5681259980589566304.post-92067036680676286992010-01-13T12:45:00.002-05:002010-01-13T12:45:35.880-05:00Deepak Chopra "TOXIC EMOTIONS" Central Park NYC Tue 1/12/2010<object width="425" height="344"><param name="movie" value="http://www.youtube.com/v/ieBxQ1LDg3Q&hl=en_US&fs=1&"></param><param name="allowFullScreen" value="true"></param><param name="allowscriptaccess" value="always"></param><embed src="http://www.youtube.com/v/ieBxQ1LDg3Q&hl=en_US&fs=1&" type="application/x-shockwave-flash" allowscriptaccess="always" allowfullscreen="true" width="425" height="344"></embed></object>Anonymoushttp://www.blogger.com/profile/00508849128984146799noreply@blogger.com0tag:blogger.com,1999:blog-5681259980589566304.post-70497819632605323982010-01-05T12:10:00.001-05:002010-01-05T14:26:51.735-05:00Depression May Be a Side Effect of Other Medications You are TakingWhen someone is feeling depressed or blue for a prolonged period, they often feel that they are carrying around an invisible, deeply painful and condition. Many persons with depression are also being treated for other medical conditions, and may have contributing factors that perpetuate the feeling of internal pain. A careful history as well as an honest review of over the counter and prescription medications as well as lifestyle issues such as social stress, work, sleep, diet and alcohol or other substance use needs to be factored into planning a strategy to reduce pain.<br />
<br />
You and your doctor need to also evaluate your risk of bipolar disorder (Manic Depression), panic disorder, and suicidal risk early in the conversation, all of which require a slightly or substantially different approach.<br />
<br />
It is important that you recognize that depression can be mild moderate or severe. If severe, it can be a serious life threatening condition. Treatment often requires a step wise process that often takes at least a few months to yield substantial improvement, so you and your health care provider need to maintain a longer term horizon of expectations. Your health care provider should have several strategies that can at least take away some of the immediate pain while you are waiting for longer term improvement.<br />
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<br />
Several medication classes can cause an unexpected or idiosyncratic reaction to a given individual and act as an anchor to improvement or actually lead to your current depressive episode. Keep in mind that even if you are taking a medication listed below and have concern about its side effects, any change or withdrawal of medication should occur only after you and your health care provider have had discussions about the relative risk : benefits of any such changes.<br />
<br />
Common medications that are more commonly associated with unexpected psychic pain include;<br />
<br />
1) Blood pressure and heart disease medications;<br />
Central alpha 2 receptor agonist class- Reserpine, Methyldopa & Guanfacine (Aldomet & Tenex- older blood pressure lowering medications), Clonidine (Catapress- another older blood pressure medication also used for drug and alcohol withdrawal), as well as potentially Tizanidine (Zanaflex a muscle relaxant often used in the treatment of chronic pain),<br />
Beta blockers (many brands- used to lower blood pressure and reduce heart rate and to treat coronary heart disease as well as congestive heart failure).<br />
Digoxin (Lanoxin- used for heart rate slowing as well as congestive heart failure)<br />
Diuretics (many brands- used to lower blood pressure but can especially lead to low mood if associated with lower blood and tissue levels of potassium and sodium salts)<br />
<br />
2) Sedative-hypnotic agents;<br />
Barbituate class (many different medications used for control of seizure disorders, headache treatment- Esgic, Fioricet etc, as well as for sleep. Common preparations have Butalbitol, Meprobamate, chloral hydrate as well as Phenobarbital.<br />
Benzodiazepine class (many different medications used for helping with sleep, and to reduce anxiety, panic and stress. They are also commonly used and are often appropriate in conjunction with antidepressant medications both short term and long term to reduce side effects and control anxiety. Common names include Lorazepam/Ativan, Alprazolam/Xanax, Clonezapam/Klonepin.<br />
Alcohol especially if used medicinally on a regular basis or in excess by the patient to aid with control of anxiety, pain and insomnia.<br />
Other sleep aids, OTC and Rx may play a role here as well and need to be discussed with your doctor.<br />
<br />
3) Anti-inflammatory agents and opiates;<br />
Opiates/Narcotic agents are commonly used to treat acute and chronic pain syndromes and are obtained both by prescription and sometimes by illicit means.<br />
Anti-inflammatory steroids used to treat acute and chronic inflammation, pain, allergic and autoimmune conditions. Common names are; Dexamethasone/Decadron, Prednisone, Medrol/ Medrol dose pack. Use and withdrawal can both be associated with depressed mood. Keep in mind if you are taking any steroid for more than 2 weeks be certain to discuss a slow weaning process with your health care provider to prevent a major side effect from too rapid a withdrawal from anti-inflammatory steroid use.<br />
<br />
4) Hormones;<br />
Oral contraceptives<br />
Estrogen and estrogen withdrawal<br />
Anabolic steroids used for muscle bulking and most commonly obtained through illicit meansAnonymoushttp://www.blogger.com/profile/00508849128984146799noreply@blogger.com0tag:blogger.com,1999:blog-5681259980589566304.post-63265579316202169922009-12-09T22:32:00.000-05:002009-12-09T22:32:23.192-05:00Questions to Prepare for a PCP Visit Regarding Back Pain<i>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;</i><br />
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<br />
Allergies: _________________________ Medications currently taking: __________________________________________________________________<br />
Are you pregnant? When was your last period?<br />
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When did the pain start- (acute <6 weeks chronic > 3 months acute on chronic etc.<br />
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What happened?<br />
Injury/trauma/overuse twisting lifting bending etc.<br />
Have you had this kind of pain before-<br />
If you have, is there anything different about this pain-<br />
Describe the severity of the discomfort on a scale of 1-10 10 being the worst pain imaginable, how bad is it at its;<br />
Worst<br />
Best<br />
On average<br />
How long does it usually stay at the different levels etc;<br />
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What does it feel like- quality – sharp or dull, burning, ache, stabbing, cramping/spasms, shock like etc –<br />
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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<br />
Does the pain move around or radiate anywhere or stay in one area-<br />
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?<br />
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Constant- Intermittent-<br />
Change as time progresses since started- getting better worse or the same<br />
Timing issues that affect pain-<br />
Urinating<br />
Menses or part of cycle- no association<br />
Having bowel movement or bearing down- when was your last BM?<br />
Taking a deep breath<br />
Standing, walking or bouncing/ hopping<br />
Does it hurt when you push on the area where you are feeling discomfort?<br />
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Things that make better- positions or activities<br />
Things that make it worse- moving in certain positions etc.<br />
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Any weakness in your legs, feet or ankles?<br />
Back pain triage questions page 2<br />
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Does your foot slap or flop when you walk?<br />
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Associated other signs or symptoms?<br />
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Fever chills night sweats weight loss fatigue nausea vomiting diarrhea<br />
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Black or bloody stool<br />
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Does it wake you from sleep?<br />
Does it keep you awake like a “nagging can’t get comfortable toothache”?<br />
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Any bloody or discolored urine?<br />
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Any “saddle numbness” in the crotch groin inner thighs?<br />
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Pulsatile/heart beat pulsing or tearing nature of the pain?<br />
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What if anything have you taken for the pain so far-<br />
Have you recently been taking regular NSAID medications like Advil (Ibuprofen), Aleve (naproxen), aspirin or Rx meds for arthritis or Prednisone/Medrol steroids?<br />
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<br />
If so what and how many (dose in mg. etc.) and how often are you taking them?<br />
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<br />
Recent (last 2-3 months) antibiotics or infection like pneumonia urinary tract infection<br />
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<br />
Previous tests to evaluate pain- Cat Scans, Ultrasounds, Colonoscopy or upper endoscopy Upper or Lower GI tests etc.<br />
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<br />
What things can you not do now that affect your life due to the pain?<br />
(Could you go to the market and pickup a gallon of milk without needing a shopping cart? Etc.)Anonymoushttp://www.blogger.com/profile/00508849128984146799noreply@blogger.com0tag:blogger.com,1999:blog-5681259980589566304.post-73891456978159319562009-12-09T22:22:00.001-05:002009-12-09T22:24:53.098-05:00History of Present Illness Questionnaire - For Your PCP<i>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;<br />
</i><br />
<br />
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.<br />
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Describe the quality of the pain; sharp dull cramping stabbing burning pressure pulling etc and how it changes etc;<br />
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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;<br />
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Describe the timing of the pain- day or night? wakes from sleep? constant intermittent? etc;<br />
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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;<br />
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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?<br />
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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?<br />
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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.Anonymoushttp://www.blogger.com/profile/00508849128984146799noreply@blogger.com0tag:blogger.com,1999:blog-5681259980589566304.post-28091205021332202582009-12-07T18:30:00.002-05:002009-12-07T18:37:32.013-05:00Swine Flu Blues… Part Two 12/7/09I just got this interesting Email from my State Health Dept. about the scarce H1N1 vaccine.<br />
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See my comments in italics;<br />
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<br />
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. <br />
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<br />
<br />
<i>Interesting!!! Where are you (The PA Dept of Health) getting your information/ reports?<br />
<br />
<br />
<br />
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.<br />
<br />
<br />
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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.<br />
<br />
<br />
<br />
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. <br />
<br />
<br />
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.<br />
<br />
<br />
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.<br />
<br />
<br />
<br />
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.<br />
<br />
<br />
<br />
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.<br />
<br />
<br />
<br />
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.<br />
<br />
<br />
<br />
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.</i><br />
<br />
<br />
<br />
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. <br />
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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. <br />
<br />
<br />
<br />
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. <br />
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<br />
<br />
Please contact the Department of Health by email at influenzaquestions@state.pa.us with the name of the facility, which ACIP priority group served, contact person and phone number, and number of doses needed.<br />
<br />
<br />
<br />
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.Anonymoushttp://www.blogger.com/profile/00508849128984146799noreply@blogger.com0tag:blogger.com,1999:blog-5681259980589566304.post-83480217300418355572009-12-06T08:48:00.000-05:002009-12-06T08:48:10.519-05:00Altitude Sickness - Prepare to Get HighThere'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. <br />
<br />
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. <br />
<br />
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. <br />
<br />
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. <br />
<br />
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.<br />
<br />
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. <br />
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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. <br />
<br />
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.<br />
<br />
Thanks to John West MD PhD for his inputAnonymoushttp://www.blogger.com/profile/00508849128984146799noreply@blogger.com0tag:blogger.com,1999:blog-5681259980589566304.post-63569837614210709972009-12-03T23:39:00.001-05:002009-12-03T23:39:59.825-05:00<object width="425" height="344"><param name="movie" value="http://www.youtube.com/v/OEdVfyt-mLw&color1=0xb1b1b1&color2=0xcfcfcf&hl=en_US&feature=player_embedded&fs=1"></param><param name="allowFullScreen" value="true"></param><param name="allowScriptAccess" value="always"></param><embed src="http://www.youtube.com/v/OEdVfyt-mLw&color1=0xb1b1b1&color2=0xcfcfcf&hl=en_US&feature=player_embedded&fs=1" type="application/x-shockwave-flash" allowfullscreen="true" allowScriptAccess="always" width="425" height="344"></embed></object>Anonymoushttp://www.blogger.com/profile/00508849128984146799noreply@blogger.com0tag:blogger.com,1999:blog-5681259980589566304.post-67715413773587472342009-12-03T08:43:00.001-05:002009-12-03T08:44:27.868-05:00Treatable Dementias<span style="border-collapse: collapse; font-family: arial, sans-serif; font-size: 13px;"></span><br />
<div class="MsoNormal" style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;">Although this article is filled with med-speak (sorry patients and friends), it is one I wrote about an issue I am passionate about.<br />
</div><div class="MsoNormal" style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;"><br />
</div><div class="MsoNormal" style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;">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.<br />
</div><div class="MsoNormal" style="margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px;"><br />
</div><div class="MsoNormal" style="margin-bottom: 0px; margin-left: 0.5in; margin-right: 0px; margin-top: 0px;">1)<span style="font: normal normal normal 7pt/normal 'Times New Roman';"> </span><u>Mass</u> 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.<br />
</div><div class="MsoNormal" style="margin-bottom: 0px; margin-left: 0.5in; margin-right: 0px; margin-top: 0px;">2)<span style="font: normal normal normal 7pt/normal 'Times New Roman';"> </span><u>Hydrocephalus</u>: Normal Pressure Hydrocephalus (NPH) other communication and obstructive causes.<br />
</div><div class="MsoNormal" style="margin-bottom: 0px; margin-left: 0.5in; margin-right: 0px; margin-top: 0px;">3)<span style="font: normal normal normal 7pt/normal 'Times New Roman';"> </span><u>Infections</u>: Syphilis, parasites, AIDS, Lyme disease can cause slow onset dementias<br />
</div><div class="MsoNormal" style="margin-bottom: 0px; margin-left: 0.5in; margin-right: 0px; margin-top: 0px;">4)<span style="font: normal normal normal 7pt/normal 'Times New Roman';"> </span><u>Demyelinating</u> diseases: MS, and MS imitators (especially collagen vascular diseases)<br />
</div><div class="MsoNormal" style="margin-bottom: 0px; margin-left: 0.5in; margin-right: 0px; margin-top: 0px;">5)<span style="font: normal normal normal 7pt/normal 'Times New Roman';"> </span><u>Metabolic</u> disorders:<br />
</div><div class="MsoNormal" style="margin-bottom: 0px; margin-left: 1in; margin-right: 0px; margin-top: 0px;"><span style="font-family: 'Times New Roman', serif;">-<span style="font: normal normal normal 7pt/normal 'Times New Roman';"> </span></span><u>Acquired</u>- 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)<br />
</div><div class="MsoNormal" style="margin-bottom: 0px; margin-left: 1in; margin-right: 0px; margin-top: 0px;"><span style="font-family: 'Times New Roman', serif;">-<span style="font: normal normal normal 7pt/normal 'Times New Roman';"> </span></span><u>Inherited</u>: Wilson’s Disease, etc- rare<br />
</div><div class="MsoNormal" style="margin-bottom: 0px; margin-left: 0.5in; margin-right: 0px; margin-top: 0px;">6)<span style="font: normal normal normal 7pt/normal 'Times New Roman';"> </span><u>Pseudodementia</u> (especially depression)<br />
</div><div class="MsoNormal" style="margin-bottom: 0px; margin-left: 0.5in; margin-right: 0px; margin-top: 0px;">7)<span style="font: normal normal normal 7pt/normal 'Times New Roman';"> </span><u>Other neurodegenerative</u> conditions- treated like Alzheimer’s disease<br />
</div><div class="MsoNormal" style="margin-bottom: 0px; margin-left: 0.5in; margin-right: 0px; margin-top: 0px;">8)<span style="font: normal normal normal 7pt/normal 'Times New Roman';"> </span><u>Vascular dementias</u>: treated with cholesterol, blood pressure and blood sugar control in diabetics<br />
</div><div class="MsoNormal" style="margin-bottom: 0px; margin-left: 1in; margin-right: 0px; margin-top: 0px;"><span style="font-family: 'Times New Roman', serif;">-<span style="font: normal normal normal 7pt/normal 'Times New Roman';"> </span></span><u>Cortical</u>: multiple medium to large strokes- significant rapid step like losses of function- classic vascular dementia<br />
</div><div class="MsoNormal" style="margin-bottom: 0px; margin-left: 1in; margin-right: 0px; margin-top: 0px;"><span style="font-family: 'Times New Roman', serif;">-<span style="font: normal normal normal 7pt/normal 'Times New Roman';"> </span></span><u>Sub cortical</u>; True Binswanger’s disease asn other disorders of leukoariasis- (“UBOsis” on MRI) – diffuse small vessel arterial disease<br />
</div><div class="MsoNormal" style="margin-bottom: 0px; margin-left: 1in; margin-right: 0px; margin-top: 0px;"><span style="font-family: 'Times New Roman', serif;">-<span style="font: normal normal normal 7pt/normal 'Times New Roman';"> </span></span><u>CADASIL</u> (cerebral autosomal-dominant arteriopathy with sub cortical infarcts and leukoencephalopathy); the notch3 gene mutation<br />
</div><div class="MsoNormal" style="margin-bottom: 0px; margin-left: 0.5in; margin-right: 0px; margin-top: 0px;">9)<span style="font: normal normal normal 7pt/normal 'Times New Roman';"> </span><u>Collagen-vascular diseases</u><br />
</div><div class="MsoNormal" style="margin-bottom: 0px; margin-left: 0.5in; margin-right: 0px; margin-top: 0px;">- Rheumatoid arthritis, Systemic Lupus, Systemic Scleroderma, Polymyositis/Dermatomyositis, Polyarteritis nodosa, etc.<br />
</div><div class="MsoNormal" style="margin-bottom: 0px; margin-left: 0.25in; margin-right: 0px; margin-top: 0px;"><br />
</div><div class="MsoNormal" style="margin-bottom: 0px; margin-left: 0.25in; margin-right: 0px; margin-top: 0px;">Mini mental screening 30 point test;<br />
</div><div class="MsoNormal" style="margin-bottom: 0px; margin-left: 0.25in; margin-right: 0px; margin-top: 0px;">21-26 mild, < 20 moderate < 1-10 severe<br />
</div><div class="MsoNormal" style="margin-bottom: 0px; margin-left: 0.25in; margin-right: 0px; margin-top: 0px;"><u>Cerefolin NAC</u> for pre dementia Mild Cognitive Impairment<br />
</div>Anonymoushttp://www.blogger.com/profile/00508849128984146799noreply@blogger.com0tag:blogger.com,1999:blog-5681259980589566304.post-27057998816396943472009-12-02T17:20:00.001-05:002009-12-02T17:20:47.362-05:00Electronic Medical Records - The Trouble with Tribbles <div class="MsoNormal">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.<br />
</div><div class="MsoNormal"><br />
</div><div class="MsoNormal">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.<br />
</div><div class="MsoNormal"><br />
</div><div class="MsoNormal">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.<br />
</div><div class="MsoNormal"><br />
</div><div class="MsoNormal">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.<br />
</div><div class="MsoNormal"><br />
</div><div class="MsoNormal">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.<br />
</div><div class="MsoNormal"><br />
</div><div class="MsoNormal">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.<br />
</div><div class="MsoNormal"><br />
</div><div class="MsoNormal">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.<br />
</div><div class="MsoNormal"><br />
</div>Anonymoushttp://www.blogger.com/profile/00508849128984146799noreply@blogger.com0tag:blogger.com,1999:blog-5681259980589566304.post-78843276912257557082009-11-30T23:57:00.000-05:002009-11-30T23:57:45.533-05:00No Flu For You!?<!--StartFragment--> <br />
<div class="MsoNormal"><b>Novel influenza A H1N1 “Swine Flu” vaccine in those over 65 years of age - not recommended.</b><br />
</div><div class="MsoNormal"><br />
</div><div class="MsoNormal"><i>Why Not?</i><br />
</div><div class="MsoNormal"><br />
</div><div class="MsoNormal">One of the most frequently asked questions that I have gotten from my adult patients has been why, after decades of indoctrination from public health officials, the news and their own doctors, that the new H1N1 influenza A vaccine is not being suggested for those over 65.<br />
</div><div class="MsoNormal"><br />
</div><div class="MsoNormal">This same age group commonly has at least one if not several underlying chronic medical conditions which in the past would put them into high risk for hospitalization or even dying from complications of influenza infection. It seems intuitive that they too should get this vaccine in addition to the usual seasonal flu shot.<br />
</div><div class="MsoNormal"><br />
</div><div class="MsoNormal">The epidemic has however shown an unusual pattern in those at high risk. Since this new virus appeared in Mexico in early 2009, as well as throughout it’s spread across the world, including becoming the predominant seasonal winter flu in the southern hemisphere, it seems to hit the very young, pregnant women, and people under 65 who have chronic medical problems much harder than those over 65. The number of people 65 and up who have been hospitalized or worse has been unusually low for this flu pandemic. This is not to say that some older adults do get a classic influenza infection and get quite ill from time to time.<br />
</div><div class="MsoNormal"><br />
</div><div class="MsoNormal">Some have conjectured that this unusual distribution of illness severity may be due to the robust immune response that younger patients mount in response to this influenza virus. Perhaps their immune systems overreact, which leads to damage of sensitive lung tissue and respiratory damage with fluid leakage and inflammation into the lungs. Older adults might have a somewhat less robust immune and inflammatory response and therefore not get into trouble from over responding to this virus.<br />
</div><div class="MsoNormal"><br />
</div><div class="MsoNormal">It has also been observed that 25-30% of those over 50 years of age have antibodies that seem to match the H1N1 virus antigen similar to what one would get following a dose of the new H1N1 vaccine. Perhaps, through previous flu shots and/or exposure to old infections, this population already developed at least partial immunity. This age group might have even more immunity that is imprinted in the immune system and not readily evident on specific antibody testing. Additionally, those who got the swine flu vaccine in 1976 seem to have a very high level of matching antibodies to the current vaccine.<br />
</div><div class="MsoNormal"><br />
</div><div class="MsoNormal">Due to manufacturing difficulties in the making of the novel H1N1 vaccine, there are not enough doses for those deemed at high risk, let alone extra doses for those over 65, regardless of any underlying condition. Some good news however, <span style="mso-spacerun: yes;"> </span>suggests that this year’s seasonal flu vaccine might also give some partial protection from more severe H1N1 infections. Now that the manufacturers have finished making new doses of H1N1 vaccine this year, at least one company has restarted the manufacture of seasonal flu vaccine without the H1N1 antigens and this hopefully will be available by the end of 2009. This is especially timely as the vaccine manufacturers had to stop production of seasonal vaccine early to make the H1N1 vaccine and were unable to fill many orders fully for the seasonal flu vaccine this year when demand has been unusually high. <br />
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</div><!--EndFragment-->Anonymoushttp://www.blogger.com/profile/00508849128984146799noreply@blogger.com0