Saturday, 28 June 2014

It never hurts to let patients second guess you

In training, we learn to ask patients all kinds of questions. But no one taught me to ask what may be the most important question of all: "What do you think is wrong?" I've found that even if the patient's answer isn't on target, it helps me address his concerns. And sometimes when I'm puzzled, the patient actually makes the correct diagnosis. Consider these cases:

Stabbing in the dark for answers

Over a three-month period I saw a 66-year-old woman four times. Her problem was pain in her left knee, but only at night. I could find little if any sign of arthritis, and everything else was normal, including blood tests and X-rays of her knee and hip.

Neither analgesia nor physical therapy helped. I considered depression or a family problem, but there was no evidence of either.

I was stumped. So I asked, "What do you think is wrong?" Without an eye-blink's hesitation, she responded, "I think I have cancer."

"Why would you think that?" I asked.

"I read in a magazine," she explained, "that pain that gets worse at night is often cancer-and it's often missed by doctors."

I was able to reassure her that she didn't have cancer, and she was visibly relieved. The pain resolved spontaneously over the next few weeks. I encouraged her to ask us immediately about anything in her magazine reading that distressed her. (I never did find the article in question. I certainly hope it didn't say what she said it did.)

Reading that paid off

I'd seen a middle-aged woman several times over the years for peptic-ulcer disease. She'd responded well each time, and I talked to her repeatedly about avoiding ulcerogenic substances. I had even drawn a gastrin level on her, which turned out normal. She was getting along reasonably well on [H.sub.2] blockers, but now she was back with what seemed to be a flare-up of the old problem. Discouraged, I broached with her the possibility of undertaking ulcer surgery.

She frowned. I frowned. Neither of us was happy with having to resort to such a procedure.

"Do you have any idea of what else might be wrong?" I asked.

"Well, I'm no doctor," she said shy. "But may I have hyperparathyroidism."

Hyperparathyroidism? Most of my patients stumble over medical terms with half as many syllables. I was surprised that she'd come up with a diagnosis so esoteric. But guess what" Although her serum calcium was in the high-normal range, it turned out she was right. She was a well-educated person who'd come across the disease in her reading, and-unlike the woman with night pain-had been able to steer me in the right direction. She responded well to parathyroid surgery; what's more, she's had no more ulcers.

Spotting a rocky diagnosis

A 51-year-old man came to see me with a rash. It was clearly fungal, and I wrote out an Rx that I said would resolve it within a couple of weeks or so. Two days later he called: The rash was worse. I encouraged him to give the cream more time. Several days later, he insisted on an appointment because he felt the rash wasn't getting better.

In fact, though, it was healing up nicely. Clearly he had something else on his mind, so I asked, "What do you think the problems is.?"

His answer took me by surprise: "I think I have Rocky Mountain spotted fever."

I asked him why he thought that. "Well," he said, "I grew up in the Rockies, and I've got spots. I guess I'm in real trouble." I listed the reasons he didn't have to worry about that illness. I told him again that the rash was fungal, explained once more what had caused it, and assured him that it would resolve. He calmed down considerably, and the rash cleared over the next two weeks.

Itching to live down guilt

I'll never forget the 83-year-old woman with a severe vaginal itch with no findings except for excoriations caused by her own persistent scratching. All tests were normal, all treatment was ineffective, and she was increasingly tearful and anxious. We both felt terrible.

Because I really don't know what to do next, I asked her what she thought was wrong. She knew exactly, and tearfully told me all about it:

"Soon it will be my 6oth wedding anniversary, and my family is having a big party for us. But I don't deserve it! I had sexual relations with a man before my marriage, and now GOD is punishing me with a sinner's disease. Everyone will find out!"

I tested her for CG and syphilis and presented her with copies of the negative results. We talked for a long while about childhood mistakes and how we had the rest of our lives to make up for them. I assured her that she had done just that-and more-by being a good wife, mother, and member of the community. Then I recommended warm baths each night, followed by a new cream. Over the next few weeks, the itching resolved, the excoriations healed, and her mood improved. Her anniversary party, I hear, turned out to be a joyous event.

Making a rash diagnosis

One way or another, it's always helpful to know what happened to members of the patient's family. Recently, for example, a patient I'd been following for years showed up complaining of chest pain. He'd had bypass surgery four years earlier, and had been doing fine. As part of my exam, I did an ECG, and still nothing seemed to explain the pain he was experiencing now.

The I recalled having heard something about the untimely death of his 39-year-old son. "Yes, he died a month ago-he had a heart attack," my patient said, sobbing. That told me what I needed to know to gently steer the conversation to the anxieties he had been burned with.

A large part of my practice is geriatrics, and that means a lot of funny little aches and pains. Many things start out with funny little aches and pains, and their initial similarity can make them hard to nip in the bud.

One of my older patients suffers from chronic back pain, and one day it was worse than usual. She insisted on being seen that afternoon. My front-office assistant agreed to squeeze her in between appointments, and when she arrived I put on my osteoarthritis hat for her. I prescribed treatment as though her musculoskeletal problem was acting up.

She seemed to be relatively comfortable with my conclusions, but as she was standing up to leave, she turned suddenly and asked, "So you don't agree with my diagnosis?"

"What's that?" I exclaimed.

"Two years ago, you treated my sister for shingles, and this is exactly the way hers started."

It was plausible, but there was no rash yet. If it was shingles, the rash might not show up until Day Three, and this was only Day One. I sent her home with office samples of a herpes zoster medication, and told her to start it if the rash developed. And that's exactly what happened. Her intuition--and my willingness to listen-had spared her a return trip to my office and perhaps a delay in tackling the real problem.

One Friday afternoon five years ago, just as we were about to close the office for the weekend, another woman called me about her 18-year-old son's abdominal pains. Could we wait for her? She was certain it was appendicitis.

It was indeed, and we had him in the OR within an hour. "Why did you think it was appendicitis?" I asked her as the surgeon took over. "I saw a case just like this on a TV show," she said.

I remember that conversation vividly, not only because she was so definite about the problem, but also because she was right on the money. Postscript: The son is now a regular patient of mine.

Yes, I know-sometimes you'll startle or confuse the patient if you ask what's wrong. You may get, "You tell me. You're the doctor." But along with all those great questions we learned in medical school, try adding my question for a change. I bet you'll be surprised, educated, or at least amused by the responses you get.

Tuesday, 24 June 2014

History, physical crucial to knee injury evaluation

X-rays rarely nail diagnoses of acute knee injuries. They are no substitute for a good history and physical, Dr. Steven Anderson said at a sports injury meeting sponsored by the American Academy of Pediatrics.

When treating acute injuries, focus on the effects of the injury--swelling, instability, deformity--and get a history to find out how the injury occurred, said Dr. Anderson of the University of Washington, Seattle.

"My receptionist can make the diagnosis of an acute knee injury with about 90% accuracy based on what she gets over the phone, so I hope we [physicians] can all do at least that well," he said.

Acute knee injuries usually involve a limited number of structures. When a patient presents with an acute knee injury, check these: bones and growth plates, ligaments, menisci, tendons, and bursa, Dr. Anderson advised.

Start by asking patients about the mechanism of the injury:

* Was it a contact or noncontact injury?

* Was there hyperextension or hyperflexion?

* Were there any noises--a snap, pop, or tearing sensation?

Then ask about specific mechanical symptoms.

* Can the patient bend and straighten the knee?

* Does it lock or catch?

* Does it buckle or give way?

Ask about the exact location of pain: medial, lateral, anterior, or posterior. These questions should provide most of the information needed to narrow down the diagnostic possibilities, Dr. Anderson said.

Some children with an acute knee injury have minimal pain or swelling, and can stand and walk, but if asked to do something more demanding--run, jump, or hop--they'll hurt or have functional limitations.

Although acute knee injuries don't always require x-rays, they may be helpful if the child is skeletally immature or if the diagnosis is uncertain after a history and exam.

"You will never be faulted for taking an x-ray on someone who has open growth plates with acute swelling in the knee," Dr. Anderson said, but he warned against reliance on images alone--the majority of serious acute knee injuries appear normal on x-rays.

The most common acute knee injuries are sprains to the anterior cruciate ligament (ACL), medial collateral ligament (MCL), and posterior cruciate ligament (PCL); patellar subluxation or dislocation; and meniscal tears. Pediatricians who are familiar with these areas should be able to accurately diagnose the majority of their pediatric patients with acute knee injuries.

* ACL injuries. "The typical history of an ACL is twisting or hyperextension," Dr. Anderson said. Most ACL injuries are noncontact and stem from pivoting or jumping, and are usually associated with a popping noise.

These injuries usually involve swelling, posterolateral pain, and a sense of instability when the patient tries to jump or pivot. There may also be pain or physical findings due to concurrent injuries to the MCL or meniscus.

Treatment includes short-term icing, compression, and a splint, but if the ligament is torn, surgical reconstruction is the treatment of choice to get children back to play, Dr. Anderson said. "This ligament doesn't heal by resting."

* Patellar subluxation/dislocation. Patellar problems are part of the differential diagnosis if the knee twisted and gave way. A patellar dislocation has a distinctive sound--like canvas ripping or tearing--as opposed to the discrete snap or pop of an ACL injury.

The patient will have tenderness on the medial patella and apprehension if it's nudged to one side. "You can just push the patella back in," Dr. Anderson said. "Some x-rays show a fragment but it's not important to get x-rays unless you think there's a fracture, and you don't fracture the patella by pivoting the knee."

The initial treatment is ice and compression, with optional use of crutches. Surgery is not indicated initially, but if stability problems persist, surgical procedures can stabilize or realign the patella.

* MCL sprain. This is a fairly common injury. It usually is caused by stress on the outside of the knee while the foot is planted.

The point of tenderness is typically over the adductor tubercle or proximal attachment of the medial ligament on the femur. Tenderness more distally should raise concern about a meniscal tear.

Once an MCL injury is diagnosed, keep evaluating the knee for associated injuries. MCL injuries often occur in conjunction with ACL injury or patellar subluxation. An isolated MCL injury can be treated effectively with rest that allows the ligament to heal and rehab exercises to regain strength and range of motion.

* PCL injuries. A blow to the anterior portion of a flexed knee can sprain the PCL. These injuries are most common in baseball or softball catchers or other athletes who spend a lot of time on flexed knees. Most sprains can be treated with rehab and bracing, but injuries with significant instability may require surgery.

* Meniscal tears. Meniscal tears can occur in isolation or with other injuries and are less common in children than adults, Dr. Anderson said. A meniscal tear usually causes localized pain and restricted motion, and there may be clicking, catching, or popping. The medial meniscus is more often injured than the lateral meniscus. A meniscal tear is the one acute knee injury that requires an imaging test--MRI is best--to confirm the diagnosis.

RELATED ARTICLE: Seven signs of serious harm.

1. Snap, pop, or tearing sensation at the time of injury.

2. Feeling that bones have shifted or given way.

3. Immediate swelling after injury.

4. Locking of the knee or restricted joint motion.

5. Visible deformity.

6. Cross instability.

7. Diminished sensation or circulation distal to injury.

Tuesday, 10 June 2014

Shoulder sprain awareness

There are many ways in which you can incur a shoulder sprain. It can really get in the way with your everyday life. Simple things like carrying your backpack over your shoulders can create a lot of discomfort. It's not a major thing to be concerned about but it shouldn't be ignored either.

A shoulder sprain occurs when the ligaments in our shoulders suffer a tear or are extended beyond their capacity. These ligaments keep the shoulder bones in place. To be specific, it's when the glenohumeral joint is affected. The glenohumeral joint is where the shoulder blades, the bone and the humerus meet. A sprain occurs when there is a heavy blow to the shoulder causing a dislocated shoulder or a light trauma to the juncture. You can find more information at

A shoulder sprain can be caused by a forceful twist of the shoulder, a hard blow to the shoulder, using your arms to break a fall without bending them.

Before it gets worse, you must attend to the shoulder sprain. It you don't attend to it, it will aggravate the injury and interfere with your daily life. If it gets worse, you won’t be able to play any sports or do any vigorous exercise, cause problems with your balance, can cause loose joints and connective tissue disorders and decrease the strength in your muscles and ligaments.

You will be able to tell if it is a shoulder sprain if you find it hard to move your shoulder, raise your arms, have pain in your shoulder, have swelling in your shoulder or have any inflammation in your shoulder area.

You can get an x-ray, MRI or an arthrogram to check if it really is a shoulder sprain.
To treat it, rest your shoulder as much as possible, 3 to 4 times a day, apply an ice pack for 15-20 minutes. Do this for a few days.

When you have received a shoulder sprain, gentle exercises to strengthen and stretch the muscles can be beneficial. If you want more flexibility and strength, putting your shoulder through a rehabilitation regime of gentle exercises can really help.