Archive for tag: clinic

Never Stop Learning

Hello everyone.  I know I'm looking forward to only a three-day week this week and the food-coma that will be induced Thursday. I always look forward to Thanksgiving. I'm fortunate to have a huge family, who are local for the most part, equipped with two grandmothers who are incredible cooks, and one uncle who's a chef. Not to toot our own horns or anything, but we do turkey-day right. 

Today I'd like to share with you, probably, one of my last case presentations that walked into the clinic last Friday. This patient presented with strange neck and upper shoulder pain that began 4-5 days prior. The patient could not pinpoint a certain action, or mechanism of injury; he had not lifted anything heavy nor sustained any trauma. As the patient was sitting and telling me his story I could notice he was struggling with some nasal congestion. I then began to ask the patient if he had been feeling sick as of late, to which he answered that he had been fighting off some nasal congestion and a sore throat for about a week. Ding, ding, ding! So now we have a patient with some weird neck and upper shoulder pain: that is worse with laying down for extended periods of time and while on his drive to work; that feels better with massage during a warm shower; who has been fighting off what sounds like an upper respiratory infection. What's the next step? If you guessed a physical exam to rule out any life-threatening conditions, you are correct.

The patient was informed of the risks of a physical exam, he consented, and off we went. Through the physical exam we ruled out a disc issue and facet involvement. In fact, the only instigating exam finding was pinpoint tenderness at a nodule at the right suboccipital area (base of the skull), and the same in the area of the left sternocliedomastoid muscle area (left side of the neck). As soon as I palpated over these nodules, the patient would note that was his pain generator. One should not jump to the conclusion of muscle spasm just because palpating over a muscle is tender. What caused that "knot" to form? This is where listening to the patient is key, but not allowing the patient to give you a diagnosis; that's why you are the doctor and they are the patients. 

Remember, that pesky sore throat? I did. I decided to take a look down the patient's throat, and what did I find? His throat was fiery red on the right side. Can you see where I'm heading from here? Now here is where I only give myself an 80% (very generously, if Dr. Maola has anything to say about it). I honed in on a throat infection that was causing inflammation of lymph nodes beneath the suboccipital and sternocliedomastoid muscles leading to neck and upper shoulder pain. This made sense with the red throat, stuffy nose, and alleviation of pain when the lymphatic chains were manually drained by massage in a hot shower. Seems pretty sealed up, right? Wrong.

Dr. Chad Maola, our dean of academic assessment and mentor of mine, saw a very big flaw in my diagnosis. He asked me to take a look inside the patient's ears. Sure as I'm writing this right now, that poor patient's right ear was red as could be; an ear infection was the root of all the pain! The ear infection was causing the lymph nodes to swell, and the infection was draining down the eustation tube (tube that connects the middle ear to the throat for drainage) to the back of the patient's throat causing a sore throat.

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Image from Northwestern University

Now, I could have managed the patient for a throat infection and manually drained the lymphatic chains and offered the patient some relief, but what would have happened if I didn't notice the ear infection. With an ear infection in adults, ear pain is an end-stage symptom, right before tympanic membrane rupture. In real life, if this patient came to me, paid me $80 or so for a diagnosis, then had to turn around and head to an urgent care clinic to spend another $80 for them to tell him that he in fact had an ear infection rather than a primary throat infection, he wouldn't be very happy.

I adjusted the patient's cervical spine which resulted in an instant sensation of ear drainage and sent him on his way with some instructions on dripping in some warm garlic olive oil into his ear, continue to massage out his lymphatic chains in the shower, and to seek a physician for antibiotic therapy to clear up the infection. Sure enough, the patient felt ear pain that night, found relief from the garlic olive oil, and after visiting his general practitioner received an antibiotic prescription to resolve the infection. The patient was happy, and I learned yet another valuable lesson from Dr. Maola and my patient.

I hope today's entry helps someone down the line. Assess every option and always allow the patient to tell you what their signs and symptoms are, and then you diagnose them. I hope everyone has a quick short week and a terrific Thanksgiving!

Gobble Gobble,
Dex

That New Clinic Smell

It's an exciting day down here at the Florida campus; today the NUHS Whole Health Center - Pinellas Park outpatient clinic is open and ready for business. The other interns and I walked up this morning to a fresh, state-of-the-art facility, which even has that new clinic smell. It's an incredible facility, equipped with 10 treatment rooms, a physical therapy room, separate lab room, an interactive classroom, and super-cool conference room. I am typing this now from our very own intern lounge--pretty fancy.

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Yes, we are very excited about all the brand-spanking-new equipment, but we are also enthusiastic to have an outpatient facility. Up until now, the Florida campus has had to get by with a 4-room clinic that only caters to the faculty, staff and dependents of those affiliated with St. Pete College and the University Partnership (which includes NUHS, Barry University, Florida State University, University of Florida and others).

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The new facility will now allow us to treat anyone and everyone. The services we provide will still be free to the population we would see at our student clinic, but will be at a very minimal cost to anyone else who would like treatment. We are hoping that this will open up a whole new population of patients, and bring some more real-world cases through the door. The more practice we can take on while in school will just help us feel that much more confident once we graduate and are on our own.

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Speaking of being on our own, I've started the process of outfitting my clinic once I'm out of the NUHS nest. As many of my colleagues and professors around here know, I've signed on to be an associate with a great doctor, have signed a lease for my future practice (opening in South Tampa, April 1, 2013...shameless plug), and last week even bought almost all the physiotherapy equipment I'll need. These things were a learning experience in and of themselves. Finding the right location that you believe you can succeed in is very important. I staked out the building I wanted for nearly 2 years before it finally opened up about 2 months ago. Then I was very fortunate to make a relationship with a local MRI rep who clued me in on a practice that was downsizing and needed to get rid of a lot of equipment for a very discounted price. From the experiences I've had, I would recommend starting to make relationships as soon as you can, and maintain them, even its just a text or a phone call once a month to touch base. It goes a long way.

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I hope everyone has a productive week, and best of luck to everyone taking Part 4 boards this coming weekend. Please everyone wish us luck. I know we are all prepared, but a little luck never hurts either. If anyone needs any help or advice about the new clinic, or starting his or her own, please shoot me an email, its fresh in my head, so hopefully I can help.

Good Luck this weekend,
Dex

Wellness Fair

Hello, everyone. The weather down here in Florida is finally cooling off, and it feels incredible. Don't get me wrong, I love hanging around the beach and cooling off in the pool, but not much beats sitting at an outside bar on a Sunday watching some football and not sweating through your clothes.

Speaking of watching some good football, how about those FSU Seminoles? Granted we played Duke this past weekend, but 48-7 was a blowout, and I got to see it live and in person. My younger brother and I made the trip up to Tallahassee for the weekend to catch the game and party a little bit. We had a great time, and I realized how much I miss college.

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All College Day

We had a really cool, world-learning adventure last week at St. Pete College's All College Day. Dr. Jennifer Illes recruited us 10th trimester interns to perform blood pressure screenings at this SPC faculty event. We set up our NUHS table, outfitted it with brochures and cards, and started with the screenings.

I was happy to see so many of the SPC faculty and staff take so much interest in our school and clinics. This wasn't just an opportunity to practice taking blood pressures on people, it was killer practice on how to market and communicate with people who weren't all that familiar with our clinics, or profession for that matter. Now, more than ever, I am realizing how important of a trade it is to be able to communicate with the public in such a way that shows that you are knowledgeable, but at the same time able to show that you are likeable and easy to understand. This skill is invaluable, and only comes from practice.

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I would recommend jumping at any opportunity you could that requires you to talk to the public. Being able to communicate with patients in the treatment room is extremely beneficial, but you first have to get them in the door. I will be performing screenings for my own office in the months to come, and the practice we had last week really opened my eyes to how the public really views our profession, and how I'll have to work to sway people my way.

Negative Nancys

My uncle forwarded me an article last week that I thought was awesome and would like to share with all you Negative Nancys out there. The article by Hope Gillette titled "Negativity and Complaining is Bad for the Brain, Experts Say," alludes to the fact that the brain reacts differently in response to disturbing or negative information. Listening to as little as 30 minutes of complaining can damage neurons within the hippocampus, the part of the brain that deals with problem solving. The article gives some simple tips to avoid the inevitable day-to-day complaining that will be hurled your way, and even how to flip the problem on chronic complainers. It's an easy read that I thought was pretty cool, plus it gave me an excuse to tell the complainers in our office to keep it to themselves.

Congratulations!

Congratulations to everyone who passed their board exams; all the interns down here in the Florida clinic did extremely well. Hard work always pays off; so don't stop now! 

I'd also like to congratulate our very own Dr. Rudy Heiser on his second consecutive WAG (Wild Ass Guess) award win this past weekend at the ACCR (American College of Chiropractic Radiology) convention. The WAG is the pride of the DACBR community and Dr. Heiser has brought it home to NUHS Florida for the second year in a row. Florida campus representing!!

I hope everyone has a great week.

Catch you guys later,
Dex

Cases in Point

Hello, and welcome back to another installment of Dex's blog adventures. I'd first like to thank everyone for the positive response to last week's case report. I'll do my best to put together a few more cases to share in the weeks to come.

Cases really are the best way to train your mind to think critically and to pick up on subtle clues to reach a diagnosis. If you like radiology and case reports, as I do, try the American College of Radiology website's Case In Point. Each day the ACR posts a new case with images to subsequent. These cases are pretty challenging at times, as the ACR targets their cases towards radiologists, but they are at the very least a decent learning tool. 

Perfecting the Diagnosis

So today I'd like to share with everyone yet another semi-pitfall I had with a patient here in clinic. I've been treating this individual twice a week for four weeks for lower neck/upper shoulder pain. The history and exam led me to a diagnosis of cervical sign facet syndrome with some upper trapezius muscle, levator scapulae muscle and pec minor muscles hypertonicity. I treated the patient as I would any patient with these diagnoses, which you will see a lot, with adjustment of the cervical and thoracic spine, myofascial work, and postural correction. Not to toot my own horn, but I've seen a lot of success with these treatments for these issues, but not with this patient.

The patient would find some mild relief from the treatment I was giving him, but no lasting gains. Therefore, I took a step back and did some research on something else that could be causing these signs and symptoms and found a paper on Levator Scapula Syndrome.

The paper describes the origin of some forms of shoulder pain to the Levator Scapula muscle and how to treat the issue. According to the paper, I had been treating the condition pretty right on, but it alluded to the fact that an over-facilitated infraspinatus muscle on the ipsilateral (same) side could contribute to a dysfunctional levator scapula. Duh, right? The very next patient visit, I stressed the infraspinatus by resisting external shoulder rotation, and boom, the symptoms were perfectly recreated. I reformed my treatment plan to include some myofascial release of the infraspinatus muscle and within two weeks, the patient was right as rain.

As physicians we won't always get the perfect diagnosis on the first go round. Even more important than getting the correct diagnosis the first time, is recognizing you hadn't and rectifying that. It's all about putting the patient first.

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Perfecting the Weekend

This weekend I took a break from putting patients first and enjoyed myself a bit. Friday, my pals and I were first in the VIP line (no big deal) for the Brews By the Bay craft beer and food tasting at the Florida Aquarium. Needless to say we had a great time. There were over 200 beer vendors and over 100 handing out food, all with the back drop of live music, shark tanks, sea turtles, and any other creature of the sea you could think of.

Then just for good measure I hit the Bucs game on Sunday. I helped my uncle out by taking his tickets off his hands in the 5th row on the 50-yard line while he was out of town. On top of that, my Florida State Seminoles and Tampa Bay Buccaneers put wins up on the board. Pretty darn good weekend.

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Catch you guys on the flip side,

Dex

A Stressful Patient Encounter

Hello, all. Hope everyone is doing well. I had a pretty exciting day last week that I'd like to share with everyone. I'm going to set this up kind of like a case report, so try to read the case without looking at the last part of the blog, and try to formulate your own differential diagnosis and next appropriate steps in management. Mind you, this is a real case that presented to the clinic last week, so this does happen!

Case Report

A 24-year-old male who has been under your care for 3 weeks for insidious onset of back pain, presents to your office 3 days after his last appointment with a new chief complaint of difficulty urinating. Hopefully some bells are starting to go off already. The patient relates that after his treatment 3 days prior, which included IFC, ice therapy and a Thompson drop counter-nutation sacral adjustment, he has had difficulty urinating but his low back has been feeling much better. Upon questioning, the patient states he has been drinking about 120-170 ounces of water per day since the onset of urinary difficulty in hopes of having a complete void of his bladder, but has only experienced "dribbling" urinary flow, and feels as if he has to go every 10-15 minutes. The patient had not tried to forcefully urinate in fear of "hurting himself" and has not experienced any loss of control with coughing, sneezing or laughing. Patient denied any bowel issues, any burning with urination, loss of muscular function in the lower extremities, or any abnormalities in lower extremity sensation. It was suggested that if the patient had to urinate at any time during the appointment for him to try to forcefully push out the urine; he did go to the bathroom, but was unable to forcefully urinate. Before a physical exam could be performed the patient began to experience a deep cramping low back pain that referred somewhat to his flanks and down the lateral portion of both legs to about the knees. At this point the patient was told to make his way directly to the emergency room.

Thoughts?

So what are you thinking? By this time you should have at least 3 differential diagnoses rolling around in your noggin. The first, and most severe thought should be Cauda Equina Syndrome (CES). My other two differentials included nephro- or uretero-lithiasis (kidney or ureter stone), and possibly a urinary tract infection. The reason the patient was immediately asked to make an emergency room trip was to rule out CES and if surgery or decompression was necessary, he was at the hospital already.

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Cauda Equina Syndrome is a serious neurological condition that occurs when nerves of the spinal cord beyond the conus medullaris (the cauda equina) are impacted and the functions they control are disturbed. A disc herniation, a tumor, or any other space-occupying lesion could cause the neural compression. With the patient's history of aching low back pain, with progressive loss of the ability to use his detrussor muscles (the muscles which push urine flow), it was our concern that he may be on the verge of bladder rupture, and/or ascension of urine back into the kidneys which could cause a whole slew of other problems including hydronephrosis and maybe even death.

The patient was very fortunate that an MRI study of his lumbar spine revealed no compression of the cauda equina. I hope no one thinks that this was a waste of time sending the patient out for advanced imaging. As a physician you must always put the patient's well being above all else. There would be no way I would be able to sleep at night if I discounted a patient's signs and symptoms and down-played a condition which ended up hurting the patient indefinably. The patient was extremely relieved that he was CES-free, but he isn't out of the woods yet. He still is having urination issues, and therefore we referred him to an urologist for consultation. You have to know when something is out of your scope of practice, and not be too proud to refer someone to a physician who could help them.

Well, I hope someone took something away from this patient encounter of ours down here in the Florida clinic. Remember to always put your patient first, and an expensive procedure to rule out a life threatening condition will always be worth the money. If anyone has any questions on Cauda Equina Syndrome or appropriate management, shoot me an email and I'll do my best to find out any answers you may have.

Have a great week,
Dex