Dex's Blog

Hello everyone, and welcome to my penultimate NUHS blog. Yes, I know it's going to be very sad when I am longer writing about my entertaining weekends and insightful blunders with patients, but I am sure you will be able to press on. 

FSU vs. UF Game (Click photo to see full version)

Speaking of pressing on, I had to walk into the clinic this morning with my head a little lower than I would've liked. I, as some of you may know, am a huge Florida State Seminole fan. I love my alma mater and have stuck with them through thick and thin, and after this weekend, it will be no different. After a fantastic Thanksgiving Thursday, my old roommate and best pal, Rich, made the drive up to Tallahassee for one of the largest and long standing in-state football rivalry games--FSU vs. UF. It felt great being back in my old stomping grounds and hopes were high that we would best the Gators. Unfortunately, our hopes were deflated, as we lost a disappointing 37-26. To add insult to injury, my Tampa Bucs also lost a close match up against the now 10 and 1 Atlanta Falcons. I was not a happy camper last night, but some left over turkey, ham, and casserole did help a little. 

Being disappointed in sports is one thing, but what happens when you become disappointed when treating a patient with no results? At what point do you have to step back and realize that you may not be able to help a patient? Then once you have made that realization, whom do you send them to?

I have been writing mock narrative reports for the past week and came across one of my old cases in which this happened. I took over this particular patient from a graduating intern, who had been treating her for lower back, right hip and right lower leg pain. We had established that the patient had lumbar spine disc derangement, decreased core stability from two cesarean sections, and peripheral nerve entrapment of the peroneal nerve in the right lateral compartment of the lower limb as well as a pretty substantial gluten allergy. This patient was treated 2-3 times per week depending on her schedule, and would find mild relief after treatments, but after two months at this frequency she was still not experiencing any lasting relief.

At this point I reevaluated the patient and began another course of treatment. Prior, the patient was being treated with Cox Flexion and Distraction. I then switched to McKenzie end-range loading techniques (more extension-type therapy), which seemed to offer longer lasting relief. Still a month went by with very little change. Now, I started to pull my hair out. At that point I had to have "the talk" with my patient about possibly finding another treatment option. She was very apprehensive to any kind of injection or surgery, which is understandable and very common. The challenge then became finding another alternative to her care that would benefit her and she would be comfortable with. Together we decided that seeking out an established McKenzie certified practitioner might help, as I am not totally comfortable with some of the more advanced stages of McKenzie protocol. A month or so went by before the patient called the clinic, but when she did it was with good news and she was extremely happy that we made the switch.

I never looked at the situation as a failure on my part, or that I was losing a patient, because in the end something I did made her better. This should always be the goal as a doctor. Money will come and go, as will patients, and as stressful as it might be to keep your lights on in practice, you have to be able to sleep at night also. This patient ended up continuing to be treated by the other practitioner, but she did refer her husband, who is still an active patient.

I hope everyone has a quick and productive week. Everyone should be studying for finals already. Studying early always helps with the crazy amount of exams stacked in a two-week period. Make the final push of the trimester a good one.

Catch ya later,
Dex

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.

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

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.

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.

Catch you guys on the flip side,

Dex

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.

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 

Hello, again. What a weekend I had. After clinic last Friday, I met a few friends at Tampa International Airport and took off to Atlanta, Georgia. We flew up to meet another friend who had recently moved to Atlanta, plus attend the Music Midtown music festival. We could not have asked for a nicer weekend for a music festival; the sun was shining, the wind was crisp, and the music was incredible. My pals and I jammed out to Ludacris, Florence + The Machine, Neon Trees, and Pearl Jam throughout the day on Saturday. I made it home late afternoon Sunday, was asleep by 9:30 p.m. and ready to go this morning...for the most part.

With friends at the Midtown Music festival.

Today's blog somewhat plays into last week's submission, which spoke about being prepared for each patient encounter. Today I'd like to talk about peach pie. No, this isn't a foodie blog, and I won't be handing out a recipe per se, but last week I heard the analogy of peach pie, and today I'll share it with you.

So, to make a good peach pie the first thing you need is good peaches. If you make your way into the forest half-heartedly looking for peaches and end up picking up rabbit poop, you're going to end up with a pretty crappy peach pie. How does this story relate to seeing patients? If you are evaluating the patient and not looking for the right things, you end up with a "crappy" diagnosis. Get it?

As a doctor you have to think like a doctor; you have to put things together and look for things that aren't always readily apparent. Always remember, your patients haven't read the textbooks and may not always present exactly how the book tells you they should. An orthopedic test might yield a "negative" response to what its textbook definition is, but may in turn tell you everything you need to know in a significant other finding. It's all about looking for the right ingredients. Let the patient show or tell you what's wrong. Don't tunnel vision yourself into a diagnosis or orthopedic test finding and end up just picking up rabbit poop. Be present during each patient interaction. Look at every aspect of that patient and take something away from each thing they tell you, what they can do, and what they can't; it will all be leading you to the peaches you need for a quality diagnosis.

Pearl Jam at the Midtown Music festival.

I hope my analogy today made some sense. I tend to gravitate to the offbeat ways of learning, so this was right in my wheelhouse. I love dealing with patients; it's like putting together a puzzle. You really have to keep an open mind and look and listen to everything the patient says and does to find where all the pieces fit together. Man, I'm full of analogies today.

I hope everyone has a killer week. Remember to always keep an open mind, and never stop practicing!

Dex