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1209717_19610439The focus of this web site is medicine. In this blog, you’ll read about patient stories. The situations have been changed to be HIPAA compliant. Factual statements may or may not be true. I may change ages, gender or presenting complaints about patients. I may even entirely make up complete patient encounters from my fertile imagination. Trust me, if you think I’m writing about you, I’m not. There are billions of people in this world and readers send me stories about patients all the time. It isn’t you.
You’ll also read a lot about health care policy. I may throw in posts about life lessons, computers, and will even throw in family stories once in a while. If you’re looking for articles about politics, sports, or celebrities, you’re in the wrong place – unless the topics have some relationship to medicine.
If you want to add a guest post or to cross-post something from your blog, or if you have a patient story you want me to write about, e-mail me. See more information in the “About Me” page.

What’s The Diagnosis 23

A patient presents with a rash to her back for the past 24 hours. It doesn’t itch, but it does burn at times. She hasn’t had the rash before. She had no fever. There were no new exposures to soaps, detergents, etc.  She was wearing no new clothing. She did begin bowling in her bowling league two days before the rash appeared. History of hypertension only. Taking lisinopril and aspirin daily. No other complaints. The distribution of the rash provides a clue to the diagnosis. What’s the diagnosis? How should the rash be treated? Scroll down past the pictures for the answer. . . . . . . . . . . . . . Answer: Hot Tub Folliculitis (Pseudomonas folliculitis) The final diagnosis was not shingles. This rash looks similar to shingles (zoster), but the lesions with shingles (and chicken pox) tend to be vesicles (filled with clear fluid) and not pustules (filled with white/yellow material). Also, shingles almost always involves only one side of the body and one strip of skin (a single “dermatome“). Before I asked the patient the question that led to the diagnosis, the rash seemed to be some type of contact dermatitis. It spared the middle of the back (along her spine) and it spared the area above her shoulders and below her waist. There was just a little bit of the rash on the front of her legs. So I started asking her. Are you *sure* you didn’t wear any new clothes in the past few days? A leotard maybe? New underwear? Go swimming and wear a new swimsuit? Remember how the patient just started her bowling league a couple of days before the rash began? Guess what she did after the game. She went and sat in one of her teammate’s hot tubs and drank beer. The nozzles from the hot tub were pointed right at her sides. This is a classic case of Hot Tub Folliculitis. Causative organism is pseudomonas aeruginosa. The rash is usually multiple painful red spots and some have pus in the center as shown in the last picture above. Treatment is generally … nothing. The rash goes away on its own in a few days to a week. Domeboro solution may soothe the rash. Some sources recommend dilute vinegar compresses to help speed healing. Oral antibiotics (usually fluoroquinolones like Cipro and Levaquin) generally don’t help much, but may be needed if the rash doesn’t resolve. More sites with information on Hot Tub Folliculitis include Wikipedia, WebMD, and About.com.

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Healthcare Update — 12-31-2015

How well are patients in one Norwegian emergency department having their pain managed? According to this study in the Scandinavian Journal of Trauma, Resuscitation & Emergency Medicine, not very well. Of patients with moderate to severe pain (58% of all study participants), only 14% received pain medications. The authors note that “Pain management is accepted as a quality indicator of care, and additional focus on strategies to improve pain management in the ED is necessary to ensure that all patients receive optimal pain assessment and treatment.” First of all, not all patients come to the emergency department with pain complaints. It gets idiotic when asking patients with a rash, a runny nose, or a cough about their level of pain. Second, the study required that anyone with a pain rating more than 3 of 10 be treated for pain. Demanding medication be given for 4 of 10 pain? Give me a break. Third if you want “strategies” to improve compliance, just take a page from the US playbook. Call pain the “fifth vital sign,” create some silly agency that monitors compliance and documentation of irrelevant metrics (you can call it NJCAHO), and create another agency to send out patient satisfaction surveys having little or nothing to do with assessing proper medical care. You’ll get 90+ percentile compliance guaranteed. Of course, then you’ll also create an incentive to prescribe an order of magnitude greater number of pain medication prescriptions, the number of deaths from drug overdoses will skyrocket, you’ll have to create a whole different system to monitor and track patients who become addicted to the pain medications and try to con doctors into writing prescriptions for more medications, other countries will make fun of your citizens for all the pain medications they use, the morale of the healthcare providers in your country will take a hit, and eventually fewer people will want to go into the healthcare profession. But the pain will be better controlled. Want to see what you’ll look like when you stick to that diet you’re beginning tomorrow for a New Year’s resolution? This web site will give you simulated before and after pictures. Unfortunately, it only has simulated females and it appears to be less accurate as the weight increases. But you can print up a picture to tape to your bathroom mirror to remind you of your goal each morning. Want some motivational quotes to paste under the before and after pictures? This Inc. article gives you 101 of them. Here are a couple of good exercise-related ones: The secret to getting ahead is getting started. No matter how slow you go, you’re still lapping everyone sitting on the couch. I’ve tweeted about this site before, but for those of you who missed it, if you need to get a full copy of a scientific article, but can’t afford the $30+ fee to download it, the site Sci-Hub will allow you to download full copies of research papers. Just paste the URL of the article into the site and it will provide you with a full copy of the article. It has 47 million articles in its library. Study in Gut magazine shows that taking proton pump inhibitors (“PPIs”) such as Protonix, Aciphex, Prevacid, Nexium, Prilosec, and Dexilant is associated with unfavorable changes the bacteria in the intestinal microbiome. These changes may explain increases in the rate of Clostridium difficile (“C. diff”) infections in PPI users. The study also notes that the changes in gut flora associated with PPI use are “more prominent than the effects of antibiotics.” Attack of the Glasshole 2.0 nears. Newest ...

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Unique Way Of Looking At It

“Doc, he’s been having some problems at home with his wife for the past few months. Took up drinking and now he’s been tipping the bottle on a daily basis.” Wasn’t exactly what we wanted to hear for a patient having chest pain. The patient’s story was concerning for heart disease and he had several cardiac risk factors, so after his initial labs came back normal (and after we excluded pancreatitis), he got admitted to telemetry for further evaluation. But it wasn’t quite that simple. When the floor nurses heard that he was a daily drinker for the past few months, they refused to accept the patient. Didn’t want him going into DTs on the floor, ya know. So he got put onto the DT pathway and sent to the stepdown unit. His initial CIWA score was elevated, so he got his first dose of Ativan in the emergency department. “What’s that for?” he asked. The nurse explained “It’s a pill that keeps your body from having alcohol withdrawal symptoms. It has effects on the brain similar to alcohol, but allows us to slowly lower the dose to keep you from having shakes or even seizures.” “Ah. I get it. A six pack in a pill, huh? I may need to get me some more of these.” “I’m sure you will, sir. I’m sure you will.”

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Healthcare Update 12-28-2015

A must-read opinion article by Theresa Brown in the New York Times. When health care reimbursement is predicated on documentation, documentation replaces the work being done. Charting is valued more than medical care. Teams of health professionals are hired not to provide medical care, but solely to evaluate the appropriateness of what other health professionals documented while trying to provide medical care. Many commonly-prescribed drugs being used in cocktails that result in overdose. One popular mix includes methadone, gabapentin, Klonopin, clonidine, and an over the counter allergy medication. During the first 6 months of 2014, of the 501 overdose deaths in Massachusetts, Fentanyl was present in 37% of overdose deaths while Klonopin and/or Xanax were present in 13% of overdose deaths. Gonorrhea becoming increasingly resistant to antibiotics. “Super gonorrhea” showing up in England. England’s chief medical officer Sally Davies warns that the sexually transmitted disease could soon become untreatable. Scary thought. Both parties in a non-monogamous relationship should take this age-old advice: “Don’t be silly, protect your Willie (or your Wilhemina).” Then again, Maryland apparently thinks that increasing taxes on alcohol will stop the spread of gonorrhea. When alcohol taxes in Maryland increased, gonorrhea rates decreased by 24%. The article concluded that “Alcohol tax increases may be an efficient strategy for reducing sexually transmitted infections.” For this to be true, the study must assume that a significant proportion of Maryland residents are sex-crazed inebriates. This is the classic “correlation” versus “causation” argument. Just because the sun rises when the cock crows doesn’t mean that the crowing causes the sun to rise. And we certainly couldn’t prevent the sun from rising by preventing the crowing. Then again, governments wouldn’t make any tax revenue by assaulting chickens. Good news for wart treatment: There is a therapy more effective than expensive visits to the dermatologist for liquid nitrogen cryotherapy. Bad news is that you have to walk around with duct tape stuck to your wart for six weeks. That’s right … duct tape treatment was effective in removing warts in 85% of cases while traditional freezing was effective in only 60% of cases. The study was from 2000-2001 and had only 61 patients, but it’s worth a try. Oh, and if you want to know how to get your Willie unstuck from inside a PVC pipe, there was an article in the “related content” for that as well. Think blowtorch. I actually had to click off of the site because the articles in “related content” kept piquing my interest. Patients gone wild. Ohio’s own Cynthia Squire arrested for “verbal onslaught” against hospital staff and Port Clinton police officers tried to calm her down in Magruder Hospital emergency department. Ms. Squire threatened to kill her boyfriend and her daughter’s boyfriend and called “everyone around her vulgar names.” In other news, Port Clinton police then responded to another call and arrested several reindeer for disorderly conduct after their interactions with an unnamed reindeer with a red nose. Infants and toddlers being prescribed strong antipsychotics such as Risperdal? I’m a little leery about this idea.

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Prayers for Harold at Christmas

Some of the WhiteCoat family spent our holiday a little differently this year. I gave my oldest daughter some money. Usually I’ll go out and buy things for less fortunate people and donate them. This year, I gave my daughter the money. I told her she could spend it on whatever she wanted, but she couldn’t spend it on herself or her friends and she couldn’t keep it. Her brain went right to work. She spent $100 on food and lunch bags, then spent another $75 in two different Salvation Army stores purchasing all of the remaining hats, gloves, and blankets. And we got a slider whistle. Had to get one of those. We went to a pharmacy and got a few bottles of medications. Then we went to a department store and spent the rest of the money on toys. Once we got home, we wrapped all of the toys and put ages for the children on the outside of the wrapping. We wrapped up the medication in a bag and put a $50 gift card inside. Then we made about 70 lunch bags full of sandwiches and other food. My daughter made sure to write “Have a Merry Christmas. Someone is thinking about you” with red marker on every bag. We packed everything in the car, talked my son into joining us for the ride, and took off. First stop was an apartment complex. The grandmother to one of my daughter’s friends was having trouble paying for her medications. My daughter remembered what some of the medications were and picked up a few bottles of the over the counter meds. The grandmother had no idea who my daughter was when she knocked on the door. My daughter was wearing fake elf ears and told her that there were some medications in the bag and a gift card to purchase some more medications later. Merry Christmas! And she was off. Next stop was the nearby homeless shelter. We dropped off a bunch of wrapped toys for the children. A tear rolled down the face of the man at the desk. “This will mean so much to the kids. Thank you.” A tear rolled down all of our faces as we walked back to the car. The final destination was Chicago. More than an hour’s ride and we sat in a lot of traffic, but we finally made it into town. We got off on one of the exits and there were three people hanging out on the side of the street. I slowed the car down to hand a lunch bag to an older lady, but the light was green and the car behind me laid on its horn and flashed its lights. I pulled through the intersection and pulled over to the side of the road. The older lady was stuck on the other side of the intersection. The two other fellows ran up to the car and we gave them lunch bags. One of them took off walking while ripping the wrapping off of one of the sandwiches and stuffing it into his mouth. “Hey – can you give one to the lady across the street?” I asked the other fellow. “Sure. No problem. I’ll probably give her mine, too. She doesn’t have much.” We gave him a couple of extra lunch bags. We’d catch people hiding in alcoves. My son would jump out of the car with a lunch bag and some gloves, run into an alley into which few others would willingly venture, and come out with a big grin on his face. My daughter would walk up ...

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Healthcare Update – 12-23-2015

Patients gone wild. Man shot and killed in UCLA Medical Center emergency department after attacking police and attempting to grab officer’s gun. Jenny McCarthy, call your office! At-risk patient nearly dies from streptococcal infection after failing to get immunizations. Another example of how insurance for medical care and access to medical care are completely unrelated. Massachusetts has one of the highest rates of insured patients in the country, but emergency department visits for mental health issues are skyrocketing, 76% of emergency department visits are for care after the 9-5 hours of most providers, and 60% of consumers with ER visits were unable to get a visit as soon as needed to prevent an ER visit. But at least the patients have INSURANCE! Should patients be able to record their surgeries? Sure. Just as soon as everyone can record their court hearings without paying gobs of money for a court reporter, as soon as everyone can record all deliberations of Supreme Court justices, as soon as everyone can record all private discussions with their attorneys, and as soon as everyone can record all the conversations that their legislators make with lobbyists. Why should some procedures be secretive while others have open access? I don’t always agree with Megan McArdle, but she’s spot on with this article. There’s no miracle cure for health care costs. Money quote: Doctors, hospitals, other providers don’t care about the prices for individual services. They care about whether they can cover their costs. If you drive down the price of one thing very low, other prices may rise to compensate. If you look at just some of the prices, you may seem to have won a great victory on health-care costs. But if you look at aggregated spending, you may still find that you are losing the war. Medical costs will always be a game of mousetrap and mouse. When the mice can no longer find enough food, they either leave or they die.

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