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Showing posts from July, 2009

Lichen planus

The answer to yesterdays medical quiz was #4- oral lichen planus.

It is an autoimmune condition that causes inflammation on the lining of the mouth. It can affect the gums, tongue and lips, but is usually seen on the inside of the cheeks.

We see oral lichen planus during midlife, but it can occur any time and can last for years. Lichen planus can be found on the skin, scalp, nails and genitals. Like other autoimmune conditions, the cause is unknown but something triggers the inflammatory process in the mucous membranes.

The lip lesion could also have been squamous cell carcinoma and a biopsy can cinch the diagnosis. High potency corticosteroid gels are used as treatment.

Lip Lesion - You Be The Doctor

This 76 year old woman had a long-standing sore on the border of her lower lip. It was not tender and she denied any trauma or known exposure. What is the diagnosis?

1. Leukoplakia
2. Squamous cell carcinoma
3. Contact dermatitis to oral hygiene products
4. Oral lichen planus
5. Apthous stomatitis

Make your diagnosis and the answer will be posted tomorrow.
(from Consultant)

Medical Grand Rounds

Head on over to Captain Atopic to read the best of the medical grand rounds on the blogosphere. Good random reading on a number of health related subjects.

Cancer Screening Tests

I sat with non-medical friends last night and the discussion turned to "health", as it often does. One guy related the terrible story of a woman who went to her doctor with a certain pain which turned out to be cancer that had spread and she died within a week. The inevitable question; "How do you detect early cancer, so you can catch it and cure it?"

The answer I gave was less than satisfactory for my friends. In fact, they were a bit incredulous with the answer.

All cancer is genetic, in that it is caused by genes that change. Only a few types are inherited. Most cancers come from random mutations that develop in body cells during one's lifetime - either as a mistake when cells are going through cell division or in response to injuries from environmental agents such as radiation or chemicals.

Different types of cancer show up differently in the body. We have screening tests for some types of cancer. We can detect early breast cancer with mammography. We det…

Costs Skyrocket for Pharmaceuticals

I just heard from one of my patients that the cost of "Advair" (an inhaler commonly used for asthma) at the pharmacy was $160.00. That is the discounted price the patient pays WITH HEALTH INSURANCE.

I suspect the pharmaceutical companies are gouging as much as they can just in case health care reform comes along and changes things. How strong do you think the legislature will be against the Pharma lobby? Boston Tea party, anyone?

Medical Marijuana

In medicine, we say things come in "threes". Sure enough, I have written three prescriptions for medical cannabis within the past 2 weeks. One was for a patient to help manage chronic pain, one was for a patient who was losing weight with metastatic cancer and the third for a patient with multiple sclerosis and spasticity. Medical marijuana has been found to be effective in all three of these diagnosis.

In case you haven't been paying attention, much has changed in the marijuana world over the past few years. In the urban cities of California there are thought to be over 1000 dispensaries for medical cannabis. Patients with a prescription from an MD, can purchase marijuana to smoke, eat or in the form of lozenges and suckers. These public dispensaries usually get the product from small growers and have a selection of different types of marijuana to suit different problems.

In San Francisco there are 22 registered dispensaries of medical marijuana. There is no probl…
In case you missed it: Here is a link to a complete transcript of President Obama's address to the Nation on Health Care Reform. Embrace change! Read it now!

Creative Stool Collection

When doctors instruct patients to do a "stool collection" for diagnosis, we usually assume they will use the small container to collect the stool and then transfer it to the "already provided" lab specimen jars.

Not wanting to miss a thing...this patient devised his own system.

Primary Care Provider

I am ashamed to admit that I actually felt annoyed tonight over being referred to as a "primary care provider." It is hard to explain that after 21 years of education and another 23 years of practice as a specialist in Internal Medicine, I would be bothered by this.

One of my patients that I have cared for for 20 years was admitted to the hospital after going to the ER with abdominal pain. I was not informed of his admission and the "hospitalist" became the attending physician. The patient called me today from his hospital bed to inform me. He actually had a previously scheduled appointment with me in the office today and, good patient that he is, was calling to say he couldn't make it. He assumed I already knew he was admitted to the hospital.

I asked him to have the attending doctor call me as soon as he/she made rounds. I got the call from a young sounding hospitalist physician who did not know my name and wondered if I was the "primary care provi…

Sexual Side Effects of SSRIs

The SSRI drugs used to treat depression and anxiety are known to cause sexual side effects in many users. SSRIs include Paxil, Zoloft Prozac, Effexor, Lexapro and others. It is fairly common for patients to complain of low libido, dampening sexual desire and even decreased ability to have orgasm with these medications. The cause of these reactions is not known and there is no way to predict which patients will have these side effects. In my experience it is a rare patient that maintains their usual sexuality on SSRIs.

Many physicians do not feel comfortable talking to patients about the possibility of sexual side effects of SSRIs and they worry that warning patients might even "trigger" the change in sexuality. They also worry that patients who need the medication might decide not to take it and the depression will worsen.

Researchers at the University of Texas at Austin looked at educating patients about the sexual side effects of SSRIs and found that patients who were …

Is There A doctor On This Plane?

I was on a flight to Alaska (for a medical meeting) and the flight attendant came on the intercom "Is there a doctor on the plane? We need assist for a passenger." If you read my blog on Doctors as Good Samaritans, you already know my hand went up. This is the first time I've done an airplane rescue.

The 82 year old gentlemen was in first class (Alaska Airline first class is like coach..not very roomy), traveling to a cruise with his wife. He had gotten up to go to the bathroom and almost collapsed.

Doctors can assess a situation very quickly by just LOOKING at the patient. He was sitting in a seat, conscious, but pale and clammy. Pulse not detectable. Able to speak but not able to really give me a good history. A quick look at his chest as I unbuttoned his shirt told me he had had major cardiac surgery (Chest zipper sign). That already told me a lot.

First questions; "Are you having chest pain?" "No". "Are you nauseated?" "No&quo…

Airport Food

First it was the indignity of having to take off my shoes and walk on a dirty floor just to get through security at the airport. Add to that, the inability to pack a nice healthy meal to get you through a day and night of flying because you can't get it through security. As much as I would like to avoid airport food, even short flights require long stretches of time spent in the airport. There is no way to avoid eating airport food and that is bad for your health.

Some airports have a food court with some choices...if you are lucky enough to be in that terminal. Today I was not so lucky.

Hungry during a layover, I had only a few choices. I stopped in at the "bagel haven" and found a chicken sandwich (on a bagel of course). It actually had the calorie count at a whopping 1250! I don't even like chicken on bagels so that didn't seem like a good choice. I cruised down to the "deli" and found it was closed. The "pub" offered chili, pizza, h…

Nurse Shortage or Nurse Glut?

For years we have heard there is a shortage of nurses and as recently as today, the California Senate Education Committee approved a bill (AB867)to "address a severe nursing shortage in California." The Health Resources and Services Administration (HRSA) projects that 90% more RNs must be produced in order to meet the predicted need for one million new nurses in the American healthcare system by 2020.

So if there is such a shortage...why can't new nurse graduates find a position? I was pleased to pass on the name of a new RN school graduate who had great references from previous allied health care work and was told by the hospital;

"Virtually no one is doing a new grad training program at this time. We have made the commitment to "trickle in" some new grads this fall and received over 1000 applications for 5 positions. I might suggest this individual get their foot in the door as a nurses aide, phlebotomist or some other non-nursing job. Unfortunately, …

Summer Reading and Summer Tipping

I just finished a great read that I would like to pass on. It is called "The Help" by Kathryn Stockett. It takes place in Jackson, Mississippi during those transformative years of the 1940's through the changing 1960's. It is written from the voice of various "negro" maids who stayed with families for years and raised the kids and ran the households for their white employers.

The "Jim Crow" years of extreme segregation were not much better than slavery. Everyone had their place and these wonderful maids were constantly shown where their place was. They held the homes of the white southerners together and then went home and toiled in their own shanty houses.

The southern women could employ a maid for 20 years (below minimum wage) and never really know who she was or about her life. After all, it was a "privilege" to be welcomed into the white home to be "part" of the family. But make sure you never use the same toilet.


Welcome World Blog Readers

I get a kick out of my tracking software and enjoy seeing the visits to EverythingHealth from around the world. I am amazed that the internet works to connect us. In the last 24 hours I welcome: Jakarta, Guam, Australia, Nigeria, London, Anchorage, Delhi, Manila, Edinburgh, U.K., Canada, Saudi Arabia, Poland, Japan, Spain, Chile, Mexico and Costa Rica. Come back soon and I'll be humming "We are the World".

Estrogen and Progesterone for Menopause

"If you wait long enough, the pendulum will swing back", is a statement I have made to women patients who had concerns about taking estrogen and progesterone for menopause symptoms. In 2002 the Women's Health Initiative study was all over the news and it implicated hormone replacement therapy (HRT) in causing breast cancer, heart attack, and strokes. No wonder women freaked out, stopped taking hormones and decided to go "Au natural" through the aging process.

A few years later, Oprah started having hot flashes and the subject has been open for more discussion. "Natural" (and unproven) treatments have sprung up and women are more confused than ever about what is safe to deal with hot flashes, sweats, foggy thinking and aching joints that accompany menopause in many women.

The North American Menopause Society (NAMS) has published a formal consensus opinion after extensive review of the current scientific knowledge and health management. They have stat…

Bloggers Holiday

I'm taking a week off from EverythingHealth. Enjoy early July and click on my side links for great medical blog reading. Better yet, click on the "followers" and become a follower of EverythingHealth. I'd like to return and see lots more added. See you in a week with more health news, tidbits and opinions.

Should You Send a Bill after a Patient Dies?

I logged onto a physician forum website and came across the question; "Do you charge an uninsured man's family after he dies?" The patient was in the hospital for a month and the doctor cared for him daily. The man was not insured but the patient's finances are enough to pay cash for the entire hospitalization. The doctor questions if he should bill the family after the patient died?

My first though was "No, just absorb the losses. The situation is unfortunate and the family will have enough problems without receiving doctor bills." As I read the comments on the site however, I realized no one else thought that way, and in fact, I could see the wisdom of the replies.

Most comments were something like, "You provided service and you should be compensated". Or "We all have bills to pay and they sure seek me out when I owe them - the lawyer, the credit cards, even the grocery store." Or "If the plumbing stopped up at the man's …

FDA Recommends Ban on Vicodin/Percocett

I must admit my jaw dropped when I read the headline about the FDA recommending a ban on two popular painkillers...Percocet and Vicodin. Both of these drugs are combination drugs, which means they combine another ingredient with acetaminophen (AKA: Tylenol). Tylenol is available over the counter and Percocet and Vicodin both require special "secure" prescriptions, yet it is the acetaminophen component that the FDA is worried about.

In 2005, over 28 billion doses of these meds were bought by patients in the U.S. (Don't you wonder who counted?) Let me repeat...28 billion. The FDA expressed concern because of tylenol overdoses and liver damage from too much acetaminophen. They reported more than 400 people die and 42,000 are hospitalized every year from overdoses.

None of the policywonks asked, but I could tell them that pain control is a huge problem for physicians and patients. We try to use as little drug as possible but pain that does not respond to over the counter…