Saturday, September 29, 2012

Skin Rash-Pityriasis rosea

My 17 year old son showed me the strange rash that was developing on his chest and back.  It was itchy and each day seemed to be getting worse and worse.  The rash spread around his back and under the arms but spared his face and arms and legs.  After examining the pattern, I was sure of the diagnosis...Pityriasis rosea.

This strange rash occurs in the spring and the fall and mainly strikes young adults. (I did diagnose it once in a 35 yer old woman).  We think it is a virus but it doesn't seem to spread from person to person and it is usually quite isolated.

The symptoms start with a "herald patch", one larger spot that develops into a wider, pinkish, scaly rash over a week or so.  The red, raised spots can last for up to 12 weeks but usually resolve by 4-8 weeks.  As seen here, it is mainly on the body trunk.

There is no treatment for Pityriasis rosea except patience and antihistamines for itching. 

For you wordophiles- Pityriasis comes from the Greek "bran" and refers to flaking or scaling of the skin.  Rosea comes from the latin word meaning "pink" or "rose-colored".  The condition was first described in 1860 by French physician Camile Gibert.

Monday, September 24, 2012

Obama vs. Ryan at AARP

President Obama and Vice-pres nominee Paul Ryan went head to head at the recent AARP convention in New Orleans and addressed the group on Medicare and the Accountable Care Act (aka: Obamacare).  Their appearances were back to back.

Ryan told the audience,"The first step toward a stronger Medicare is to repeal "ObamaCare" because it represents the worst of both worlds".  He argued that the federal health reform law would "funnel $716 billion out of Medicare to pay for a new entitlement we didn't even ask for."  He also said that Romney's plan to transition Medicare into a premium support program "empowers future seniors to choose the coverage the works best for them" and is "designed to guarantee that seniors can always afford Medicare coverage."

The response from the group was lackluster with little applause and many boos during his speech, according to the Washington Post.

It was no surprise that Obama, who addressed the convention via satellite, defended Obamacare and told the crowd that the GOP plan would leave them "at the mercy of insurance companies."  He also addressed Ryan's remarks that $716 billion was cut to fund ACA and said, "It's simply not true.   Those savings are part of what allows us to close the doughnut hole, provide the preventive care, and is actually going to extend the life of Medicare over the long term."

AARP is a nonpartisan organization that is the nation's largest and most powerful senior's lobby.  AARP has supported the Affordable Care Act.

Sunday, September 23, 2012

Reduce Your Risk of Cancer

Imagine reducing the risk of getting cancer!

There are an estimated 1,638,910 new cases of the dreadful disease diagnosed in 2012 in the United States, not including nonmelanoma skin cancers.
Cancer is not just one disease but is a term that represents more than 100 diseases with different causes. The basic unit of life is cells, and cancer always begins in cells. When the normal process of cell growth and division is altered, these abnormal cells divide without control and can form tumors and invade nearby tissue. It is a frightening diagnosis to even think about for most people.

Hundreds of studies link lifestyle and “daily habits” to the risk of developing cancer, and researchers at a recent meeting of the Union for International Cancer Control World Cancer Congress 2012  reported that more than 50 percent of cancer could be prevented if people simply implemented what is already known about cancer prevention.
Some of these are lifestyle changes and some are interventions and discoveries that have been proven to prevent certain cancers.
The No. 1 lifestyle factor for causing cancer is smoking. Tobacco use causes cancer of the lung, esophagus, larynx, mouth, kidney, bladder, pancreas, stomach and cervix. Twenty-two percent of cancer deaths per year are caused by tobacco use, so stopping smoking brings the biggest benefit to both men and women. And the benefit starts as soon as you stop.
Other proven cancer preventions are:

*Limiting fats in the diet and keeping body mass index in a normal range. BMI is calculated using your height and weight.  A BMI between 18.5-24.9 is considered normal.  Overweight is 25-29.9 and over 30 is obesity.  This is another way of saying don’t get fat. Obesity increases the risk of prostate, liver, gallbladder, pancreas, stomach, ovary and cervical cancer. High fat diets are linked to colon, lung and postmenopausal breast cancer.

*Implementing widespread infant and childhood immunization programs targeting two viruses: Human papillomavirus (HPV) and Hepatitis B.  Hepatitis C does not yet have a vaccine but early detection and treatment can prevent liver cancer. HPV causes cervical cancer and chronic hepatitis can lead to liver cancer.

*Taking tamoxifen and raloxifene, which in high breast cancer risk postmenopausal women,  reduced the risk for invasive breast cancer by 50 percent.  Additionally weight loss after menopause reduced breast cancer risk

*Daily intake of a low-dose aspirin which reduced mortality from colon cancer by 40 percent. Aspirin also limits spread of cancer through its action on platelets. Screening for colorectal cancer also reduced mortality because small pre-cancer polyps can be removed before they become a problem.

*Minimizing occupational exposure to asbestos, formaldehyde, arsenic and diesel and certain environmental chemicals like BPA that is found in reusable plastic food containers.

*Limiting alcohol binging or over-drinking. Heavy drinking is responsible for 4.6 percent of cancer cases in men and is the sixth-biggest risk for women.  More than three drinks a day is considered dangerous drinking . And  yes, that includes beer and wine.

*Avoiding excessive sun exposure and tanning salons.  You only need 10-20 minutes of partial sun exposure during the high sun 10-2 time period to get enough Vitamin D a day.  So the average person just walking around outside  with sunscreen will get enough sun without even trying.  If you have had a skin cancer, there are no safe levels after that.  Everyone should protect with sunscreen and clothing during the high risk time.

None of these lifestyle changes or interventions will guarantee a cancer-free life if done independently of the others or erratically. But there is ample evidence that healthy living with a diet high in fruits, vegetables and fiber, no smoking, exercise and limited alcohol really does lower the risk of cancer and heart disease in all people. Other interventions like aspirin, immunizations, colorectal screening and hormone blockers are beneficial after a discussion with your doctor, taking into account your own risk factors.

The good news is that it’s not “all in the genes.” Cancer risk can be lowered.

(This article was first published in The San Francisco Chronicle)

Friday, September 14, 2012

The Battle Sign

The answer to yesterdays NEJM diagnostic challenge was #2 - Fracture of the temporal bone.  This patient has ecchymosis (bruising) behind the left ear.  This is the classic "battle sign" that is seen with underlying trauma to the temporal bone of the skull. 

My patient had struck her head very hard on a metal cabinet...hard enough to sustain a concussion and a small skull fracture with blood that is pulled down by gravity in the tissue plane behind the ear.

These fractures heal by themselves but we need to be on guard for subdural hematoma or any change in mental functioning.

Thanks for your guesses.

Wednesday, September 12, 2012

What is the Diagnosis?

I love this weeks Image Challenge from The New England Journal of Medicine because I had a patient with these exact findings about a month ago.  You be the doctor and make your best guess for the diagnosis.  Post a comment and check back for the answer tomorrow.

This patient presented with hearing loss and left ear fullness.  What is the diagnosis? (click on the image for a better view)

1.  Cholesteatoma
2.  Fracture of the temporal bone
3.  Ochronosis
4.  Otomycosis
5.  Relapsing polychondritis 

Winner gets bragging rights at your next cocktail party!

Tuesday, September 11, 2012

The Best Jobs in Health Care

The health care sector is a good place to look for job opportunities and to plan career goals.  The workforce is expected to increase 27% through 2014, compared with 14% for all industries combined, according to the Department of Labor.  But special education is needed to enter the health work force and now CareerCast has posted the top jobs based on stress level, solid job security, work environment, training and income.  Here is how the list came out:

1.  Dental hygienist
2.  Audiologist
3.  Occupational therapist
4.  Physical therapist
5.  Optometrist
6.  Pharmacist
7.  Physician assistant
8.  Chiropractor
9.  Primary Care Physician
10. Registered Nurse

Dental hygienists were first based on a median salary of nearly $70,000/year, low stress, a job growth outlook of 38% by 2020 and a small educational investment in a two year associates degree.  They set their own schedules, work in comfortable environments and never have to take their work home!

Compare that to a Primary Care Physician who makes more than $200,000 on average a year but they pay expensive malpractice insurance, have patient demands 24/7, have high stress levels and can incur training debt of over $200,000.  Additionally the post graduate training after a college degree is another 7 plus years, delaying any income potential that can never be caught up.

Occupational therapy and Physical therapy also have  high rankings and with the baby boomer's aging, the growth potential is strong.   But the physical demands are higher and patience is needed as they are dealing with injuries and disabilities.

The stress level for a Registered Nurse was ranked higher than the PCP.  The stress level for a chiropractor was as low as the dental hygienist and the audiologist has the most stress free job of all.

Friday, September 7, 2012

Primary Care Payment Struggles

The way doctors bill and get paid is a byzantine process and it is no wonder the "private practice" doctor is an endangered species.  It takes a keen sense of business, a love of medicine-not money, and a sense of humor to survive.  Here is my latest story.  You can't make this stuff up....

I saw a patient in September 2001  (note the date...11 years ago).  I billed her insurance company, Employers Mutual, LLC for $185.00.  I never got paid.

Now fast forward to September 2012.  I received a document from an attorney who informs me that he is a receiver in a class action suit and $48 million in unpaid claims is being claimed.   It appears I am a Category B creditor and will receive a pro-rata share.  He recovered $16, 559, 576.88 and took $4,831,214.40 in attorney fees.

It looks like in the future (?) I may receive a check for $37.00.  No promises are given.

I remember my practice back in 2001.  I worked about 80 hours a week and never even had enough money to fund a retirement plan for myself.  Getting paid a fraction of my charges was common and getting stiffed by insurers completely was also par for the day.

 I am happy for the windfall of $37.00 for the work I did 11 years ago.  I still see patients in a private practice but my main income now comes from my employed administrative position.  Waiting 11 years for a fraction of payment is not a sustainable business model.

Bedbug Bites

The answer to yesterday's medical diagnostic challenge is #1 - Bedbug bites.  Bedbugs frequently attack exposed areas of the skin and are attracted to humans' high body temperature.  Cutaneous (skin) reactions to bedbug bites are characterized by erythematous (red) or "hive-like" papules.  Lesions observed in a linear or cluster formation are typical. 

This patient's bites responded to treatment with topical glucocorticoids.

Wednesday, September 5, 2012

What is the diagnosis?

'This is a great diagnostic challenge from The New England Journal of Medicine.   Let's see if you can make the diagnosis.

1.  Bedbug bites
2.  Dermatitis herpetiformis
3.  Ecthyma
4.  Guttate psoriasis
5.  Lichen planus

Make your choice in the comments column.  The answer will be posted tomorrow.

Saturday, September 1, 2012

Beware of Fake Viagra

If you have a computer, you have certainly seen the many ads for on-line pharmacies where you can get just about any medication mailed to you.   Beware of fake Viagra (sildenafil).   According to researchers at the World Meeting on Sexual Medicine, they reported an analysis of tablets purchased from 22 different websites.  They found 77% of the samples were counterfeit and contained only between 30%-50% of the levels of active ingredient.  Some were adulterated with dangerous chemicals.

None of these phony websites required a prescription and 91% offered "generic Viagra" which the FDA has not yet authorized.  The fastest growing drug class in the world is counterfeit medications and it isn't just Viagra.

Not all on-line pharmacies are crooks.  Some Canadian and UK pharmacies deliver a quality product for a fraction of the price. They require authorized prescriptions from the doctor.  But if you see something that is too good to be is.  Not true that is.

When to Use Urgent Care

We all know that Emergency Departments are over-crowded with long waits and exorbitant fees.  Free standing Urgent Care is a great solu...