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Category Archives: Today In the Office

Epley Maueuver Rocks!

April 15, 2011 Dr. Pullen

I finally tried the Epley maneuver a few months ago after struggling with vertigo for a few weeks. As a family physician I was certain that I had benign paroxysmal positional vertigo (BPPV), and that it would likely improve if I just waited it out, but I was getting pretty tired of walking around the office like Frankenstein, head held still, trying not to move suddenly. For years I had been referring my patients with persistent BPPV to ENT doctors for repositioning therapy, but had not been doing it in the office. Most of the time patients just get better in a week or two without specific treatment.

Finally I used Dr. Google to look up home repositioning therapy after one of my younger partners told me about the Epley maneuvers. These are really pretty simple, and I did them myself with excellent relief. Within 2 days I was about 95% free of vertigo symptoms. Yesterday morning I awoke with a recurrence of the vertigo again. I use my iPhone as my alarm now, and it was lying on the floor charging at the bedside. On rolling over to turn off the alarm I got so dizzy with the whole room spinning that I had to quickly lie down and let the alarm keep going. I finally managed to get the alarm off, but felt pretty lousy. I got to the office and went right to an exam room, and put myself through the Epley maneuvers, with only slight help. I struggled through a reduced workload day, and last night again did the maneuvers.

I took care last night to avoid rolling to the left, my affected side, and this morning am much better, at least 90% improved, with no true vertigo. For those readers who say, “What’s vertigo?” first I’m happy for you that you’ve not experienced this miserable symptom. It is the type of dizziness where there is a sensation of spinning or movement of yourself or the surroundings. It feels like motion sickness, often associated with nausea and severe imbalance. It can be caused by inflammation or other disorders of the inner ear, particularly the vestibule (semi-circular canals). BPPV is a type of vertigo where the fluid and tiny granules in the vestibule get out of position, leading to a sensation of motion and vertigo.

I think I managed to practice for 30 years without knowing about the Epley maneuver because John Epley didn’t describe this treatment until 1980, the year I graduated from Med School, and somehow I never heard about it until recently. The procedure is really simple, though it can produce really miserable vertigo during the procedure for many patients, and can be tough to do without support from a confident helper, like your physician if your vertigo is severe. It’s also important not to just assume your vertigo is BPPV as there are other more serious causes that may need diagnosis and treatment. If there is any doubt of the diagnosis see your physician for evaluation. Here is a You Tube of the maneuver:

As you can see, it’s not really difficult to do, and I now often suggest to my patients to do it at home, or sometimes do it with them at the office. Now I can just send them to this post for details :.) For more information on the Epley Maneuver and vertigo and dizziness see a later post on the Epley Maneuver.

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Painless Jaundice

April 6, 2011 Dr. Pullen

I saw an older male patient yesterday who had painless jaundice. This is one of the conditions every medical student learns has cancer until proven otherwise. Although there is a big list of causes of jaundice, in older adults who develop jaundice without having significant abdominal pain a less than acute cause of obstruction of the outflow of bile is the most common cause. Unfortunately the cause of this obstruction is most often a cancer that blocks the outflow of bile.

This patient had presented to our same day clinic three days previously, and had liver function tests as well as testing for hepatitis A,B and C, as well as an abdominal ultrasound ordered. The LFTs showed significant elevation of the transaminases, a bilirubin of 5.6, and the tests for viral hepatitis were all negative. The ultrasound added some hope with a gall bladder full of stones, but no common bile duct stone seen on the scan, and the common bile duct was dilated to 16 mm, far larger than normal.

The anatomy of the outflow of bile from the liver and gall bladder is fairly simple to think about, and the pancreatic duct empties into the common bile duct near where the cystic duct from the gall bladder joins the common bile duct. The head of the pancreas is near this area, and cancer of the head of the pancreas can cause obstructive jaundice of the bile duct. Cancers of the gall bladder or common bile duct can also cause jaundice as a presenting symptom. Cancers metastatic to the liver can also cause jaundice by obstruction of intrahepatic bile ducts.

I’m praying that this patient has a common bile duct stone and obstruction that can be cured with removal of the stone and cholecystectomy, but know that it is likely that the stones are not the problem.

Other causes of jaundice include the many types of cellular inflammation of the liver called hepatitis, overly rapid breakdown of red blood cells called hemolysis that can overload the liver with hemoglobin that is metabolized into bilirubin and can lead to jaundice, bile duct disorders like the autoimmune disorder called primary sclerosing cholangitis, and other causes of bile duct obstruction. Still common things being common I am anxiously awaiting word from my gastroenterology consultant on the results of the ERCP (endoscopic retrograde cholangiopancreatography- a test where a scope passed through the stomach into the duodenum is used to inject dye into the bile and pancreatic ducts) to see what is causing my patient’s jaundice symptoms.

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Unintended Consequences

March 4, 2011 Dr. Pullen

The Law of Unintended Consequences: Actions of people—and especially of government—always have effects that are unanticipated or unintended. (1)

From the Noise to Signal social media cartoon

Starting in January most OTC products, excepting some medical equipment like crutches and diabetic supplies, now cannot be purchased with flexible spending account dollars without a physician prescription. One of my partners asked last week how I am dealing with this issue. He has had several patients ask for a long list of prescriptions for OTC products so that they can use their FSP to pay for these things with pre-tax dollars. This puts us in a no-win situation. Either we spend the time to write several prescriptions for whatever the patient asks for or spend a similar amount of time explaining why we decline to write the prescriptions.

It is very likely that this is a great example of the law of unintended consequences. The law was clearly written to increase tax revenue. The unintended consequence is that patients are now asking for a prescription for things like aspirin, Tylenol, body lotion, dandruff shampoo, shoe inserts and nearly anything else you can imagine. Here are some of the issues I have with this situation:

Even in the highest tax brackets the savings for some of these items just are not worth my time to write and document a prescription: Aspirin cost $2. Tax savings potential $0.66
This is one more task added to the primary care physicians to do list after patients are seen to accomplish before we can go home. It takes at least 30 seconds to open a patient’s chart, write a prescription, and get the Rx to a patient’s pharmacy or to leave at the front desk for them to pick up. Patients often ask for prescriptions for multiple items, some requiring more time than just writing a prescription.
These requests use up minutes in a patient visit that can be better used for other care. Do I want to spend my time gathering enough information to help a patient adjust their insulin and eating to control their blood sugar, or writing prescriptions for their corn pads, aspirin (see aspirin side effects), body lotion and anti-perspirant.
Once a physician writes a prescription they incur some liability for the product used. Let’s say a patient uses a product that they ask me to prescribe. If they then have a problem in any way related to that product you can bet my name will be added to the list of defendants in the product liability lawsuit.
I really don’t know about much about many of the OTC products patients use. Some of the herbal and supplement products used have labeling that is nearly indecipherable, and certainly nothing I would ever recommend. Should I now be writing a prescription for these as a money saving service to patients? I think I’ll say no to these requests.

Really this new law is a good example of a decision made with one intended consequence that leads to another unintended consequence. In this case the government is responding to concerns about the cost of health care, so they have tried to save costs to the government by eliminating the pre-tax status of some OTC products. By doing so they have increased primary care physician overhead costs. This is likely a false savings. It is certainly poor use of primary care physician’s time and is unlikely to be an incentive for new medical school graduates to choose primary care over higher paying specialty care where few of these prescription requests will be seen.

Let me know what you think about this new law? Leave a comment. This health blog loves comments.

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Oxycontin vs Oxycodone

January 3, 2011 Dr. Pullen

Oxycodone is the active ingredient of both Oxycontin and oxycodone, and at first glance it may seem like they are interchangeable as prescription opioids for pain management. I’ve posted about this before in an article titled, Oxycontin: What’s the Big Deal? A comment recently stating, “The big deal is that people are dying and going to jail every day because of untreated addiction to prescribed medication.” brought this issue back to the front of my mind.

Oxycodone is the active ingredient in many prescription pain meds, including Perocet, Tylox as well as the single ingredient generic oxycodone. It is also the active ingredient in the combination immediate and time release Oxycontin. The problem with Oxycontin is that a large percentage of the oxycodone is immediately released, while the rest is released over time. The purpose of this is to give immediate relief of pain, while keeping pain controlled over time with the delayed absorption of part of the medication. Unfortunately the large percentage released immediately of this particular opioid which has a higher euphoria effect than most opioids makes it a very popular drug of abuse, and even used appropriately it has a high incidence of addiction.

This has resulted in the development of a whole sub-culture of Oxycontin abuse. It’s become known as Hillbilly Heroin or just oxy on the streets. Oxycontin is very commonly pulverized into a powder to void the delayed release effect, and ingested, injected, snorted, or inhaled. Smoking Oxycontin has become a common problem in some areas of the country. Oxycontin is arguable the most abused opioid in the US. It is a drug of choice for many prescription opioid addicts and the Oxycontin side effects can be severe. It has little if any advantage over alternative opioids and is generally best avoided in non-malignant terminal pain patients.

Although physicians have come under a great deal of criticism, sometimes appropriately for excessive prescription of opioids, especially Oxycontin, we have also come under criticism for inadequate treatment of chronic pain. Recommendations for obtaining expert consultation when prescribing long term opioids sound fine at face value, but at least in the community where I work it is nearly impossible to find such an expert for consultion.

In the last two months I’ve had two young male patients present to the office for help with Oxycontin addiction. Neither of them had ever received a prescription for Oxycontin from a health care provider. Both had been given the drug by a friend at their work. One was trying the med to help with a nagging back ache, another just to see how he liked using the drug. Both told me they quickly became physically and psychologically addicted within a couple of weeks.

In my community it drug seeking patients have become such a problem that many chronic pain patient can’t find a doctor to prescribe pain meds. Physicians who become known as willing to take new patients for chronic pain medication management are quickly targeted by both patients with serious medical problems with pain medication requirements and by the drug seeking abusers. This reputation can quickly make a practice unpleasant and put the physician at risk for sanctions by their state review board.

Look at Oxycodone side effects for another great resource and thanks for reading this medical blog. Leave a comment and contribute to the discussion about Oxycontin versus Oxycodone below in the proper field.

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Coupons For High Priced Drugs – Just Say No!

November 11, 2010 Dr. Pullen

I hate coupons that reduce the copay of prescription meds. I just refuse to use them. Today essentially all insurance companies divide their medications into tiers, where the lowest tier is for inexpensive generic meds., the next tier is for more expensive generics and branded drugs that the plan negotiates substantial discounts from the manufacturer in exchange for encouraging their use on the plan, and the third tier is for more expensive drugs and the rest of the branded drugs that did not win in the negotiations to be tier 2 on the plan. The purpose of these is to provide incentive to physicians and patients to try to manage patients health using the least expensive medications possible. These coupons are designed to take away this incentive to use less expensive drugs. Drug salespersons tell us that their expensive drug is just as inexpensive to the patient as lower tier or generic meds, because they will pay the pharmacist for most of the copay. Obviously in all these cases the profit margin for the company is so high they can discount the Rx by a large amount and still afford to pay a sales person, print the coupons, manage the bookkeeping, and come out ahead. I find this subversion of the system just wrong, and don’t participate. Government plans, Medicare and Medicaid do not allow pharmacists to accept coupons for meds for patients they insure. This was never more in my face than today at the office.

I was again appalled today at the audacity of the pharmaceutical industry and their pricing. A drug rep told me about a great new sleeping medication that is not a benzodiazepine, has a low side effect profile, is a non-schedule drug, and is ideal for the typical patient we struggle with, i.e. has trouble falling asleep and staying asleep for more than a few hours. She then told me that this is a new dosing regimen of an old drug doxepin. I grew up in medicine with the tricyclic antidepressant meds. Doxepin was sold as Sinequan, a branded drug when I was a med student, has long been used as a very sedating antidepressant. It has been used more recently for help with chronic pain, as an add-on med in depression when sleep is needed, and sometimes alone for insomnia. It is available as a generic in doses of 10,25,50,100 and 150 mg all except the 150 mg doses for $4./ 30 doses at the discount pharmacies. The drug rep assured me that I did not need to worry about the cost of this medication, because although the med will the in the highest tier copay on essentially all plans, i.e. $ 40-$60./ month for most patients, they would supply coupons to reduce this copay by $25./ month so the “real” cost to the patient will be only $15-35. As always, I asked her what the real cost is, and after some arm twisting she told me it was about the same as the other “branded” hypnotics. Asked how much this is she said about $200./ 30 pills. The new drug is called Silenor, and is simply doxepin packaged in a smaller dose, of 3 and 6 mg. I presume that this company buys generic doxepin in bulk, that is available as a generic 100 mg dose for $0.13/ dose and sells 3/50^th or 3/25^th the dose for 51x as much as the higher dose. I was told that they need this pricing to pay for all the research they needed to do to allow them to bring this lower dose to market. The rep did not mention they also needed to hire a sales force good enough to somehow convince feeble minded physicians that this somehow is better than a dose of ½ of a 10 mg of the generic.

Usually I don’t waste my breath, but this was so insane that I gave the rep my usually silent rant about how unethical coupons are, as they essentially remove the disincentive for patients to try to hold down medication costs that the high tier copays are designed to provide. I added a tirade about their need to pay for the research was not really necessary, because the research only served to allow them to “brand” this low dose of an available generic medication, and to send reps to the field to sell this drug. She was obviously used to these responses, because when I told her she had a tough sell in front of her, she simply moved on to the next doc and started her sales pitch again. If any of you are unfortunate enough to have a physician who is convinced that somehow this new dose of doxepin is what you need, just go ahead and ask them to try generic doxepin, save yourself a little money, and take a tiny step toward controlling health care costs.

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Telogen Effluvium

October 9, 2010 Dr. Pullen

Telogen effluvium. It sounds so much more intriguing than stress related hair loss. Everyone likes cool names. Physicians are no different. The closest I got to taking a Latin class in college was a Classics for Jocks class where a professor fond of helping football and hockey players with a passing grade in a fun class taught a course on the classic Latin and Greek literature. Still, I like the sound of Latin sounding names for medical conditions, especially when I can both remember and spell them.

I enjoy telling my patients who have this condition what is going on because it’s an interesting condition, it’s not serious, it gets better with time and patients can easily understand the cause and course of the problem. This week in the office a very pleasant woman came in with this condition, and although not happy to hear that there was nothing I could do to help, she at least appreciated a diagnosis, and was relieved to hear that her hair would grow back.

Each hair on our body has two major periods in its lifespan. Each hair starts growing and continues to grow for an average of 3 years, the phase called anagen. Then the growth stops, and the hair follicle enters the phase called telogen. At any one time 5-10% of a person’s hairs are in telogen. After about 3 months, and this period of time varies widely from one person to another, the hair in telogen falls out as a club hair. It’s called this because the root of the hair if looked at microscopically has a rounded, thickened, club-like appearance. A hair pulled out in anaphase has a ragged, ripped-out looking root microscopically. On average 1-200 scalp hairs are shed daily. I don’t think I have enough hair left to lose that many.

Certain major stresses and conditions can shock a large percent of the body’s hairs to stop growing and enter telophase simultaneously. This phenomenon is called telogen effluvium. When this happens, a few months later a large percentage of an individual’s hair can be shed as club hairs over a few weeks or months period of time. It can be very disturbing to the person losing their hair. The classic stress to cause this is childbirth, and in the days when I did maternity care it was not uncommon for me to see women in the office a few months after delivery distraught that they were losing lots of scalp hair. Other stresses that can cause this are major surgery, high fever, serious illness, major emotional stress, and rapid weight loss. Medical conditions associated with telogen effluvium are anorexia nervosa, iron deficiency, hypothyroidism, and the sudden conditions mentioned above.

This is a good news/ bad news situation to tell patients about. The good news is that it is completely reversible, and usually resolves in a few months. The bad news is that is quite a while before the hair grows back, and that there is nothing to do to speed the process along. In my experience although many patients come to the office thinking hypothyroidism is the cause of their hair loss this is very rarely the problem. Emotional of physical stresses are more common causes.

If there is anything good about telogen effluvium, it’s that it has a cool name, and you can impress your friends by telling them a snazzy name for your condition. You might as well take advantage of the little things. There’s not much else you can do except wait for your hair to grow back.

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I Like Unna Boots

August 30, 2010 Dr. Pullen

I have to say that I really like Unna boots as therapy for veinous stasis ulcers. I have no idea why they are called Unna boots. If anyone knows, let me know. I couldn’t find anything on-line to explain the name. It’s an odd name for a really simple old-fashioned treatment that’s about as low tech as you can get. Technically an Unna boot is an inelastic compression wrap, basically a cotton bandage impregnated with zinc oxide that hardens after application, and forms a sort of boot. They are easy to apply and help with the pain and swelling usually associated with veinous stasis ulcers. They are often quite effective in getting ulcers that don’t seem to be healing very well otherwise to start to heal. In a recent article in American Family Physician by Collins and Serai compression therapy of stasis ulcers is considered to be the standard of care, and a Cochrane Review in 2009 concludes that veinous ulcers heal more quickly with compression than without.

All this is good, but I think I really like Unna boots because it is one of the times where as a family physician I get to use a hands-on therapy that really works. It also just feels good to apply the cool, soothing bandage to the patient’s leg and see them feel better almost immediately. In addition it’s a treatment where I see the patient weekly, and when it works well we see regular, fairly steady improvement. Almost always patients are really happy with this treatment, though it usually takes far more visits that they would like.

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A Consultant’s Letter that Made Me Smile

August 20, 2010 Dr. Pullen

Today I read a letter from a pediatric ophthalmologist after he saw a young child whose parents were concerned about his vision. One of my partners referred him for evaluation and this letter came back. I loved that the letter was not just concise and complete, but made me smile. If we all could take the time to have fun writing our notes maybe we’d all be a bit happier in our jobs.

Dear Dr. B.,

R. was in 08/09/2010. He is 2-years 9-months-old, and dad says he runs into things.

He appeared to have good central maintained fixation in each eye. The eyes look straight at distance and near. They deny any crossing.

After dilation, unlike the last 10 children who are 2 years old and run into things and whom had normal eyes, R. has 7 diopters of farsightedness. He needs to wear glasses and will be checked in 2-3 months. I talked to his dad about this.

Sincerely,

Dr. S.

Dr. S has been around for a while, and had the confidence and sense of humor to make his letter not just functional but entertaining. Many thanks.

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Grand Rounds Here August 17th

August 13, 2010 Dr. Pullen

This will be my first time hosting Grand Rounds. I’ve enjoyed reading posts on the Grand Rounds circuit since I started DrPullen.com last December. Thanks to Rob Lambert for helping me understand what Grand Rounds is about, and accepting a post on his version several months ago. I’ll try to make Grand Rounds Vol. 6 number 47 worthy of the honor of hosting. The theme this week is “In the Office” or as it may apply to you the ED, the hospital ward, the war zone, or where every you work or experience patient care. Send your best recent post having anything close to this subject, or if this doesn’t work for you something you’re proud of and want included. Deadline is Sunday August 15^th at noon west coast time (that’s 3 PM east coast time). To submit your post just use the contact page at the top of this site, put Grand Rounds in the subject line, put the url link in the body, along with your name and if you can a little bit about yourself and why you chose this post to submit. Thanks to Nick Genes and Val Jones for keeping this forum going, and for allowing me to host.

Now: Send me your best stuff.

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Pitiriasis Rosea – The Christmas Tree Rash

August 6, 2010 Dr. Pullen

I was happy today to have a case of Pitiriasis rosea today in the office to show off to my medical student. The 14 year old girl with the rash was a great sport to let me show her torso rash to my young male 3rd year student. I love diagnoses that are easy, where the condition is not serious, and especially when they have a fun name. Pitiriasis as a general term refers to a flaking or scaling condition and comes from the Greek word for bran. Add to that a differential diagnosis that includes syphilis and a distribution on the skin of the torso compared to a Christmas tree and you’ve got a great teaching case.
Pitiriasis rosea is usually a mild and self limited skin rash felt to be caused by a virus, possibly a Human Herpes Virus of the group 6 or 7 which can cause Roseola infanatum in very young children possibly presenting differently in older children or adults. It is felt to usually be non-contagious, although small outbreaks have been reported. The rash usually first shows up as a large reddish flaky patch, called a herald patch because it heralds the onset of the disease, and followed by multiple smaller reddish patches that are often oval shaped and run with the skin lines of the torso. The skin lines of the torso run diagonally sloping upwards as they run from the mid anterior abdomen outwards, so the distribution is described as a Christmas tree distribution. The rash is sometimes preceded by a minor illness, and the rash sometimes itches mildly to more severely. The good thing is that it resolves without treatment, usually in about 6 weeks or so.
As a medical student we were always drilled to remember that secondary syphilis can present with a similar rash, although I suspect most of us have never actually made a diagnosis of a case of secondary syphilis that presented this way. Still I made sure to quiz my medical student today on this to keep up the tradition of thinking of zebras as well as horses when we hear hoof beats.

Here is a link to several photos of Pitiriasis rosea.

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