Category Archives: Today In the Office

Oral Decongestants: Marginally Effective or Ineffective Drugs with Serious Potential Side Effects

August 2, 2010 Dr. Pullen

I really discourage the use of pseudoephedrine and phenylephrine as a decongestants, especially in adult men. The biggest reason is that they just don’t work very well, and the potential side effects seem to outweigh the benefits. Friday in the office I saw a man in his early 50’s with acute urinary retention. He had been having some cold symptoms and was using OTC cold meds that contain both antihistamines and decongestants. He had been having very mild prostatism symptoms for a year or two prior to this visit, but never significant urinary symptoms. He was drinking lots of water, because he thought he might have a bladder infection causing his difficulty urinating. By the time he came to the office he had been complete iunabloe to void for 9 hours, and had a painful distended bladder. I needed to place a urinary catheter to drain over a 1200 mililiters of urine, and needed to leave the catheter in place over the weekend to allow the bladder to regain its tone. I had him stop the decongestants, and suspect he will be able to void fine after a few days off the cold meds.

Over the years I’ve seen several cases of acute urinary retention, and more often than not they have been related to medication use. Although the list of medications that can cause urinary retention is long in recent years, since we stopped using as many tricyclic antidepressants and anticholinergic medications for bowel problems, decongestant use is by far the biggest culprit.

In addition to causing occasional acute urinary retention, these decongestants can cause anxiety, insomnia, and irritability especially in children. They can raise blood pressure especially in hypertensive patients, and can lead to rebound nasal congestion when stopped if used for more than a few days. Millions of us subject ourselves to these risks for medications with essentially no evidence that they shorten the course of congestion with a cold or prevent complications like sinusitis or otitis media. There is also very little evidence that they even help with symptoms of congestion. My guess is that if men realized that the cold medicine they use could lead to having a urinary catheter for a few days they would stay far away from that aisle in the pharmacy.

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Grand Rounds – A Time Gone By

July 16, 2010 Dr. Pullen

This week at the office I heard one of our physicians inviting our two new medical students to attend “Perinatal Grand Rounds” at a restaurant in Tacoma. My first thought was that some pharmaceutical company had the gall to call one of their sponsored programs “Grand Rounds.” Their programs are usually little more than a free meal at a nice restaurant to induce physicians to listen to a program on a subject for which their highlighted drug happens to be the preferred treatment by the hired speaker. They are flagrantly a live commercial endorsement for their products. I was relieved to hear that this really was a program sponsored by one of the local hospitals for its physicians about pregnancy induced hypertension, a legitimate subject by speakers with no sponsorship by big pharma. Still this is a long ways from the Grand Rounds format I remember from medical school days in Boston. Grand Rounds for many years were a clinical case presented to a senior faculty member, put on live, often with the patient present, to the medical staff. Often the senior physician was hearing the case for the first time, or interviewing the physician live in real time. It was usually a stunning display of raw brilliance by a terrific clinician. Now they are generally a power-point driven lecture. The history of Grand Rounds is really not completely documented anywhere that is easily accessible, but a NY Times article in 2006 gives a nice summary and is a fun read:

By LAWRENCE K. ALTMAN, M.D. Published: December 12, 2006

The Doctor’s World

Socratic Dialogue Gives Way to

PowerPoint

For at least a century at many teaching and community hospitals, properly dressed doctors in ties and white coats have assembled each week, usually in an auditorium, for a master class in the art and science of medicine from the best clinicians. Before us was often a patient who sat in a chair or rested on a gurney and two doctors, one in training and the other a professor or senior doctor at the hospital. In a Socratic dialogue, they often led the audience in a step-by-step deciphering of the ailment.

But in recent years, grand rounds have become didactic lectures focusing on technical aspects of the newest biomedical research. Patients have disappeared. If a case history is presented, it is usually as a brief synopsis and the discussant rarely makes even a passing reference to it Read the rest of the article

Another version of Grand Rounds is put on weekly by the medical bloggers, and sponsored each week on a different site. I’ve even contributed to this occasionally. It’s far less grand then the old days, but times do change.

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Teaching Medical Students

July 9, 2010 Dr. Pullen

I’m headed off to a reception for students from the new Pacific Northwest University of Health Sciences in Yakima, WA who are spending their third year of osteopathic medical school in Puyallup, WA doing rotations with the physicians in our community. I’ve had a student with me this week, and it brings back memories of my third year in med school, and how things have changed. It also leads me to mull over why I’m choosing to take on this uncompensated work.

In my third year of med school at Tuft’s University School of Medicine in Boston I opted to spend my whole third year at Maine Medical Center in Portland, ME. Looking back this was one of the defining decisions I made> It let me see how medicine was practiced in a smaller community than Boston, and in a far more progressive environment. In Boston third year students were first and foremost unpaid labor, pushing patients to and from procedures on gurneys and in wheelchairs, drawing blood, starting IVs. They stood on the fringe of large groups of student, resident, and attending physicians hoping to be noticed when they knew something and not noticed when they didn’t. In Portland there were no 4^th year students, so we got to do many of the things the fourth year students did in Boston, and because there were relatively few students, there was staff hired to do the simple tasks like getting patients to places and drawing blood each morning. I came back to Boston to start my fourth year far ahead of my fellow students who spent their third year in the mecca in many ways, but far behind in understanding the politics and pecking order that existed in the city hospitals. I felt I had a far better ability to make diagnoses, decisions, and do procedures. I often was chastised for overstepping my unwritten boundaries finding that students “don’t do that” here.

I have a third year student with me in the office now. She’ll stay for 4 weeks studying family medicine. It seems odd to have a student so green working in an outpatient setting. In my third year I really never left the hospital for any training. I met my first outpatients in the few electives of the fourth year. The experience for my student will be vastly different. She will have spent most of her time under my direct observation, watching me, presenting cases to me, and hopefully learning from me. I spent the majority of my time independently seeing patients, checking back with interns and residents, only occasionally with attending physicians, and feeling primarily overwhelmed. She is protected from this type of learning by immersion, and has far closer supervision than I experienced.

The experience for me was so overwhelming that then I lost about 15% or my not overweight body mass in the first 2 months of my third year, until I realized I’d need to make time to eat and sleep to survive. The work was simply never done, and there seemed so much to learn that the days and rotations seemed too short. My student comes to the office at 8 AM, and leaves by 6 PM. I rarely showed up after 6 AM, and never left before 6 PM. I was on call every 3-4^th night, and so far I don’t see that she will be on call at all, at least on the FP rotation. Was my experience more intense? Definitely. Will her experience give her a better idea of what primary outpatient care is all about? Definitely.

She will get to see a practicing family physician at work, and hopefully leave respecting that we can do a good job, see lots of patients, and play a valuable role in the medical care of our patients. I chose family medicine really on faith and a gut feeling that it was the best career for me. I had never really seen a civilian, non-hospital based FP work. She will have seen family medicine up close and for real.

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Can’t Find it in there Doc?

June 25, 2010 Dr. Pullen

As I went through my routine heart exam for a patient this week, he commented, “Can’t find it in there Doc?” I’m not sure if he was joking, or worried. This made me think about the routine things I do as a physician that may seem odd to patients. When a physician listens to a patient’s heart certain aspects of the heart sounds are best heard by listening at different areas on the chest. The area just below the left nipple is where we listen for sounds from the mitral valve. This is also where we palpate (doctor talk for feel) to estimate the size of the heart and to see if there is a diffuse heave like movement of the chest wall that can suggest heart enlargement. The murmur heard from mitral valve disease is often best heard in this area, called the apex. At the left upper sternal border we listen more for the pulmonic valve sounds. At the right upper sternal border sounds from the aortic valve can be heard best. Careful auscultation of the heart involves listening carefully at all of these areas. To a patient I guess this may seem like we are searching to see if there is a heart in there somewhere.

If this seemed odd enough to a patient to make a comment, I have to wonder what patients may think when I examine their abdomen when they complain of swollen nodes and sore throat. I know I’m seeing if the liver or spleen is enlarged, as a clue to infectious mononucleosis, but they may think I’m just distracted or off target. Maybe questions I ask are just as obscure. Asking about bowel or bladder control problems in patients with back pain may seem weird to a patient, when I know I’m just screening for lower spinal cord injury symptoms. Sexual function problems can be a clue to cardiovascular disease, but I wonder what men may think when I ask them about erectile dysfunction when their complaint is chest pain, or visa versa. I find that the best visits are usually when I talk the least and listen the most. Maybe I need to talk more, at least enough to explain why I’m doing what I’m doing, or why I’m asking obscure questions. Maybe not! Maybe the mystery of the doctors visit is a part of our ability to heal. I’ll be interested to see if readers have any experiences of this type to share as comments. Has your doctor sometimes done things or asked questions you wondered why they were doing or asking. I’ll try to respond with a reply comment to any comments you leave on this issue. .

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Hemicrania Continuum

June 15, 2010 Dr. Pullen

I saw a patient a couple of weeks ago who had what sounded to me like trigeminal neuralgia, except that the severe one-sided head pains she was having lasted several minutes to an hour each episode, and recurred many times a day. The sharp, severe head pains of trigeminal neuralgia usually last only a second or two, maybe a few seconds, but not minutes to an hour. They can be really miserable, as they can come every few seconds in severe cases, but this just seemed like something different. I asked her to see a neurolgist as I’d never seen a patient with this type of pain, and when I got the consultation back the diagnosis was hemicrania continuum.

Hemicrania continuum is an uncommon head pain condition that seems midway between a cluster headache and trigeminal neuralgia. It has the lancing, sharp, almost electric shock type of pain described by patients with trigeminal neuralgia, but the pain lasts far longer, and is often assoicated with eye watering and nasal congestion on the affected side like cluster headaches.

Treatment of hemicrania continuum is usually with indomethacin, a tough-on-the-stomach anti-inflamatory medication, or sometimes with Celebrex (See Celebrex side effects), a newer COX-2 type anti-inflamatory medication.

It’s always good to feel like you learn something new in a day at the office. Too bad sometimes it is because a patient has a tough to treat, painful condition like this.

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Exam Room Favorites

June 11, 2010 Dr. Pullen

How can a physician have time to use the internet while seeing patients in the exam room. How is this possible when as a family physician I need to keep visits brief, and can’t spend time surfing the net. Actually I do go online to facilitate patient visits a few times every day. I find specific uses of the internet can be both efficient and helpful. I suspect some of these sites will also be useful to non-physicians too as reliable sources of information.

I find Dr. Google has a great memory. Certainly better than mine. Just yesterday I had a patient on Byetta, an injectible non-insulin medication for diabetes who was having side effects and I wanted to switch her to the newer drug in the same class. Google is great for this. I searched for “Injectible non-insulin diabetes medication” and the second item in the Google search has the names Byetta and Symlin right in the search bar summary. This took about 10 seconds, certainly less time than using my PDA would have taken, and far less than walking out of the room to look elsewhere. I don’t use search engines for much else though. It’s too slow. I need to go directly to a known site. In exam rooms where we use a Citrix thin client, keeping a list of favorites on a browser is problematic. Every room is different, and it would just take too much time.

The solution was one site to use as a homepage in our EMR that has all the good sites as links. I had my daughter make me a web site with most of my favorites on it to use as my in-office home page. We call it Exam Room Favorites. I find it extremely useful, and encourage any of you to use it too.

The most used sites for me include:
Epocrates: Now that I’ve switched from a regular PDA to an iPhone, the Epocrates app is somewhat slow unless I have a good Wi-Fi connection, so I use Epocrates online. It is fast, has the same great info as the PDA applications, and is very useful, mostly for cost information, but also for dosing and side effect information. Exam Room Favorites has an Epocrates search bar right on the page, saving a click or two.

Inner Body On-line: This used to be called Anatomy On-Line. I love this site. It lets me show a patient a picture much like the old CIBA monographs that give diagrammatic pictures of most body parts. I find patients love to see graphics that help me explain their issues to them.

Traveler’s Health CDC Site: Indispensible when I’m asked about international travel issues. Here you can find what immunizations are needed, what precautions to take, what type of malaria meds to prescribe, and other issues for any place in the world. I urge my patients to use this site prior to international travel.

Patient Handout sites: The AAFP Family Doctor.Org site and the Mayo Clinic patient information sites are the best. Here you can get printer friendly handouts for most types of problems. These are reliable places to tell patients they can look for information about whatever they have questions about.

Costco Drug Prices Site: Most pharmacies don’t publicize prices for their meds on-line, except for the discount pharmacies and their $4./ $10. generic lists at Target, Walmart and in our area Fred Meyer. I find the Costco site a great place to tell patients what they should have to pay for a medication, and many local pharmacies will match Costco pricing on generics.

New PAP smear guidelines: The new recommendations for management of abnormal PAP smears can be confusing and difficult to memorize. Why try when they are easily available on-line.

Lab Tests On-line: I occasionally have a consultant order a test I am not aware of, or need to know how to interpret in the case of a patient. This site has a good explanation of most of the common and obscure lab tests that may get done from time to time.

If any of you have other great sites you often use leave comments and share them with us.

and share them with us.

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Mother’s Day thoughts of a Family Physician

May 9, 2010 Dr. Pullen

As a family physician I see mothers from many different viewpoints. Of course there are the personal viewpoints; I have a great Mom, an incredible wife who is mother to our children, and expect my daughter to be a mom someday, but I’m going to focus here on the moms I see in my practice.

I delivered babies for 25 years, and some of the highlights of my time as a physician were in labor and delivery. I remember the last baby I delivered. This was the 4^th baby I delivered for this Mom, and she had her Mom, three of her sisters and at least one of her daughters there for the delivery. It went as hoped for with a quick and uncomplicated birth. I remember the involvement, joy, and my sense of loss at knowing I was no longer going to have this type of experience again. I remember a delivery about 20 years ago, when late term ultrasounds were not done often. I was taking care of a young Mom, maybe 20 years old, having her second baby with me. The pregnancy had been difficult, in part due to marital difficulties she was having. Completely unexpectedly the baby was born with a large midline cleft lip and palate. I almost cried. I didn’t know how this Mom could cope with this unexpected and dramatic birth defect. As I held the baby and stood up to show her the child, I tried to find words to explain the situation. I don’t recall the words I used. I do remember the response of this Mom though, as though it was yesterday. She looked at the babies face briefly, and then carefully looked him all over. Her first words were, “He’s perfect. Everything else looks just perfect.” Motherhood is a strong, a lesson this Mom taught me with her natural and spontaneous demonstration of just how perfect every child can be in the eyes of their Mom.

I see another family where three generations of Moms come to see me. My first patient in this family was a Mom for whom I delivered two children. She was in her early 40′s at the time and the first of these two children was unexpected. She had two previous children who were in their late teens/early 20′s at the time, and already out of the house. She and her husband decided if they were going to have one more child then they wanted two in this second ”generation” of their own children. She jokingly told me she thought she was being given a second chance to do it right. Maybe 15 years ago she started bringing her elderly Mom to me as a patient. A few years later her Mom had a stroke and has had an expressive aphasia and hemiplegia for about 10 myears now. Now, in her mid 90′s, she cries every time I see her. The extended family takes care of her at home. I have seen motherhood from both ends of life in this one family, and it can be beautiful in a different way from that viewpoint also.

I see moms bring in infants, toddlers, adolescents, and young adults for care. I see moms grieve the loss of their adult children. It is not meant for mothers to outlive their children, but they sometimes do. Mostly I marvel at the strength and love most mothers have. Certainly we see and read about exceptions, but mothers in the vast majority of cases do their very best to give love, care and comfort to their children. Thanks to all mothers everywhere, you have a difficult and critical job, and this Mother’s Day let’s be thankful for all of our Mothers and for the gift that motherhood can be. Seeing the love that motherhood brings to the world helps make most days in the office a bit brighter.

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Never seen before – by me at least – Tibialis Anterior Tendonitis

March 9, 2010 Dr. Pullen

: Tibialis Anterior

Until today I had never heard of tibialis anterior tendonitis. I saw a case toeay in the office. I knew what it was easily, but it was something I had never seen in 30 years of practice. The patient was a 61 year old gentleman who had taken a very long walk, maybe 10-15 miles, two weeks ago, and had noted pain and swelling over the lower front of the leg and ankle. It has continued to hurt for 2 weeks, and he came to see me because he is going on a mission trip in a few days, and is concerned it will be a problem there. On exam he was quite swollen over the tendon sheath of the muscles that pick up the front foot (the tibialis anterior tendon sheath for you anatomy geeks) and had crepitas (a creaking feeling when I felt over the tendon sheath). We often see this in the wrist and forearm after a weekend of hard work in the yard or other unusual activity, but it is much less common in the leg. I found a nice article on it using Dr. Google on Sports Injury Clinic on the Net. Fun to have a first time case every now and then, especially one I can diagnose, and when the prognosis is good. Loved to find a name for it too. Tibialis anteroir tendonitis

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Home Health Hospice – Sooner better than later

February 18, 2010 Dr. Pullen

This week in the office I was again slapped in the face with the reality of our own fragile existence, and reminded how wonderful Hospice care can be as a resource as the end of that existence approaches. As a family physician I’d like to think I can embrace all parts of our lives, including the last stages. This is especially difficult when I see patients with illnesses like COPD who have been struggling mightily for a long time, and a seemingly small event pushes them over the edge into an irreversible spiral toward death. In reality I often am so focused on trying to heal, and focusing on physical needs, that I wait too long to recognize the inevitable discuss using hospice services. Sometimes when the patient silently gives up, simply stopping the fight without verbally expressing their decision, it takes more courage than I muster to openly address this with them or their family. I love these patients too, though in a clinical way I hope, and sometimes this can get in the way of facing the facts. Sometimes I am not ready to give up, seeing that a medical intervention would have a pretty good chance of restoring the prior state of precarious equilibrium. I think what the patient decides, sometimes consciously, sometimes subconsciously, is that they are done fighting. It is just too hard and the value of continuing is outweighed by the effort and misery of continuing. Once I was able to recognize the situation with my patient this week, I contacted Hospice, who in their usual compassionate, efficient, and practical way took charge of the difficult situation, and helped my patient regain control of their existence. A hospital bed in the living room so he could be near his wife, and some anti-anxiety medication that though it may reduce his incentive to oxygenate, will allow him to relax and enjoy his remaining days were beautiful choices. Almost always I find that Hospice intervention makes a difficult situation better. Sometimes so much better that a patient improves to a point where Hospice is not appropriate, but usually a better route to death. Thanks again Hospice for all you do. I’ll try to see more clearly next time, and call you a little earlier.

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Can’t find a doctor to prescribe pain meds?

February 4, 2010 Dr. Pullen

Don’t feel alone. This doctor is worn down and just saying no. Opioid poisoning as a cause of death more than tripled in the US between 1999 and 2006. Death from prescription opiates is now more common than death from heroin and cocaine combined. (USA Today)

Today a new patient came to the office looking for a physician to prescribe the opiates she wanted to take for her fibromyalgia, interstitial cystitis, and chronic low back pain. She proceeded to say she just wished the good doctors who had previously been prescribing her massive doses of opiates were still around. She thinks one of them must have done something wrong, because his office was just closed down suddenly and all his medical records were taken away. I’m sure this is the Lakewood, WA physician who lost his license for inappropriately prescribing opiates. She was a caricature of the opiate-seeking patient. She had not just one of the ill defined painful conditions that are impossible to exclude, but at least three. She had been prescribed both Oxycontin, as well as large doses of “breakthrough” oxycodone. I am not accepting new pain management patients into my practice. This made it easy to explain that I would not be able to treat her for these problems with opiate medications. Actually the abuse of opiates have become such a rampant problem that I don’t know of a physician in the county who is accepting new pain management patients. This is sad for patients new to the community with legitimate need for pain medication, but just an impossible position for physicians. Any physician who becomes known as accepting chronic non-malignant pain patients would be quickly overwhelmed by the droves of new patients needing pain medications who would show up to receive care. Years ago a wise older physician (he was probably as old as I am now, and likely far wiser) told me we all have our albatrosses. These he described as very needy and difficult patients that you’d just like to find a way to get out of your practice. He explained that if we all just keep a few then no one will be overburdened with too many. Otherwise they will just keep circulating in the medical community, and all of us will still need to take care of them. It’s best to just buck up and keep doing our best for them. These days I feel like these patients are not like rare albatrosses, but rather like common crows, just everywhere, and dashing in to pick me apart like road kill.

There seem to be so opiate seeking patients now that an open door to see them would just overwhelm anyone. Cynically yet realistically I know that this is in part because no one physician will knowingly prescribe the quantity of drugs that they want, so they need to have multiple physicians prescribing their meds who are unaware of each other. (this problem to be the subject of another post soon) Anyway this episode made me smile because this patient was either incredibly naïve, or a very good actress. I suspected the latter. Most opiate seeking patients are very smooth and make me at least feel like maybe I should try to help them by seeing if I can help them manage their pain with less opiates and good care. In my experience this very rarely works, because the customer really just wants the drugs. I know that although there are some patients for whom opiates for non-cancer pain is the best available treatment, there are so many professional patients who resell the drugs on the street and others who are addicted to the meds and overuse them in vast amounts, that as primary physicians we are in an impossible position. We either become suppliers of the prescription drug culture, or we turn away some appropriate patients. Which is worse? This depends on your viewpoint, but at this point I generally just say no.

Oxycodone side effects

Oxycontin: What’s the big deal?

How to spot a drug seeking patient

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