Working diagnosis: Lupus

A 55 y.o. man presents with the following intermittent symptoms over the past year:

• fatigue
• multiple joint aches
• multiple areas of muscle ache
• facial rash for several months
• one episode of bronchitis with thick white mucus production
• one isolated bout of reddened eyes and some blurred vision

What is your diagnosis?

• ANA is positive at 1:1280
• CRP:  normal
• Sed rate:  normal
• anti ds DNA antibodies : indeterminate
• anti smith antibodies: pending

Working diagnosis: systemic lupus erythematosus

What is your diagnosis?

A 55 y.o. man presents with the following intermittent symptoms over the past year:

• fatigue
• multiple joint aches
• multiple areas of muscle ache
• facial rash for several months
• one episode of bronchitis with thick white mucus production
• one isolated bout of reddened eyes and some blurred vision

What is your diagnosis?

New drug for stroke prevention

The FDA is considering a new drug -Dabigatran – for the prevention of stroke in atrial fibrillation patients.

Dabigatran inhibits thrombin and is reported to be as safe and effective as warfarin but without the needed blood monitoring.

In Europe, the drug is being used for blood clot prevention in post hip and knee replacement patients.

For more information, see article in New England Journal of Medicine December 6th, 2009.

abstract

LUTS and ED

A 45 y.o. male presents with urinary urgency, dribbling and frequency worsening for several months.  He also complains of difficulty maintaining an erection.

No fever, no back pain, no dysuria, no history of CAD, no history of prostatitis.  No abdominal pain. No diarrhea or constipation.

Physical exam in normal including symmetrical, non boggy, non enlarged prostate.

Urine dip: normal

Assessment:

• Lower urinary tract symptoms (LUTS)
• Erectile dyfunction (ED)

Treatment plan:

• Cardura 2mg one po daily
• PSA
• refer to urologist to test for urinary flow analysis

Follow up:

Urologist report normal urinary flow without residual volume elevation.  Confirmed normal prostate exam.

Patient reports he is now assymptomatic and maintaining erections during intercourse.

 

 

Campylobacter jejuni

Campylobacter jejuni is a bacteria which can cause infectious diarrhea.

Symptoms may include fever, abdominal pain, vomiting and diarrhea – sometimes bloody.

Occasionally the abdominal pain may mimic appendicitis with right lower quadrant pain.  CT may reveal mesenteric addentitis but no appendix inflammation.

Exposure to wild birds or ducks e.g. hunters; travel to developing countries or exposure to contaminated water are important historical findings.

Stool cultures, fecal leukocytes and shiga toxin levels can be obtained.

Treatment includes azithromycin 500 mg for 3 – 5 days and maintaining hydration level.  (Fluoroquinolone and Bactrim resistance has been growing.)

 

Treat flu symptoms with essential oils

Good afternoon,

We’ve all been hearing plenty about the flu going around. Well, last week we actually got it.  We did not have it absolutely confirmed that it was H1N1, but we did have the main symptoms — muscles aches and fever.

Although we did have the flu, it really was not that bad — thanks to the oils.  In fact, we found them to be very effective in reducing symptoms and getting over the bug quickly.

There are three main ways we used our essential oils:  rubbing on the feet, with moist hot packs on the back and chest, and through a diffuser.
Especially effective seemed to be the use of the moist hot packs.

When my husband came down with the bug, he was determined to get over it quickly, so he had me applying Thieves, Eucalyptus Blue, Oregano, Copaiba, and Peppermint several times a day along the spine, followed by about twenty minutes of relaxation with warm, moist heat on the area.  This approach had a significant impact on his fever, bringing it down every time we applied it.  It worked so well, he was able to shake the fever in just about a day’s time.

This whole experience reminded us that while using essential oils will not make you “bullet-proof” when it comes to sickness, it does equip you with what you need when sickness sets you back.

A mainstay of the oils when it comes to addressing flus of all kinds is Thieves, because of its antiviral and antibacterial  properties.

Stay well!

Laura Bostrom

Family Essential Oils

To purchase Thieves, go to Young Living.com Use member #973559

Essential oils at medical assistant conference

The Michigan Medical Assistant Association hosted its Fall conference in Dearborn MI this past weekend.

I had the honor of presenting the topic: An Introduction to Essential Oil Use in Primary Care Medicine.

The talk went well and focussed on:

• defining an essential oil
• how essential oils are produced
• the importance of therapuetic grade essential oils for medicinal use
• indication for lavender, peppermint, eucalyptus and wintergreen essential oils
• two cases studies: one on MRSA and the other IBS

All in all we covered the basics.  Information was research supported.  And audience acceptance was good – lots of questions.

For more information on the conference lecture/material,  I would like to share it with you.

Send me an email.

Anal warts in homosexual men

Anal warts (condylomata acuminata) are caused by human papilloma virus (HPV).  The virus needs  1-6 months incubation before manifesting warts and two years are required for the body to clear the infection.

Risk of infection increases with multiple partners and lack of condom use.

In men having sex with men (MSM), anal warts occur with and without HIV infection but incidence in higher in HIV infected men.

Some types of HPV infections raise the risk of anus malignancy while recurrent infections in HIV positive men is associated with squamous cell carcinoma.

Diagnosis is made by clinical examination (picture of anal warts) and by history.  Patients may report anal burning, tenderness, bleeding or itching.   Anal intercourse or passing stool may be difficult.  An anoscope can be used to examine internal anal tissue.

An anal Pap smear should be done using Dacron swab saturated with water and inserted into the anus about 2″ reaching the rectal wall then swirled as it is removed catching anal tissue cells.  The swab is placed in Thinprep container.

Treatment includes acetic acid topical application, cryotherapy or surgical excision.  Also, see algorithm for treatment.

Currently, there is no approved vaccination for HPV in men.

Loss of Smell Causes

People who lose their sense of smell may joke that it sometimes serves as a blessing but realistically loss of smell can be bothersome and certainly reduces the joy of flavorful food.

Here are some more common causes of loss of smell:

• allergic rhinitis/ nasal polyps / sinus infection: are the most common cause of smell distortions
• viral rhinitis / head colds: may damage the smell sensors in the nose and more proximal nerve paths.
• old age
• head trauma: damage to the nasal structures including the olfactory nerves and receptors.
• influenza:
• Parkinson’s disease: may also notice shuffled gait, blank or flat emotional affect, history of falls especially forward and tremors.
• Alzheimer’s disease: symptoms also include loss of memory, decreasing ability to take care of check book and finances, irritability and difficulty finding words.
• Sjogrens syndrome: may notice dry mouth, dry eyes, and poor taste (salt, sweet, bitter, sour).
• toxins: for example – tobacco smoke, ammonia, benzene

So if you have a change or loss of smell,  see your physician who may order further testing to rule out secondary causes or refer you to a otolaryngologist.

Carpal Tunnel Syndrome (CTS)

Carpal tunnel syndrome(CTS) is caused by the compression of the median nerve in the carpal tunnel. The carpal tunnel is formed by the carpal bones below and the flexor retinaculum (transverse carpal ligament) above (the “roof”). The contents of the carpal tunnel include finger flexor tendons and the median nerve.

CTS can result from any mechanism which compresses the median nerve – inflammation or tumor. Diabetes, hypothyroidism and pregnancy may also be associated with carpal tunnel problems.

Typically, however microtrauma from repetitive finger or wrist flexion movements is the causative factor. Occupations prone to CTS are factory work and typing.

Symptoms include: numbness, tingling, pain, and weakness in the hand especially toward the thumb or index finger. In severe cases, the thumb muscles become weak and decrease in size.  Often, people will report waking at night needing to “shake their hands out” to relieve numbness.

Besides the history, special tests in the focused physical exam include:

• Phalen’s test (most helpful): the patient places the dorsum aspects of each hand together with the wrists flexed and brings the hands to the chest. Hold for 30-60 seconds asking for subjective complaints of numbness, tingling or pain.

• Manual compression of the median nerve: place thumb on the median volar wrist crease and press firmly holding from 10-20 seconds. Positive sign is symptom reproduction.

• Tinnel’s sign.

Diagnosis is made from history and physical. Occasionally a nerve conduction velocity or EMG test is performed to judge extent of nerve damage.

Treatment of carpal tunnel syndrome includes

• NSAIDs

• Ice packs 10-15 minutes for acute inflammation

• Bracing:  Should contain a metal stay used maintain the wrist in 30 degrees of extension -to be worn at night while sleeping and during activities of daily living or work which aggravate or contribute to the CTS symptoms (e.g. typing)

• Exercises:

  • Nerve gliding¹: Use heating pad on the wrist for 15-20 minutes then make a fist, extend fingers, extend wrist, supinate forearm, extend thumb. Repeat 5-10 times.

  • Wrist extension strengthening: Rest the forearm on the

    

    Extend the wrist upwards.

    thigh (or a flat surface) with the hand beyond the edge of the surface, palm down, holding a light weight (1-3 lbs). Extend the wrist (against gravity) 10 times. Continue sets of 10 until the forearm muscles  fatigue.

• Corticosteroid injection

• Mechanical traction²: a relatively recent showed that a mechanical carpal ligament traction unit was effective at relieving a substantial amount of numbness, tingling, and pain due to median nerve entrapment after four weeks of therapy.

With conservative management, expect 4-6 weeks for improvement. If no improvement or if symptoms worsen, consult surgeon for consideration of a carpal tunnel release.

In determining risk versus benefit of surgery, up to 20% of patients report recurrent symptoms. Most failures are due to incomplete release of the transverse carpal ligament.

Resolution of symptoms is to expected from 6 weeks to 6 months.³

Return to work and activities of daily living is dependent on restoration of full range of motion and strength. Strength testing includes objective grip and finger pinch strength testing via dynamometer. Pain levels should be monitor but not be used as the sole basis for return to work.

References:

1. Essential of Musculoskeltal Care 3^rd Edition, American Academy of Orthopedic Surgeons, pg 325.

2. New carpal ligament traction device for the treatment of carpal tunnel syndrome unresponsive to conservative therapy. Porrata H. et al., Journal Hand Ther 2007 Jan-Mar;20(1):20-7; quiz 28.

3. CTS: Postoperative Care and Complications, Wheeless Orthopedic, www.wheelessonline.com