Archive for the 'Progress Notes' Category

Two Cases of Bubbly Urine

I saw two patients with a chief complaint of bubbles in their urine this month.

One middle aged woman had eaten some wild mushrooms she was pretty sure she had identified correctly, but once her urine turned bubbly a few days later, she came in to make sure her kidneys were okay.

Even though she was feeling quite well they were not and she ended up going straight to Cityside hospital for IV fluids, a kidney biopsy and dialysis. We don’t know yet how much her kidney function will recover and we still don’t know if the mushrooms had anything to do with it.

I saw her in followup the other day and she was taking everything in stride, showing more curiosity than fear and despair.

The other, a woman in her thirties, came in for sudden swelling of her ankles. She mentioned her urine had been bubbly for months. She had googled her symptoms and was convinced she had either acute kidney or heart failure. She felt weak.

Her review of systems had several positives, including joint pain. Specifically, one knee had been swollen and painful for a while.

“Have you taken any ibuprofen or naproxen for your knee?” I asked.

“Yes, why?”

“Nonsteroidals can cause sodium and fluid retention”, I explained.

Her cardiovascular exam was normal.

Because of her obvious anxiety, I minimized the EMR on my computer screen and googled “leg edema NSAIDs” and showed her that Dr. Google agreed with me that this was a plausible explanation.

“The problem with Google is that it displays possible diagnoses without ranking their probability. Exotic things may rank higher because more people look them up”, I explained.

She understood but was visibly not reassured. She did agree to hold the ibuprofen for a while to see if her swelling resolved and to get some labwork to check her kidney function.

So far, I know that her kidney function is perfectly normal. We’ll see if her swelling goes away and stays away.

I didn’t tell her that I once had a woman about her age come in one December day with just a little ankle swelling and, ten years later, ended up with a heart transplant.

As I told another patient the other day, it is my job and not the patient’s to think of the worst case scenarios.

Only Pain and Fear Bring Patients to the Doctor

It’s been said in the world of business that people only buy two things: Good feelings and solutions to problems. In medicine, the single most important factor that brings patients through our doors isn’t a “toward” kind of desire, but an “away” one – away from feeling bad.

More specifically, it is pain and fear that most often cause patients to call and ask for an appointment. They hopefully leave with good feelings and solutions to their problems, but that only happens when we have the knowledge, resources and, perhaps most important, the time to give them the relief they seek from us.

I am not considering the purely administrative functions we perform, but even some of them are more “away” desires, like patients needing a work excuse due to illness out of fear of otherwise losing their jobs. Even getting a flu shot or a physical is often rooted in pure fear of illness.

So, how often do we have the knowledge, resources and time to help our patients escape their torments?

And also, forbid the thought, how often is this relief of suffering in the broadest sense the overarching principle that guides each doctor and each healthcare organization?

In my random readings the other night I came across an article, almost a manifesto, by the British National Health Service from 2011. The document was titled “A Better NHS” and I am quoting the part about patients’ pain and the profound responsibility of the treating physician:

“The commonest reason for visiting a GP is ‘fear’.

Fear that the lump is cancer, that the chest pain is another heart attack, the headache a stroke, like the one that tragically disabled Maureen. Fear that I may die before my children grow up, fear that I may lose my sight, my balance or my mind. Fear that I cannot cope, that I am a failure or that I will be judged unfairly and blamed for my suffering. To be a patient is to be unfamiliar with oneself, to inhabit an unfamiliar shell, barely in control and in need of help. The world and our relationships are radically altered when we are patients.

What an extraordinary job we do. Grounded in a therapeutic relationship, everything we do depends on trust. What an extraordinary responsiblity to be charged with caring for people when they are at their most vulnerable and most easily exploited.

Because of this it is absolutely vital that we are not led into temptation. Just as monks and nuns need to be protected from the distractions of the world so that they can dedicate themselves to God, so we need to be protected from mammon and the perverse incentives of the market-place, so that we can dedicate ourselves to our vocation and our patients, and be the doctor that they need, not the doctor the market makes us.”

This was a call, or a prayer, not to be led into temptation by greed. As employed physicians, which is what most of us primary care physicians now are in the US, our temptations to profit from our patients’ fear, misfortune and illness are limited. Here and now, the temptation we all face is maybe not one of the deadly sins, but it is gaining traction:

Distraction from what really matters is perhaps our biggest temptation and a poison we are constantly exposed to. We let our focus wander away from the patient and toward the clock, away from the therapeutic moment and toward the measurable quality indicators. Even when we embark on practice redesigns to become more patient focused, the certification process itself becomes a distraction from the work we set out to improve.

This week I saw two new patients, both of them with shortness of breath and heart palpitations, both fearful that something was dreadfully wrong. Each one ran over their allotted thirty minutes (my longest appointment type, reserved for new patients and hospital followups) by a good ten minutes, but each one left reassured, one with a clean bill of health, the other with reassurance that only two tests were needed to confirm my clinical assessment that there was nothing serious. Both women gave me a firm handshake, repeated by their largely silent accompanying husbands, both of whom silently mouthed the words “thank you”.

I laid it on fairly thick, I invoked what I sometimes refer to as the source of my calling, and I drew on my experience and they gray hair I have earned recently, and my ability to use simple language and everyday analogies to dispel the mystery of how our bodies work.

Instead of feeling pressured or overwhelmed by these encounters, I felt satisfied and energized. I easily caught up with my schedule and I didn’t give the daily distractions much thought.

I had done some real Doctoring. I had mitigated the fears of two fellow human beings.

Instant Relief

Few things in primary care give patient and doctor mutual and instant gratification.

It’s been a while since I reduced a “nursemaids elbow” or a spontaneous shoulder dislocation other than my own, or a finger dislocation, but those all count.

I once wrote about curing deafness in a man with a movement disorder by flushing ear wax more or less on the run as he bobbed around the exam room. That was instantly rewarding and also both exhausting and exciting. Even more ordinary cases of cerumen impaction are rewarding to treat. I almost never let my medical assistants get the satisfaction, or the risk, associated with that procedure.

A few months ago a man came to my Saturday clinic with a plastic tip from his hearing aid lodged sideways deep inside his ear canal. With the help of my modern headlamp (I trained on the cartoonish forehead mirror ENT doctors used to sport) and a delicate long pair of forceps I was able to remove it and relieve the stranger’s suffering.

Often, I delight in asking a patient to make the shoulder movements that hurt them so much a few minutes earlier and now feeling no pain, confirming that my steroid-Xylocaine (Hurrah Sweden!) injection hit the right spot.

A few weeks ago I saw a patient for an unrelated problem, who had recently received a nerve block by a nurse practitioner to the minor occipital nerve. The patient had presented with severe pain on the side of her head and the shot gave instant relief. I had never heard of that injection, so I read up on it.

Wouldn’t you know it, the following week I saw a different woman with an excruciating pain on the left side of her head. The pain seemed to originate in the back of her head. She was tender on the scalp over her ear and even more so over the lesser occipital nerve. She agreed to an injection. It was instantly successful.

In medical school it was “see one, do one, teach one”. This time it was “read about it, then do it”. Now I’m ready to teach it, thanks to a clinician with fewer years of education, born well after I started medical school. I’ll happily learn from anyone who knows something I don’t.

Lists of Three: Unforgettable Lessons from Medical School

A few weeks ago, I saw a patient with shortness of breath during my Saturday clinic. He had been short of breath for a few of weeks, and on a couple of occasions he had also experienced mild chest pain. He has known aortic stenosis, moderate according to his last echocardiogram two years ago.

My brain kicked into autopilot and I asked “have you fainted or passed out recently?” It was a flashback to medical school, where it seemed we were inundated with lists of threes.

For aortic stenosis, the triad of surgical indications for critical degrees was: Angina, synkope (remember I’m Swedish) and svikt, which is Swedish for failure, specifically congestive heart failure.

I’ve already written about a diagnosis right under my nose that I missed because the onset was so gradual: Dementia, urinary incontinence and gait disturbance, the diagnostic triad of normal pressure hydrocephalus.

A few months ago a crackerjack nurse practitioner came to me with the question: “What’s the syndrome with a droopy eyelid and a small pupil?”

“And a sunken-in eyeball?” I added.

“Yes!” She exclaimed.

“Horner’s Syndrome”, I proclaimed. “I still remember it from medical school and from a patient and my first Persian cat who both had sinus cancer.”

I don’t know why there are all these diagnostic triads out there, is it by some divine design or just because medical students can only retain short lists because of the multitude of diagnoses we have to memorize?

Where would we be without memorization? Sure, we could use computers to sift through endless lists of symptoms, most of which are red herrings, but there’s nothing quite as satisfying as knowing, in an instant, what the diagnosis is.

Wikipedia has a list of fifty clinical triads:

And, I almost forgot, last week I saw a patient with Reiter’s Syndrome, now called Reactive Arthritis: Persistent conjunctivitis, frequent urination and migrating arthritis that all began after a bout of severe diarrhea. She had already seen one other primary care clinician and her optometrist and both knew there was a bigger, overarching diagnosis behind her eye irritation. I was the one who nailed it.

If Not a Doctor, Then What?

One of the questions I was asked recently in an interview was something along the lines of could I say something about myself that few people know about.

The answer came to me fairly quickly.

After my military service, I applied to medical school. I had decided I wanted to go to Uppsala University. The Karolinska Institute was more famous, not the least because they pick the Nobel Prize winners in Medicine. But Uppsala is the second oldest university in the world, and the history behind it impressed me as the most classical medical education I could get.

In what now seems like a reckless thing to do, I only applied to Uppsala. It never occurred to me until after the deadline that it might have been wise to make a second and maybe even a third choice.

That fall semester I worked as a substitute teacher in my home town. I found myself one week in front of a room full of wide eyed second graders and the next facing one with bored and sullen fourteen year olds.

During those months I knew what I could do if Uppsala wouldn’t have me: I might become a teacher. I loved explaining things plainly and simply. I enjoyed presenting the hard to engage teenagers with an opening hook to gain their interest, or at least some degree of curiosity.

Today, again and again, day in and day out, I explain, challenge and engage patients in similar ways. As I often find myself pointing out, the word doctor is derived from “docere”, to teach.

So I got both jobs – a doctor, educated at the school of my choice, and a teacher for all ages, having to adapt my style and approach for a wide variety of patients, toddlers to centenarians.

It’s all the same, in a way. And I love it.

A Rare Form of Deafness or a Trivial Case of Congestion?

I chose doxycycline to treat Norman Starks Lyme disease. A week later he went to a walk-in clinic with sudden loss of hearing in his right ear. The PA who saw him suspected that the doxycycline had caused it and told him to stop the medication. Meanwhile, he needed at least one or two more weeks of antibiotics. He got amoxicillin.

When I saw Norman I asked what kind of exam they had done on him, he said “they just looked in my ears”.

“Did they do any kind of hearing test?” I asked.

He shook his head.

“Did they put a tuning fork on your head?”

“No”, he said quizzically.

I pulled my tuning fork from a plastic basket on the counter. I have one in every room.

“So how is your hearing now?” I asked.

“I think it’s a little better.”

“OK, tell me, if I put this tuning fork in the middle of your head like this, where do you hear it the loudest?”

Norman looked like he concentrated hard. He seemed confused.

“It’s louder in my right ear.”

“And which of these is louder, on the bone behind your ear or in the air in front of it?”


I put the tuning fork away and sat down next to him.

“Your hearing is going to be fine. You can hurry it along by using some cortisone nose spray for a while. This is not nerve deafness, you’re just congested. And the doxycycline had nothing to do with it.”

I love low tech medicine.

And just the other day I saw a new diabetic who complained of blurry vision. After a split second of worry, I excused myself and got several sheets of dark paper, stapled them together and pierced a small hole in the center.

“Come with me, let’s check your vision”, I said.

We went down the hall and I asked him to look at the eye chart through the pinhole, one eye at a time.

“What’s the smallest line you can read?”

“D,E,F,P,O,T,E,C”, he read.

“Perfect. The lenses inside your eyes are just swollen from your high blood sugars. Hold off a little before seeing the eye doctor, and don’t order glasses until your blood sugars have settled down.”

Another early lesson all the way back from medical school.

Myopic Versus Hyperopic Views on Physicians’ Work

There is a constant tension in medicine between the details and the big picture. Many factors magnify this tension, and they make our work as clinicians harder. We really need to find our own balance between tending to the details and grasping the big picture, or, in optical terms, a myopic or hyperopic view of our work.

A jeweler working on a delicate mechanical watch, with a loupe pinched over his dominant eye, is not well equipped to also watch the front door of his store for shoplifters.

The more pressured I feel from the number and complexity of patient visits in my schedule, and the further behind that schedule I fall, I know that I become increasingly hyper-focused. It is definitely my survival mechanism for days that threaten to spin out of control. I revert to a razor sharp focus on THAT patient in order to make decisions, sometimes in a triage sort of way: What is the WORST thing this could be? What is the NEXT step for this patient? What would make the BIGGEST difference in this situation? If I instead tried to think of how to get the next two or three patient visits to go smoothly, I don’t think I would be much help to the person I am with RIGHT NOW.

I don’t verbalize or claim this nearly enough: If my team wants me to handle THIS MANY patients in THIS LITTLE time, they need to watch the flow for me; there is no way I can do both. I can’t get enough from them of things like:

“I put out the instruments you might need if you decide to lance this.”

“I got a urinalysis/EKG and a copy of the last culture/tracing…”

“You need to look at this ankle ahead of your next patient, because x-ray is leaving in twenty minutes…”

My other persona, the Medical Director, zooms effortlessly between the two focal distances. Unfettered by a near-superhero clinic schedule, I can zero in when consulted by a new nurse practitioner on a clinical case, and the next minute I can watch the clinic flow and sense the energy of a dozen coworkers as they go about their day, or I can glance at lists of data and get the “big picture” or spot incongruences.

The difference is that pressure, which is so insidious that you can’t really understand it until it is gone: When the last patient has left, the phones are off, most people have left the clinic and the sounds of air conditioners and office equipment have eased off, you realize there had been a pressure on your mind and even your body, coming from every angle as if you were a deep sea diver far below the surface.

Suddenly, the air feels lighter, I am aware of my surroundings and not just striving to tune them out. I didn’t feel the pressure building, but when it eases off this suddenly, it is a very physical sensation.

I throw the word “pressure cooker” around now and then. My mother had one back in the early sixties. Long before microwaves and convection ovens, we cooked things faster by using airtight lids on heavy pots. Without that extra pressure, dinner would be late. Without that extra pressure, clinic would run longer and overtime costs would mushroom. Without that extra pressure, revenue would drop. But like kitchen technology, aren’t there more elegant ways of doing this? The heavy iron lids and the steam escaping through their rattling top vents evoke yet more images – steam locomotives of a bygone early industrial era.

Oh well, I’m just letting off some steam…

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