Good morning. Happy hump day to all, and to all the medical students out there getting ready to take Boards, good luck! I’m going to try and keep the entry today light, although there is something that I definitely want to discuss, and it might be a little heavy, so just stay with me. On to the blog!
It was another fibromyalgia day yesterday, although interestingly, the majority of the claimants complaining of said disease were males (FM is a predominantly female condition). My last patient of the day was a 21 y/o male, who stated that his main complaints were Chronic Fatigue Syndrome, Fibromyalgia and (can you guess it?) depression. His mother accompanied him, and he shuffled into the office, all sweaty and nervous. I had glanced over his chart prior to calling him back, and it said that he received all of his treatment from the Institute of Fibromyalgia and Chronic Fatigue Therapy (name changed), located in another city, and run by a PhD Psychologist and a dentist. As you might imagine, I found this to be rather odd, seeing as dental health and a musculoskeletal disorder have very little in common, at least to my knowledge. He stated that “if I lift anything heavy, I’ll be tired for like 20 minutes afterwards.” Likewise, he stated that he was often too tired to do chores or drive, so he had his parents and friends take him where he needed to go. Sounds nice, right? After some additional questioning, the claimant stated that he received treatment at the Institute once a month, and admitted that he received all of his medication in the mail. This fact alone would have had my “spider senses” tingling, but when I looked at his medication sheet, I definitely realized something was amiss.
As I’ve said before, FM is usually treated with SSRIs, with the occasional pain medication thrown onboard for good measure. Well, this kid had no anti-depressants on his sheet, heck he hardly had any conventional treatments at all. What follows is a list of the medications, and their usage, for his condition.
1. Mobic – chronic pain
2. Tylenol – pain
3. Azithromycin 500mg– to keep the bugs down
4. Midol – pain
5. Depo testosterone injection – hormone issues
6. Natural Cortisol – hormone issues
7. Ambien – hormone issues/sleep
8. Centrum Silver – multivitamin
Ok, well, you might have already noticed some…irregularities, namely the Centrum silver (he’s 22) and the Midol (he’s a he, although it’s basically just Tylenol and a mild diuretic, anyway). As for the other medications…Azithromycin is an antibiotic (it’s the medication in a Z-pack), which is normally taken over five days. In some instances that therapy may be continued longer, but it is definitely not a daily medication. Then there’s the hormone issue – Ambien does not affect hormone levels at all, it works on neurotransmitters in your brain to make you drowsy. Likewise, unless he had some underlying endocrine disorder which he failed to mention in the “do you have any medical conditions” part of the interview, there’s absolutely no reason that he should be taking supplemental hormones like testosterone (a sex hormone) and Cortisol (an adrenal hormone released during periods of stress). In fact, by adding extra hormones, he could possibly be decreasing the amount of hormones he naturally produces, thereby giving his side-effects such as (get ready for this) fatigue, decreased mood and weakness. Hooo boy (or hautbois) I think we might have found the cause of his problems! Never mind the fact that most people feel like crap taking antibiotics, even if it’s only for a week, and 500mg is above the loading (or largest) dose for a Z-pack. Man oh man.
Needless to say, when I performed the Fibromyalgia point tenderness test, he reported 2/18 points tender (you need 11 to be clinically diagnosed). As for the rest of his physical exam, well, it was as normal as can be. I guess the lesson to learn today is to be careful who you get your care from. There are a bunch of people out there who will sell and tell you anything to get a buck. If your “doctor” starts telling you that you have a disease, but you can only order your medication through the mail, I’d be a little suspicious of their training. There was a chiropractor in town a few years ago that stated that he could tell a person’s health by the Red Beaker Test – a test in which he had the patient hold a beaker of red liquid, and based on the way it jiggled, he could tell if you had gallbladder problems, heart disease or even infertility. He offered the test for the low, low price of $25, and wouldn’t you know, it didn’t really tell anything. Amazing, right? I have no idea how much this kid (or his parents, for that matter) was paying each month for treatment, but as the saying goes, “there’s a sucker born every minute.”
And now, for the disability quotes of the day:
Me: “I’m going to need you to bend at the waist to test the range of motion of your back.”
Older, buxom woman: “You’re not going to look down my shirt, are you?”
Me: “Oh no, ma’am, I’m just looking at your spine.”
Woman: “Well you can look, I won’t mind. At my age, it’s all the action I get.”
Me: “I’m going to test your grip strength. Please take my hands and squeeze them.”
Dude: [Squeezing gently] “I’d squeeze harder, but I might make you explode with the force of my grip.”
Me: “I’ll keep that in mind.”
Caveat emptor,
-DD
Wednesday, June 2, 2010
Tuesday, June 1, 2010
Hypertension Dimension
Good Tuesday! I hope everyone had a wonderful Memorial Day, ours was spent traversing from family to family, but overall it was a lot of fun. My work schedule in June is going to be a little different – this week I’m working today, Wednesday, Thursday and Friday. Starting next week, however, I’ll be in the office on Monday, Tuesday, Wednesday and half days on Thursday, so expect blog entries on those days. Anyways, onwards!
Since the last few entries have been more lighthearted, I thought that I would talk about something a little more medical today. I’ve had a plethora of patients recently that have all had severely elevated blood pressures, and (of course) they’re not on any type of medication. Most of them also smoke, say that they can’t afford any medication because it’s so expensive, and of course, and can’t go to a doctor because they can’t afford that, either. Let’s look at the first and second excuse.
A pack of cigarettes is around (last time I checked) $5. So if you smoke 1 pack of cigarettes a day, your habit just cost you $150 for that month. Lisinopril (a common first line high-blood pressure medication) is $4 for a month’s supply. Now, I’m no math expert, but 4$ for 30 days worth of medication…$5 for 20 cigarettes that you smoke in one day….well, I guess it’s your lungs and your life. What I don’t understand is people that smoke two or three packs of cigarettes a day – when do they have time to do anything else? I guess if you light up the second you wake up, and then smoke yourself to sleep that night you could do it, but otherwise, man, that’s a lot of time spent puffing.
As for the last excuse, most cities have some sort of free-clinic(s) system set up - mine is no different - but like I’ve said before, it doesn’t matter how many free clinics there are, if the patients can’t get to them, they won’t use them. Now, you might say, “what about buses or trolleys?” Unfortunately, Mass Transit in this city is about as prevalent as actually disabled people applying for disability, so that’s out. The same goes for adequate sidewalks (not that most of these people could walk more than a block at a time anyway.) So, what do we do? Some cities have proposed a type of “mobile free clinic” that serves “needy areas.” What, however, defines needy? Should it just be limited to lower income populations, or should anyone be able to get, say, blood pressure medication or their eyes checked for free? Without delving in the whole socialized medicine debate, my own personal belief is that basic health services should be available to everyone regardless of economic status. As for more than that, well, that’s the subject of another blog.
So, in summation, we have a large number of people with high blood pressure who…
A:) Can’t afford to see a doctor to have their blood pressure checked and receive a prescription
B:) Can’t afford said prescription (maybe because they smoke, maybe other reasons)
C:) Are unable to travel to a free clinic to receive free medication
D:) And definitely can’t afford the resultant hospital bill when they stroke out or have a heart attack
What do we do with this problem? Aside from putting hypertension medication in the water, I feel that the only way we’re going to do something about this conundrum is to really increase the availability of basic care options throughout the city. That said, it doesn’t matter how many free clinics we have if people aren’t going to take responsibility for their own health. Maybe it seems like common sense, but if you have lung problems, don’t smoke. If you have heart problems, don’t smoke. If you want to get pregnant, don’t smoke. In fact, the only people who should be smoking out there are people who want to have that “aged” look without having to wait for time to roll by.
Sigh, I know a lot of times I sound like a broken record on this blog, but really people, please cherish your bodies – it’s the only one you’ve got. That said, wear some sunscreen, too. And exercise…oh forget it, you get the picture!
And now for the disability quote of the day:
Me: “So I see you’re on disability currently, why?”
Dude: “Because I got made fun of in school.”
Me: “There has to be something more than that.”
Dude: “Well, I was only reading at an 8th grade level in 12th grade. But I graduated anyway, so they can TAKE THAT, SUCKERS!”
Me: “Ok ….”
Dude: “Yep, I’m getting rich off of being clinically stupid.”
Prevention is the best form of medicine,
-DD
Since the last few entries have been more lighthearted, I thought that I would talk about something a little more medical today. I’ve had a plethora of patients recently that have all had severely elevated blood pressures, and (of course) they’re not on any type of medication. Most of them also smoke, say that they can’t afford any medication because it’s so expensive, and of course, and can’t go to a doctor because they can’t afford that, either. Let’s look at the first and second excuse.
A pack of cigarettes is around (last time I checked) $5. So if you smoke 1 pack of cigarettes a day, your habit just cost you $150 for that month. Lisinopril (a common first line high-blood pressure medication) is $4 for a month’s supply. Now, I’m no math expert, but 4$ for 30 days worth of medication…$5 for 20 cigarettes that you smoke in one day….well, I guess it’s your lungs and your life. What I don’t understand is people that smoke two or three packs of cigarettes a day – when do they have time to do anything else? I guess if you light up the second you wake up, and then smoke yourself to sleep that night you could do it, but otherwise, man, that’s a lot of time spent puffing.
As for the last excuse, most cities have some sort of free-clinic(s) system set up - mine is no different - but like I’ve said before, it doesn’t matter how many free clinics there are, if the patients can’t get to them, they won’t use them. Now, you might say, “what about buses or trolleys?” Unfortunately, Mass Transit in this city is about as prevalent as actually disabled people applying for disability, so that’s out. The same goes for adequate sidewalks (not that most of these people could walk more than a block at a time anyway.) So, what do we do? Some cities have proposed a type of “mobile free clinic” that serves “needy areas.” What, however, defines needy? Should it just be limited to lower income populations, or should anyone be able to get, say, blood pressure medication or their eyes checked for free? Without delving in the whole socialized medicine debate, my own personal belief is that basic health services should be available to everyone regardless of economic status. As for more than that, well, that’s the subject of another blog.
So, in summation, we have a large number of people with high blood pressure who…
A:) Can’t afford to see a doctor to have their blood pressure checked and receive a prescription
B:) Can’t afford said prescription (maybe because they smoke, maybe other reasons)
C:) Are unable to travel to a free clinic to receive free medication
D:) And definitely can’t afford the resultant hospital bill when they stroke out or have a heart attack
What do we do with this problem? Aside from putting hypertension medication in the water, I feel that the only way we’re going to do something about this conundrum is to really increase the availability of basic care options throughout the city. That said, it doesn’t matter how many free clinics we have if people aren’t going to take responsibility for their own health. Maybe it seems like common sense, but if you have lung problems, don’t smoke. If you have heart problems, don’t smoke. If you want to get pregnant, don’t smoke. In fact, the only people who should be smoking out there are people who want to have that “aged” look without having to wait for time to roll by.
Sigh, I know a lot of times I sound like a broken record on this blog, but really people, please cherish your bodies – it’s the only one you’ve got. That said, wear some sunscreen, too. And exercise…oh forget it, you get the picture!
And now for the disability quote of the day:
Me: “So I see you’re on disability currently, why?”
Dude: “Because I got made fun of in school.”
Me: “There has to be something more than that.”
Dude: “Well, I was only reading at an 8th grade level in 12th grade. But I graduated anyway, so they can TAKE THAT, SUCKERS!”
Me: “Ok ….”
Dude: “Yep, I’m getting rich off of being clinically stupid.”
Prevention is the best form of medicine,
-DD
Saturday, May 29, 2010
Honey honey
Good morning! It’s another bright Saturday at Disability Physicals – today’s forecast is showing chronic pain with a chance for neuropathy. I hope everyone is able to get some rest over this holiday weekend, because next week promises to be a doozey in disability land. Thanks to the genies at social security, we’re totally full for the first two weeks of June, which is nice. Anyway, on to the blog!
I pulled up to the building this morning around 7:30 AM. A little early, I know, but we’re training a new physician today, and I like to go over some of the “ins and outs” of the exam with them before they face the onslaught. As I was putting my key into the door, a 19ghetto Chevy zooms up behind me, and a toothless woman with I-just-stuck-my-finger-into-a-light-socket hair leans out of the window and yells, “is this the place for my boytoy’s disability thingie?”
“Well,” I responded, “it could be, who are you here to see?”
“Some doctor or something, I can’t pronounce his or her name. It’s like xxxxx.”
Now, without revealing my secret identity, I’ll just let you know that my name is really not that hard to pronounce…I’m of Gaelic heritage, it’s not like I have eight consonants in a row or something (no offense to people with eight consonants in a row). For some reason, however, people have a really difficult time spelling or pronouncing it – maybe I should change it to Dwayne Wayne or something. Anyway, I responded to the banshee with “that’s me, let me just open up the building.”
“Oh that’s ok, honey,” she replied, “we still gotta drink our coffee, so it’ll be a bit.”
Argh, big pet peeve. I really don’t like being called “honey” by patients. For that matter, I don’t like it when other doctors call their patients honey, but that’s another story. Anyway, 40 minutes later, they walked in the door…I guess it was a big cup of coffee. The boytoy’s complaint was that “my back hurts all the time – it’s like a 2 on a 0-10 scale.” When questioned how that pain kept him from working, he responded, “Well, it makes me forget things all the time, like where my wrench is, or what I’m doing. I just can’t function on that level of pain, and all the Lortab my doctor is giving me isn’t helping anymore.”
Have you ever wanted to just tell someone to tough it up? I mean, I understand that pain can be debilitating – heck, almost every person I see doing these physicals tells me how debilitating it is. But a 2? Really? Anyway, he started crying through the physical exam…after I told him that he was going to have to bend at the waist. Apparently the thought of bending was too much for him to handle. I have to say, however, he bent…about 10 degrees, and then begged me to “make the pain stoooooooooppppp!” Well, it did after he stood up, and wouldn’t you know, he didn’t seem to be in all that much pain after I watched him run to get into his care after the exam. Go figure.
And now for the disability quote of the day:
Me: “Have you ever held a job?
Dude: “I worked at Little Caesar’s for three days, but they fired me because I cooked too many square pizzas.”
Me: “….ok then.”
Have a good one, honey.
-DD
I pulled up to the building this morning around 7:30 AM. A little early, I know, but we’re training a new physician today, and I like to go over some of the “ins and outs” of the exam with them before they face the onslaught. As I was putting my key into the door, a 19ghetto Chevy zooms up behind me, and a toothless woman with I-just-stuck-my-finger-into-a-light-socket hair leans out of the window and yells, “is this the place for my boytoy’s disability thingie?”
“Well,” I responded, “it could be, who are you here to see?”
“Some doctor or something, I can’t pronounce his or her name. It’s like xxxxx.”
Now, without revealing my secret identity, I’ll just let you know that my name is really not that hard to pronounce…I’m of Gaelic heritage, it’s not like I have eight consonants in a row or something (no offense to people with eight consonants in a row). For some reason, however, people have a really difficult time spelling or pronouncing it – maybe I should change it to Dwayne Wayne or something. Anyway, I responded to the banshee with “that’s me, let me just open up the building.”
“Oh that’s ok, honey,” she replied, “we still gotta drink our coffee, so it’ll be a bit.”
Argh, big pet peeve. I really don’t like being called “honey” by patients. For that matter, I don’t like it when other doctors call their patients honey, but that’s another story. Anyway, 40 minutes later, they walked in the door…I guess it was a big cup of coffee. The boytoy’s complaint was that “my back hurts all the time – it’s like a 2 on a 0-10 scale.” When questioned how that pain kept him from working, he responded, “Well, it makes me forget things all the time, like where my wrench is, or what I’m doing. I just can’t function on that level of pain, and all the Lortab my doctor is giving me isn’t helping anymore.”
Have you ever wanted to just tell someone to tough it up? I mean, I understand that pain can be debilitating – heck, almost every person I see doing these physicals tells me how debilitating it is. But a 2? Really? Anyway, he started crying through the physical exam…after I told him that he was going to have to bend at the waist. Apparently the thought of bending was too much for him to handle. I have to say, however, he bent…about 10 degrees, and then begged me to “make the pain stoooooooooppppp!” Well, it did after he stood up, and wouldn’t you know, he didn’t seem to be in all that much pain after I watched him run to get into his care after the exam. Go figure.
And now for the disability quote of the day:
Me: “Have you ever held a job?
Dude: “I worked at Little Caesar’s for three days, but they fired me because I cooked too many square pizzas.”
Me: “….ok then.”
Have a good one, honey.
-DD
Saturday, May 22, 2010
Wayne's World
Good morning! It’s another Saturday at Disability Physicals, and so far I’ve had to field two calls from people asking for directions. Now, my wife will tell you I’m one of the most directionly-challenged people you’ll meet, but I think I did an ok job. We’ll try and keep things light hearted this AM, as I don’t really feel like tackling a heavy topic at 7:56 in the morning. Oh, my schedule in June is really picking up (apparently social security realized that I wanted to work other days besides Saturdays), so expect more blog entries throughout the week next month.
There are a couple of things that I’ve realized after doing this type of job for almost a year. 1.) People tend to think that any aliment that causes pain or a change in lifestyle is a disabling condition, and 2.) almost every male who applies for disability has the middle name of Wayne. Let’s talk about the Waynes first. My first day at the new office, every male patient had Wayne in their name. I swear, it was like Gary Wayne xxx, then Charles Wayne xxx, followed by Dwayne Wayne (yep, that’s real) xxx. I don’t know if there’s a link between the name and the potential for applying for disability – maybe there’s an abundance of people who perform manual labor with the middle name Wayne – but without fail I will at least see one [first name] Wayne [last name] every time I step into the office. Gary Wayne by itself seems to be a popular combination for disability claimants. There’s a “note to self” to all you future parents out there, if you want your child to eventually apply for disability, name them Gary Wayne. Or Dwayne Wayne, because that’s just awesome. Finally, if your last name is Wayneson, please, please name them Dwayne Wayne Wayneson. Not only will they probably apply for disability, but they’ll either get beat up at school, or end up being a professional bull rider, who will probably, one day, need disability anyway.
As for the first topic, well…if you’ve been reading this blog for any amount of time, you’ve seen some strange reasons why people think they need disability. I still think my personal favorite is “my left breast hurts after I eat hamburger.” It’s been a while since we’ve done a complaint list, so here you go. Merry Christmas.
1.) My hands hurt after I sit on them
2.) I got depression after my mouse died
3.) I died three times
4.) I have cancer (when questioned, the patient couldn’t tell me what organ the cancer affected, just that she had it)
5.) My wife hits me
6.) I only got to the 11th grade
7.) I can’t read or write at all (this was in the patient’s handwriting)
8.) I get angry when people yell at me
9.) My feet hurt after standing on them for 10 hours
10.) My knees hurt after I gained 100 lbs
The question is, dear readers, will any of these people actually receive disability? Only time will tell. I for one think that the person who can’t write anything, with the exception of their disability statement, of course, should at least get a little something…I mean, that’s legit, right?
Have a good weekend!
-DD
There are a couple of things that I’ve realized after doing this type of job for almost a year. 1.) People tend to think that any aliment that causes pain or a change in lifestyle is a disabling condition, and 2.) almost every male who applies for disability has the middle name of Wayne. Let’s talk about the Waynes first. My first day at the new office, every male patient had Wayne in their name. I swear, it was like Gary Wayne xxx, then Charles Wayne xxx, followed by Dwayne Wayne (yep, that’s real) xxx. I don’t know if there’s a link between the name and the potential for applying for disability – maybe there’s an abundance of people who perform manual labor with the middle name Wayne – but without fail I will at least see one [first name] Wayne [last name] every time I step into the office. Gary Wayne by itself seems to be a popular combination for disability claimants. There’s a “note to self” to all you future parents out there, if you want your child to eventually apply for disability, name them Gary Wayne. Or Dwayne Wayne, because that’s just awesome. Finally, if your last name is Wayneson, please, please name them Dwayne Wayne Wayneson. Not only will they probably apply for disability, but they’ll either get beat up at school, or end up being a professional bull rider, who will probably, one day, need disability anyway.
As for the first topic, well…if you’ve been reading this blog for any amount of time, you’ve seen some strange reasons why people think they need disability. I still think my personal favorite is “my left breast hurts after I eat hamburger.” It’s been a while since we’ve done a complaint list, so here you go. Merry Christmas.
1.) My hands hurt after I sit on them
2.) I got depression after my mouse died
3.) I died three times
4.) I have cancer (when questioned, the patient couldn’t tell me what organ the cancer affected, just that she had it)
5.) My wife hits me
6.) I only got to the 11th grade
7.) I can’t read or write at all (this was in the patient’s handwriting)
8.) I get angry when people yell at me
9.) My feet hurt after standing on them for 10 hours
10.) My knees hurt after I gained 100 lbs
The question is, dear readers, will any of these people actually receive disability? Only time will tell. I for one think that the person who can’t write anything, with the exception of their disability statement, of course, should at least get a little something…I mean, that’s legit, right?
Have a good weekend!
-DD
Saturday, May 15, 2010
Mullets unite!
Buenos dias, amigos. In their infinite awesomeness, Social Security decided to only schedule me on Saturday s in May…which makes no sense, especially since I literally have nothing to do now that the medical school is out for the summer. What that means for you, dear readers, is that I’ll probably only be posting once a week. So make sure you keep an eye on the Disillusioned Doctor Facebook group, for that’s where I’ll post new entries. Onwards!
Things seem to come in clumps in disability land. One day it’ll be depression, another day COPD. This morning it’s been anxiety…and mullets. I’m not aware of a condition that combines the two…maybe I’ll call it Mulletosis Nervosa. Anyway, anxiety patients are always…challenging. They usually want to keep the exam room door open, have a problem with me taking their blood pressure, and some of them even refuse the physical exam because they’re so nervous. Well, the anxiety patients this morning have all fit the bill. One in particular, however, has risen above the others in my mind, and not only because his mullet would make MacGyver cry with envy.
He walked into the office, his hair a dyed jet black, and in true mullet fashion, party end hanging to his backside, business end cut short and plastered with gel. He was a dichotomy of eras – the rocker 80’s mating with the Emo 90’s. His life was truly, as one of my friends from medical school would say, muffins…muffins and pain. I called his name after glancing over his disability form; the main complaint read “chest wall stuck in/heart murmurs.” He and his equally Emo girlfriend walked into the exam room (leaving the door open, of course), and sat down in front of my desk.
“So, tell me about your heart condition.” I asked.
“I dunno, it’s like always been there…I guess.” He replied.
“Have you seen a cardiologist?”
“No, well, I did when I was a kid…but not since then…that’s been like a few years ago.”
“So does your heart bother you now?”
“Only if I do things like run eight miles.”
“…what does it do if you run eight miles?”
“It beats really fast, like it’s trying to really pump my blood fast.”
“Yes.” Woohoo normal physiology.
At this point, the girlfriend leaned over and whispered something in his ear. He immediately said “and my chest is really caved in!”
Ok, so Pectus Excavatum. A relatively normal variant in which the sternum or breast bone is “caved in.” This condition can cause problems if the concavity is large enough, but usually those patients receive surgery at an early age… this dude didn’t. He lifted up his shirt to reveal a tattoo of a monkey eating an apple (?) and a very, very mild Pectus.
“Should I get surgery on this?” He asked.
“Well, I wouldn’t, but I’m not a Thoracic surgeon.” I replied.
“Oooooh, ok, because like, I thought I was going to get surgery for this.”
I think I audibly sighed. “No sir, this is a disability exam…nothing more.”
The remainder of the physical exam was normal, and as he walked out, he said, “it’s a good thing I didn’t get surgery today, I have stuff to do.”
“I’m sure you do.” Idiot.
And now for the disability quote of the day:
Lady: “My cat can ‘matrix walk,’ and it knocked me over. That’s how I got a head injury.”
Me: “Did you take any medication after that?”
Lady: “Just some pills.”
Me: “Were they…red or blue pills?”
Lady: “Huh? I think they were white.”
Me: “Ok, just checking.”
Free your mind,
-DD
Things seem to come in clumps in disability land. One day it’ll be depression, another day COPD. This morning it’s been anxiety…and mullets. I’m not aware of a condition that combines the two…maybe I’ll call it Mulletosis Nervosa. Anyway, anxiety patients are always…challenging. They usually want to keep the exam room door open, have a problem with me taking their blood pressure, and some of them even refuse the physical exam because they’re so nervous. Well, the anxiety patients this morning have all fit the bill. One in particular, however, has risen above the others in my mind, and not only because his mullet would make MacGyver cry with envy.
He walked into the office, his hair a dyed jet black, and in true mullet fashion, party end hanging to his backside, business end cut short and plastered with gel. He was a dichotomy of eras – the rocker 80’s mating with the Emo 90’s. His life was truly, as one of my friends from medical school would say, muffins…muffins and pain. I called his name after glancing over his disability form; the main complaint read “chest wall stuck in/heart murmurs.” He and his equally Emo girlfriend walked into the exam room (leaving the door open, of course), and sat down in front of my desk.
“So, tell me about your heart condition.” I asked.
“I dunno, it’s like always been there…I guess.” He replied.
“Have you seen a cardiologist?”
“No, well, I did when I was a kid…but not since then…that’s been like a few years ago.”
“So does your heart bother you now?”
“Only if I do things like run eight miles.”
“…what does it do if you run eight miles?”
“It beats really fast, like it’s trying to really pump my blood fast.”
“Yes.” Woohoo normal physiology.
At this point, the girlfriend leaned over and whispered something in his ear. He immediately said “and my chest is really caved in!”
Ok, so Pectus Excavatum. A relatively normal variant in which the sternum or breast bone is “caved in.” This condition can cause problems if the concavity is large enough, but usually those patients receive surgery at an early age… this dude didn’t. He lifted up his shirt to reveal a tattoo of a monkey eating an apple (?) and a very, very mild Pectus.
“Should I get surgery on this?” He asked.
“Well, I wouldn’t, but I’m not a Thoracic surgeon.” I replied.
“Oooooh, ok, because like, I thought I was going to get surgery for this.”
I think I audibly sighed. “No sir, this is a disability exam…nothing more.”
The remainder of the physical exam was normal, and as he walked out, he said, “it’s a good thing I didn’t get surgery today, I have stuff to do.”
“I’m sure you do.” Idiot.
And now for the disability quote of the day:
Lady: “My cat can ‘matrix walk,’ and it knocked me over. That’s how I got a head injury.”
Me: “Did you take any medication after that?”
Lady: “Just some pills.”
Me: “Were they…red or blue pills?”
Lady: “Huh? I think they were white.”
Me: “Ok, just checking.”
Free your mind,
-DD
Friday, May 7, 2010
Warning: Controversy
Good morning! Fridays are day-long affairs for me at Disability physicals. I’m trying to squeeze a blog in between patients, so forgive me if my thoughts are a little discombobulated. My wife told me yesterday that my next blog should be a little more philosophical, since the last few entries have been more comic than serious in nature. So…I decided to listen to her, and write about something that we see quite a bit of here in disability land – Fibromyalgia. Oooooh boy, controversy here we come.
Fibromyalgia (FM), the redheaded step child of the chronic pain population. Nobody really knows what causes it…maybe it’s depression, maybe it’s obesity, maybe it’s eating too much Thai food. What we do know, however, is that the number of people diagnosed with FM seem to be on the rise, even though the criteria for diagnosis is foggy at best – subjective pain elicited by specific point compression. To make things more…concrete, there is a FM tender point sheet, with 18 tender points scattered over the body. To be diagnosed with FM, one must have 11 of those points “elicit pain with approximately 4 lbs of force applied.” Now, I know I have sensitive hands and everything, but can you really differentiate between 3 lbs and 5 lbs? Do I need to get a pressure-gauge thing like they use to measure the force of kinetic motion and strap it onto my hands before I test said points? I don’t know, maybe I’m over analyzing things, but it seems to me that if you push hard enough, people will say “ouch,” regardless of whether or not you have the disease.
Things get even foggier when we delve into the treatments for fibromyalgia. OTC pain relievers, topical pain reducers, and even narcotics are common therapies for the condition, all of which have questionable efficacy. Interestingly, new studies are coming out left and right revealing a decrease in symptoms with the use of selective serotonin reuptake inhibitors (SSRIs). In case you didn’t know, serotonin is a neuro-hormone that, among other things, produces a sense of “well-being” in the body. SSRIs work by increasing the amount of circulating serotonin, thereby making the patient feel happier…sounds like a great way to treat depression, right? That’s because Paxil, Prozac, Celexa and a slew of other anti-depressant medications are SSRIs. Why then, are we using SSRIs to treat fibromyalgia? Could there be a correlation between fibromyalgia and depression? This Disillusioned Doctor thinks so. My guess is that in a few years some study will come out that will show fibromyalgia to be a form of the “psychomotor aspect of depression” – an elusive symptom that is defined by, among other things, lowered pain threshold, muscle weakness and problems with coordination. Now, I’m not saying that all patients with fibromyalgia exhibit the above symptoms. What I am saying is that every one of the disability patients I’ve seen that lists Fibromyalgia as their main complaint also has depression somewhere in their medical history. Coincidence? I doubt it.
So, now that we’ve “defined” the disease, what do we do about it? Sure, we can keep prescribing pain pills and muscle relaxers, maybe even throw in a few SSRIs for good measure. My opinion is, however, that we’re not approaching this condition correctly. By calling it a disease, putting ads on the TV, and making medication that is “specifically for fibromyalgia” (which, amazingly, is just an SSRI), we as a medical community are giving teeth to something that should be listed as a symptom, and not the main cause of a problem. Fact: Depression lowers your pain threshold. Fact: The majority of medications used to treat FM can also be used to treat depression. Fact: The population that is at highest risk for FM is also at highest risk for depression. There are just too many coincidences here to ignore. We as physicians need to get to the heart of this matter, and really reevaluate the way we look at fibromyalgia as a whole. Is it something that exists totally by itself, or is it something that only occurs when other factors are present? In summation, are we just treating the symptoms (the muscle aches and pains) and forgetting about the actual disease? Only time will tell.
And now, for the disability quote(s) of the day:
Me: “So tell me about your seizures.”
Girl: “Well, I ain’t never seen them, but my boyfriend tells me I’m like ‘I’m shaking!’ Then I go ‘ooogh’ or something. Then the seizure is done.”
Me: “…so…how long do your seizures last?”
Girl: “Just as long as I can say ‘ooooogh.’”
Me: “Alrighty.”
Patient’s written response to the question, “Who can we call for further information about your condition?”
“You can call Gerry On the Hill. I don’t know her number, though.”
Have a good weekend,
-DD
Fibromyalgia (FM), the redheaded step child of the chronic pain population. Nobody really knows what causes it…maybe it’s depression, maybe it’s obesity, maybe it’s eating too much Thai food. What we do know, however, is that the number of people diagnosed with FM seem to be on the rise, even though the criteria for diagnosis is foggy at best – subjective pain elicited by specific point compression. To make things more…concrete, there is a FM tender point sheet, with 18 tender points scattered over the body. To be diagnosed with FM, one must have 11 of those points “elicit pain with approximately 4 lbs of force applied.” Now, I know I have sensitive hands and everything, but can you really differentiate between 3 lbs and 5 lbs? Do I need to get a pressure-gauge thing like they use to measure the force of kinetic motion and strap it onto my hands before I test said points? I don’t know, maybe I’m over analyzing things, but it seems to me that if you push hard enough, people will say “ouch,” regardless of whether or not you have the disease.
Things get even foggier when we delve into the treatments for fibromyalgia. OTC pain relievers, topical pain reducers, and even narcotics are common therapies for the condition, all of which have questionable efficacy. Interestingly, new studies are coming out left and right revealing a decrease in symptoms with the use of selective serotonin reuptake inhibitors (SSRIs). In case you didn’t know, serotonin is a neuro-hormone that, among other things, produces a sense of “well-being” in the body. SSRIs work by increasing the amount of circulating serotonin, thereby making the patient feel happier…sounds like a great way to treat depression, right? That’s because Paxil, Prozac, Celexa and a slew of other anti-depressant medications are SSRIs. Why then, are we using SSRIs to treat fibromyalgia? Could there be a correlation between fibromyalgia and depression? This Disillusioned Doctor thinks so. My guess is that in a few years some study will come out that will show fibromyalgia to be a form of the “psychomotor aspect of depression” – an elusive symptom that is defined by, among other things, lowered pain threshold, muscle weakness and problems with coordination. Now, I’m not saying that all patients with fibromyalgia exhibit the above symptoms. What I am saying is that every one of the disability patients I’ve seen that lists Fibromyalgia as their main complaint also has depression somewhere in their medical history. Coincidence? I doubt it.
So, now that we’ve “defined” the disease, what do we do about it? Sure, we can keep prescribing pain pills and muscle relaxers, maybe even throw in a few SSRIs for good measure. My opinion is, however, that we’re not approaching this condition correctly. By calling it a disease, putting ads on the TV, and making medication that is “specifically for fibromyalgia” (which, amazingly, is just an SSRI), we as a medical community are giving teeth to something that should be listed as a symptom, and not the main cause of a problem. Fact: Depression lowers your pain threshold. Fact: The majority of medications used to treat FM can also be used to treat depression. Fact: The population that is at highest risk for FM is also at highest risk for depression. There are just too many coincidences here to ignore. We as physicians need to get to the heart of this matter, and really reevaluate the way we look at fibromyalgia as a whole. Is it something that exists totally by itself, or is it something that only occurs when other factors are present? In summation, are we just treating the symptoms (the muscle aches and pains) and forgetting about the actual disease? Only time will tell.
And now, for the disability quote(s) of the day:
Me: “So tell me about your seizures.”
Girl: “Well, I ain’t never seen them, but my boyfriend tells me I’m like ‘I’m shaking!’ Then I go ‘ooogh’ or something. Then the seizure is done.”
Me: “…so…how long do your seizures last?”
Girl: “Just as long as I can say ‘ooooogh.’”
Me: “Alrighty.”
Patient’s written response to the question, “Who can we call for further information about your condition?”
“You can call Gerry On the Hill. I don’t know her number, though.”
Have a good weekend,
-DD
Thursday, May 6, 2010
Heart Breaker
Well, it’s another Thursday morning. That means Yoga at 5:30 AM, then disability physicals…and since it is finals week at the medical school, I have to adjudicate a clinical skills practical at 1:00. All in all, not too shabby, although the first patient of the morning decided to no-show, how nice of them. Anyway, if you’re wondering why my last post was sometime last week, it’s because I’ve been trying to write while I’m at work, and since my schedule is all over the place, well you get the picture. On to the blog!
Saturday was a day of depression claimants. Every stinkin’ one of them came in stating “I feel down, I can’t work,” or “I’m just sad, so I can’t work,” or “My girl left me for a girl, now I can’t work.” Seriously, that last statement came from a guy whose father left an angry message on the office machine at 7:30 stating “Where you all at, my son’s appointment is at 9:00, why ain’t nobody in the office?” While I understand the need for the business to open before the first patient of the day, I honestly can’t see any office opening an hour-and-a-half before the first patient, let alone on a Saturday. Anyway, once 9:00 rolled around, the door flew open, dude and his father walked in.
The claimant was 45, dressed in a t-shirt and jean shorts, his (mid 60’s appearing) father was dressed in a partially open Tommy Bahama shirt, short, short khaki shorts, and bright blue flip-flops (or thongs, as some people call them). I ushered them into my office - the claimant slumped to the corner chair, and the father walked towards my desk, pulled out the chair in front of me, spun it around, and straddled it…which as you can imagine, was not what I wanted to see first thing Saturday morning (did I mention that the shorts were short?). Anyway, the dad did most of the talking – the son couldn’t work because his girlfriend of “a really long time – six months, left him for another woman.” Apparently the g/f decided that she would rather be a lesbian than be with the claimant, and this had insulted his masculinity to such an extent that according to the father, he just “sits on the couch, cries all the time, and watches the history channel.” When further questioned, the claimant admitted that he couldn’t do any household chores or help with activities because “my girl used to do all of that, and trying to do it reminds me too much of her.” I asked him if there was any physical reason why he couldn’t perform those tasks, and he replied “no, but the memories of our love are just too painful to allow me to do those things.” How touching. Who knew that disability patients could be so poetic? We proceeded to the physical exam, which was normal, as you might expect.
As they left, the father said to me, “Doc, you gotta help him. He’s just so lovesick, I don’t know what to do. Any advice on how to win the girl back?”
I shook my head, “The government doesn’t allow me to give medical advice at these appointments,” I replied.
“Then the government don’t understand love,” he mumbled as he walked out of the door. And that was that.
And now for the disability quote of the day:
Patient’s written response to the question “How does your condition limit your ability to work?”
“It doesn’t, but my friend got money this way, so I thought I would try too.”
Until later,
-DD
Saturday was a day of depression claimants. Every stinkin’ one of them came in stating “I feel down, I can’t work,” or “I’m just sad, so I can’t work,” or “My girl left me for a girl, now I can’t work.” Seriously, that last statement came from a guy whose father left an angry message on the office machine at 7:30 stating “Where you all at, my son’s appointment is at 9:00, why ain’t nobody in the office?” While I understand the need for the business to open before the first patient of the day, I honestly can’t see any office opening an hour-and-a-half before the first patient, let alone on a Saturday. Anyway, once 9:00 rolled around, the door flew open, dude and his father walked in.
The claimant was 45, dressed in a t-shirt and jean shorts, his (mid 60’s appearing) father was dressed in a partially open Tommy Bahama shirt, short, short khaki shorts, and bright blue flip-flops (or thongs, as some people call them). I ushered them into my office - the claimant slumped to the corner chair, and the father walked towards my desk, pulled out the chair in front of me, spun it around, and straddled it…which as you can imagine, was not what I wanted to see first thing Saturday morning (did I mention that the shorts were short?). Anyway, the dad did most of the talking – the son couldn’t work because his girlfriend of “a really long time – six months, left him for another woman.” Apparently the g/f decided that she would rather be a lesbian than be with the claimant, and this had insulted his masculinity to such an extent that according to the father, he just “sits on the couch, cries all the time, and watches the history channel.” When further questioned, the claimant admitted that he couldn’t do any household chores or help with activities because “my girl used to do all of that, and trying to do it reminds me too much of her.” I asked him if there was any physical reason why he couldn’t perform those tasks, and he replied “no, but the memories of our love are just too painful to allow me to do those things.” How touching. Who knew that disability patients could be so poetic? We proceeded to the physical exam, which was normal, as you might expect.
As they left, the father said to me, “Doc, you gotta help him. He’s just so lovesick, I don’t know what to do. Any advice on how to win the girl back?”
I shook my head, “The government doesn’t allow me to give medical advice at these appointments,” I replied.
“Then the government don’t understand love,” he mumbled as he walked out of the door. And that was that.
And now for the disability quote of the day:
Patient’s written response to the question “How does your condition limit your ability to work?”
“It doesn’t, but my friend got money this way, so I thought I would try too.”
Until later,
-DD
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