Family Medicine?

A question I get asked a lot is "Family Medicine, huh? Is that like a GP?"

It is strange but a lot of people do not know what a Internist does, much less a Family doc.

I was pleased when I came across this article in the Annals of Family Medicine: FAMILY MEDICINE: WHAT ARE WE GRADUATING?
From the Association of Family Medicine Residency Directors

The original guidelines from family medicine covered a mere 3 pages laying out the length of training, and general content, as well as proposed categories of programs that reflected and embraced the wide variation of locations where family medicine physicians lived and worked. Our founding document also defined the family medicine physician in 4 domains

First, the family medicine physician was to serve as the physician of first contact with the patient who provided an entry for the patient into the health care system.

Second, the family physician was tasked to evaluate the patient’s total health care needs and to provide personal medical care and referral management.

Third, our graduates were to provide continuous and comprehensive care as well as the coordination of care.

Lastly, the vision asserted that family medicine physicians were to provide care for the patient within the context of the patient’s family and social milieu.

Primary care. Primary as in First contact. Total care as in from beginning to end. Family medicine -- with a focus on the context of interrelationships, family, and society. I love it! It's all in the name but the IDEA is somehow so foreign to the sort of fragmented, disjointed care that we have now that we've lost sight of these sorts of basic principles.

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The Residency Directors ask this question:

Do we need to expand the definition of the family physician to include alternate types of practice? And, lastly are our values antiquated, are our visions of ourselves valid, or should we change?

I answer with an emphatic No.
I will strive to have a committed relationship with each and every one of my patients. One of the most frustrating thing about being a medical student is the time and effort required to get to know a patient in a 30-45 minute time span only to see them vanish into the Healthcare system never to be seen again. So I look forward to a time when a patient is scheduled for a follow-up appointment in 6 months and I actually get the chance to follow-through.

Adventures in Brain Tumors (Prolactinoma!)

notmy2ndopinion: Adventures in Brain Tumors, (by @mathowie) http://bit.ly/37DMa4 (via @JoshuaSchwimmer)

My favorite part comes in the conclusion and it is very revealing about how AWFUL the patient experience can be. All too often, health care professionals feel pressured by their own time schedule and do not take the time to move at the pace more comfortable for the patient. Even small, simple things can make a big impact, like pulling up a chair to sit while talking, tuck the blanket in after pulling it down to examine their abdomen, etc...

The days in the hospital didn't go by so much as a blur as they did a smear. I was either asleep, passed out and seizing, lethargic, and very briefly completely awake each day as an army of medical professionals grilled me with a couple dozen identical questions and eventually life altering decisions were presented to me when I had been awake for all of 30 seconds.

I came away from this experience feeling the OHSU hospital in Portland continues to impress me with its amazing staff, but that the process of dealing with patients could be done in a more efficient manner. I know they all sort of kept an internal log of my story but to constantly be asked the same things by different groups of people and then not know who is your main decision maker was a challenge. Given my state of sickness and exhaustion, I felt like what an elderly man might feel like in the medical system. I had trouble understanding what people were saying as they woke me from sleep, I was constantly poked and prodded without descriptions of what results entailed, I literally wanted to "phone a friend" when those surgeons asked me in the early morning hours what I wanted to do.

"Time Lost is Brain Lost"

I woke up at 0430 and I couldn't get out of bed. Oh, that's weird, I thought. My right arm was completely numb from the shoulder all the way down to the fingertips. After about two minutes I jumped out of bed but I fell straight down onto the floor with a crash. My legs were weak -- it was like the right side of my body didn't exist!

My wife awoke in the commotion and asked me what was wrong.

I opened my mouth to talk to her, but nothing came out! I could understand her but my words weren't there.

After about three minutes, I got up and I said "oh, I'm okay now." I took a shower (there was still some numbness in the arm) and went to work. I figured something was probably going wrong so I called the doctor and he told me to go to the ER.

Lucky thing too... it sounds like you had a mini-stroke or what we call a"transient ischemic attack," (TIA) -- a temporary event. The residual numbness suggests more long term damage though. Since you're right-handed, you are most likely left-brained -- and your language is controlled by that side of your brain too. When you had the brain ATTACK (as threatening as a heart attack!), you wiped out your left brain, paralyzing your right body and knocking out your ability to talk.

We call this right-sided Hemiparesis (weakness) or hemiplegia (no movement), right hemineglect (inability to register things on the right side of the world) and Broca's aphasia (inability to verbalize thoughts; staccato, halting speech.)

I went over the ABCD2 scale with him and calculated a moderate risk for stroke:

2-Day Stroke Risk: 4.1%.
7-Day Stroke Risk: 5.9%.
90-Day Stroke Risk: 9.8%.

We started him on clopidogrel (Plavix) and he is undergoing a cardiac workup to rule out an embolic cause for his TIA/stroke.

In stroke patients, further assessment is done with the NIH Stroke Scale.

An pdf of the NIH Stroke Scale is available at http://www.ninds.nih.gov/doctors/stroke_scale_training.htm

An online course for provider education is available on
http://www.strokeassociation.org/presenter.jhtml?identifier=3023009

Hoarseness

In my Neurology rotation, I saw a lot of patients with "spasmodic dysphonia," which makes people sound like they are choked up with emotion or they are sick. It is described as "breathy," or "halting, strangled" voice that trips up on diphthongs, two vowel sounds. It can be precipitated by a stressful event, leading many physicians to think that it is psychogenic.



Surprisingly, Botox (Botulinum toxin A) is a definitive treatment! With EMG guidance, a needle is advanced into the vocalis muscle and injected with a small amount of Botox to paralyze the spastic muscle for 3-4 months.



Other causes for hoarseness include:
Inflammation-> allergies, trauma, URI
GERD-> laryngopharyngeal reflux (treated with a PPI)
Vocal cord lesions (granuloma, papilloma, edema, squamous cell carcinoma,)
Recurrent Laryngeal Nerve injury or Vagus nerve injury (aortic aneurysm, mass effect)
Neurological problems like Parkinson disease, multiple sclerosis, myasthenia gravis
Systemic disease (acromegaly, amyloidosis, hypothyroidism, inflammatory arthritis, sarcoidosis)

The Mito Mystery

Brownout: The Mitochondria Detective work Gets a Little Easier

“The mitochondria are like engines,” he says. “When a car engine doesn’t work right, it smokes.” Similarly, malfunctioning mitochondria produce nasty gunk Enns refers to as “biochemical smoke.”

I love little pictorial metaphors that just make sense.

The article delves into the medical mystery of a young girl who is "anorexic" despite a healthy appetite who had two siblings who passes away with some sort of muscular dystrophy. They get referred to a mitochondrial specialist.

But sometimes, for a single patient, a glimmer of hope breaks through the fog. Veronica Segura recently learned what’s at the root of her disease: a mutation in the cellular instructions for building the enzyme thymidine kinase 2, which plays a key role in synthesizing new mitochondrial DNA. Most important for Segura, a child must receive a bad copy of the gene from each parent to manifest disease. Segura’s husband, Aurelio, doesn’t carry the disease gene, which means their little daughter will never suffer her mother’s mitochondrial illness.

The article ends on this happy note, but I am doubtful of its veracity.
It is my understanding that mitochondrial DNA are EXCLUSIVELY inherited by the mother, who provides ALL of the baby mitochondria as the egg donor -- the sperm mitochondria do not become a part of a zygote->baby...

"The Neuro Exam is not dead"

Bedside Eye Exam Outperforms MRI in Identifying Stroke

"We only misclassified 1 out of 25 patients who had a vestibular disease that was a benign condition of the inner ear,"

"This study demonstrates the critical importance of function-linked tests over purely time-static anatomic tests in discerning the localization of vestibular dysfunction early in its course," session cochair Nina Schor, MD, PhD, from the University of Rochester Medical Center, New York, told Medscape Neurology. "It's so much the better that the tests described by Dr. Newman-Toker can be performed at the bedside in these often critically ill patients."

There are three signs to look for:
Head Impulse test
Beating Nystagmus in lateral gaze
Test of Skew with the Cover/Alternating Cover

These signs showed a Sensitivity of 100% (n=69) and a specificity of 96%(n=25) which is remarkable... while it makes sense to "wait and see" if future tests show that these results are reproducible, it really does not hurt to spend a few extra minutes in a neuro exam to check for these things:

"I No (know) Strokes!" Impulse/Nystagmus/Skew.

ddx

I have a project that I am putting together about differential diagnosis.

it is by no means a topic that I have "mastered" by any means... but there are a few things that i try to keep in mind.

one of them is the quote:

if you hear hoofbeats, think horses, not zebras.

this quote is supposed to remind people that common things are common.

But db reminds me that premature closure is also a problem.
So I would revise the old saying thusly:

If you hear hoofbeats, think horses, not zebras. unless you're in a savannah and you see stripes.

Differential Diagnosis Generation

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