Tag Archives: headache

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Tenacity

Two skills needed in primary care are tenacity and listening. That is a combination that can make a diagnosis. Here is an example.

In residency, many years ago, I have a patient with developmental delay. He lives in a group home. He can’t talk though makes some noises. The group home staff bring him to me. His head is misshapen because his mother had measles in her pregnancy.

The staff says, “We think his head hurts. He just isn’t behaving right.”

“Did he fall?”

“We don’t think so.”

“Fever? Nasal congestion? Cough?”

“No.”

“How long?”

“Over the last week.”

I do an exam. I really can’t see his tympanic membranes because of his skull shape.

“Maybe he has an ear infection. I can’t see. We’ll try antibiotics, but if he is not improving, bring him back. In five days.”

They bring him back. “He’s no better.”

I get on the phone. I need a CT scan of his head and the group home say he won’t stay still. I need anesthesia to sedate him for the CT scan. It takes two tries and quite a bit of phone explaining with both the anesthesia department and the radiology department. Persistence. I am looking for a subdural bleed in his head from a fall, or a sinus infection, or something.

It is done and I get a call. Not from radiology or anesthesia but from the ear, nose and throat surgical resident. He is very excited. “Your patient!”

“Yes,” I say.

“He has a pseudocyst! In his sinuses! He has abnormally large sinuses and this is the biggest pseudocyst anyone here has ever seen!”

“Um, ok.” Honestly, I’ve never heard of a pseudocyst. It turns out to be packed nasal drainage in the sinus. Bad ones can erode through bone into the brain. Certainly that seems like the cause of the headache!

“We are taking him to surgery!”

Residency can be pretty weird, when someone gets really excited about a rare disease or interesting trauma case or whatever. I found that I was entirely happy just doing health maintenance exams and encouraging people to quit smoking and exercise and drink less. However, I was also good at finding weird things.

The ear, nose and throat surgeons in training were very happy about the surgery. The group home staff were happy too. “He’s back to his old self. Thank you!”

It took tenacity to set up the head CT. It’s important to listen to the families and caregivers too, because they know the person better than I do. They were right: his head hurt. And we found out why and were able to treat it.

For the Ragtag Daily Prompt: tenacity.

Water is tenacious too, wearing down stone and wood and glass.

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Why is she really here?

For the Ragtag Daily Prompt: object. I strenuously and loudly object to medicine meaning pills.

During my three months temp job at a nearby Army Hospital in 2010, I wanted to work with residents, Family Practice doctors in training. I finished residency in 1996 and have worked in rural clinics and hospitals for 14 years. I want more rural family practice doctors and I agitated to work with the residents in training.

The Family Practice Department had actually hired me to do clinic. They are swamped and trying to hire temporary and permanent providers as quickly as they can. Six different temp companies called me about the same job, so the word is definitely out.

Initially the department head explained that I was there to do clinic, but she changed her mind. I was cheerful about the electronic medical records. Learning a new electronic medical record is awful, but I was happy to be there, excited about working with residents and in a hospital more than 16 times as big as my usual small town hospital. Most importantly, I was patient with the computer. I have finally realized that computers don’t actually speak English. They speak computer and they are dumb as rocks and they make no effort to understand what I am saying. They don’t care. So it is no use getting mad at the dumb thing when it crashes or when it doesn’t do what I want: I have to go find someone who knows the exact language that the stupid machine will understand.

Since I was cheerful, my department head let me do what I want. I was on the clinic schedule every day, but it was empty. I would arrive and see walk-in active duty people from 6:30 to 8:00. At the same time, I would email the department head and ask what I was doing that day. Half the time, a physician was sick or had a family crisis, so she would move people around and put me with the residents. If not, I would open clinic.

I enjoyed the “Attending Room” duty. Family Practice Residents have their MD but then go through three years of training. The first year residents must precept every clinic patient. That is, they see the person and then come discuss the case with the faculty. Second year residents were required to precept two patients per half day and third year residents had to do one; and all obstetric cases were precepted.

Back when I was in residency and the dinosaurs roamed the earth, no one ever read any of my notes. This has changed. Every note that is precepted must be read by the attending and co-signed. After three years hating the electronic medical record that my small hospital bought, it was very interesting to see a different system. In some ways it was better and in some worse.

We had one or two “Attendings” in the faculty room, no more than three residents per attending. One case stands out, more because of the resident than the patient. He was a first year.

He described an elderly woman in her 80s, there for headaches. Two weeks of headaches, getting a bit worse. History of present illness, past medical history, medicines, allergies, family history, social history and the physical exam. He said, “She’s tried tylonol and ibuprofen, but they aren’t helping that much.” He frowned. “She doesn’t seem to want another medicine.”

“No?” I said.

“No.” he said. “I started to talk about medicines. It doesn’t sound like migraines and she doesn’t have anything that’s really worrisome for a tumor……but she doesn’t seem to want a headache medicine.”

“Why is she really here?”

He looked more confused. “What do you mean?”

“Why is she really here?”

“I don’t know.”

“You already said why. Think about the history.” He frowned. I said, “Ok, you said that she was worried that she was going to have a stroke. Are these headaches likely to be a precursor of a stroke?”

“No.”

“Right. But that is why she’s here, because that is what she’s worried about. Look at her blood pressure, see what her last cholesterol was, talk to her about what symptoms ARE worrisome for strokes. Find out if a family member or friend has had a recent stroke. She doesn’t need a medicine. She is here for reassurance.”

“Oh.” he said. He left and came back.

“How did it go?”

“She was happy. She didn’t want a medicine. Her blood pressure is great, her cholesterol is great, we talked about strokes and she left.”

“That’s real medicine. Forget the diagnosis if the visit seems confusing. Ask yourself what is your patient worried about? What are they afraid of? Don’t focus on giving people medicine all the time. Ask yourself, why are they really here?”

And that is why I wanted to work with residents. It’s not all diagnosis and treatment. It is people and thinking about what they want and what they are worried about.

Why is she really here?

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previously published on everything2.com
According to dictionary.com, precept is a noun. Medical school and residency have verbed it. Hey, get updated, dictionary.com!

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Headache without words

When I was in residency, a staff member brought a young man to see me.

The young man couldn’t talk. He could make some sounds. His head was a funny shape, asymmetric. His mother had rubella during her pregnancy: German measles.

“His head hurts.” said the group home staff member.

“How do you know?” I asked.

“He isn’t acting right. There is something wrong. He’s different.”

“How long?”

“About a week or ten days.”

“Did he fall?”

“We’ve talked about that but we don’t think so.”

I tell the young man what I am going to do before each part of the exam. I look in his ears carefully. His ear canals are odd too and I can’t see well. His exam is basically pretty normal for him. He is not running a fever. He doesn’t have a stiff neck. He doesn’t seem to have nasal congestion.

“If he hit his head, he could have a subdural, a bleed pressing on his brain.”

The staff member shakes their head.

“Ok. I can treat him for an ear infection, though I can’t see that well. If that doesn’t work, we will have to image his head. Would he stay still in a CT scanner?”

“No.” says the staff member.

“Then I would have to set it up with anesthesia. Which is difficult.”

So we treated him for an ear infection. No improvement. He returned. Exam unchanged. The staff was still sure his head hurt. I had never seen him before the initial visit, so I couldn’t tell.

I set up the CT scan with anesthesia. Twice, because they mucked it up the first time and it wasn’t coordinated right. I had to explain to multiple people on both anesthesia and radiology what and why I was doing it. “His head hurts and he can’t talk?” I argued until they gave in.

The ENT chief resident called me with the results. Not radiology. “What?” I said.

“It’s the biggest pseudocyst we’ve ever seen!” said the ENT chief. Surgeon. “He needs surgery!” His voice said “Cool!”

In residency I’d noticed a striking difference between family practice and other residency folks: internal medicine, surgery, neurology, all the subspecialties. They got excited when there was something rare or weird. I always thought, oh, shit, my poor patient.

“What is a pseudocyst?” I actually didn’t ask, because they knew I was just a lowly family practice resident and would probably not have heard of a pseudocyst. A cyst like structure can form of snot in the sinuses and can cause headaches. It can erode through the bone into the brain. His hadn’t, thank goodness, because that can be bad. Bad as in lethal.

Because of the measles, he had some of the largest sinuses ENT had seen ever, and the largest pseudocyst. ENT happily took him off to surgery. Great case.

I got to see him in follow up. He was his normal self. His group home staff member was delighted. “He’s back to normal! Thank you so much!”

But it’s the group home staff that noticed and cared and brought him in. “Thank you for bringing him in,” I said, “I would not have noticed. And some people wouldn’t have cared.”

Differentiating pseudocysts and other things: http://www.oapublishinglondon.com/article/1266

More on pseudocysts: http://www.ncbi.nlm.nih.gov/pubmed/6595617

Pseudocyst images: https://www.google.com/search?q=maxillary+sinus+pseudocyst&biw=1366&bih=634&source=lnms&tbm=isch&sa=X&ved=0CAcQ_AUoAWoVChMIoZzWwv_QyAIVUJuICh248gGC

Rubella in pregnancy: http://www.marchofdimes.org/complications/rubella-and-pregnancy.aspx

Rubella, aka German measles: http://www.mayoclinic.org/diseases-conditions/rubella/basics/definition/con-20020067