Chronic cough

For this topic, I’ll begin with a recent patient encounter:

“11y/o male patient with history of asthma and allergies, seeing me for first time with Mom, has been seen with our providers here for the past 3-4 months for a chronic, persistent cough. In review, he was seen and treated by 2 of our for asthma and likely whooping cough with various inhalers, codeine cough syrup, Tessalon Perles (cough tabs), Singulair, Claritin, Advair, steroids and Azithromycin (antibiotic). His most recent appointment was a week ago, where he was treated a second time with steroids and antibiotics due to the persistent, dry cough occurring in fits. He denies sick contacts, shortness of breath, fever, post nasal drainage, wheezing, or night time cough. He’s been skin tested for allergies, with +horse hair and tree allergies. He notes some mild acid taste in throat occasionally. There is no smoke exposure. He never had a swab to confirm Pertussis (whooping cough infection) and a chest x-ray done in January which was negative”.

His mother and I racked our brains for the cause of his never-ending cough. It was now keeping him, a straight A-student, out of school, due to the disruption of his fits of cough. It was distracting to him and his classmates and was embarrassing. It was concerning to his mother because nothing worked. She wanted him to see a lung specialist. After various trials of cough medicines, antibiotics, asthma inhalers, and allergy medicines, the cough was non-stop.

Causes of chronic cough generally include the following: side effects from medicines, allergies and mucus production, asthma, respiratory infections, and acid reflux. With GERD, or gastro-esophageal reflux disease, there is increased acid production and decreased acid suppression in the stomach. The acid rises and ascends up the esophagus into the pharynx, or back of the throat, and irritates the vocal cords. Sometimes, it can also cause growths, or cysts, on the vocal cords, which can cause hoarseness out of nowhere, or produce a chronic cough.

For this patient, we’d already treated him for allergies, asthma, and infection multiple times. After thinking, I realized his cough probably started out as a whooping cough infection, but after many rounds of antibiotics and chronic irritation, he was likely developing some acid reflux on top of it. We tried Zantac twice a day, and his cough quickly stopped. Success! He was still seen with a lung specialist for follow up, but by then, his cough was gone. I saw his mother later and she was very pleased the cough was gone, and he could return to school without embarrassment. 

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Why the long wait?!

Published Wednesday, April 3, 2013
by C. Nicole Swiner, M.D., Columnist 

Two of the most difficult things to balance as a medical provider are seeing enough patients during the day and staying on time. Patients who schedule us for care check in at the front desk (on time, hopefully) and usually have to wait a while before they are brought back to the exam room.

Once in the exam room, they still have to wait some more before seeing the doctor. This usually leads to frustration and irritation on the patients’ parts, which leads to decreased satisfaction after their visit. Why does all of this happen?

 At risk of confusing this issue even more, I thought I’d put my two cents in and see if I can clarify some things from both sides.

From the doctor’s perspective, many patients don’t realize we only have 10 minutes to 20 minutes total for a patient encounter or visit. That doesn’t mean we have that amount of time to see you; it means your ENTIRE VISIT from start to finish is supposed to be done in that time. 

So stop a minute and think how unrealistic that may be. If a patient has an appointment at 10:30 a.m. and checks in on time, there may be a three minute to five minute process of waiting in the check-in line behind other patients and getting checked in by the front desk. If their information is out of date, this has to be updated at check-in. That takes time.

Once a patient sits in the waiting room, he has to wait for the appointment ahead of him to finish. Now, stop for another minute and imagine what’s going on with the patient ahead of you; he’s waited just as long to see the doctor, if not longer and also has important questions to ask. Even though his appointment was made for “a cold,” he also wanted to squeeze in some questions about his weight, low mood and if he can also get a physical done.

For the provider, this is difficult because we all want to give our patients the best care possible and satisfy them without overwhelming ourselves and the other patients we have waiting. Patients can be forceful and demanding oftentimes or may guilt us into doing more than we should. Now, multiply that situation by 15 to 30 people we see a day.

Or, take this situation for instance, which is what happens to me more often than not: An established patient comes in for a routine “follow-up” visit. We get started, and at the very end of the visit, tears begin to fall. It’s usually in response to my asking “So, how’s the family?” or “How’s work?” or “Are you sleeping well? 

There is almost always an underlying element of stress that leads to these issues. These are also the type of scenarios that we should start with at the beginning and not at the end of the visit. As the doctor, how do I rush that patient away when he clearly needs extra time with me to vent? The answer is I can’t. It’s a very difficult but necessary part of the job of taking care of people. 

This is what I would suggest to patients to help all of us be more efficient and gain more satisfaction:

• Come to your visit 10-15 minutes early to account for standing in line, checking in and editing information at the front desk.

• Schedule the appointment for only what is needed, i.e. medication refills, physical exam/pap, cold, etc. If you have issues that may take additional time, schedule another visit.

• Start with your most important complaint first. This means not waiting until the last minute of the visit to bring up the issue that would take the most time discussing.

• Make sure all of your demographics, addresses and insurance information are up to date at the time you schedule your appointment and don’t wait until check-in.

• Ask to come in two to three days before a scheduled visit for fasting blood work, if needed. This saves time and prevents you from having to come back to discuss results, and saves back and forth phone calls from the nurse or doctor trying to reach you later.

• If your lab has the ability to send your results via Internet or email, sign up for it. This way, you get your results quicker and saves time on the phone.

• Make sure to ask for refills needed at your visit. Most “extra” time that takes away from seeing patients for the staff and providers is spent on the phone or online filling refills that could have been handled at the time of the patient’s visit.

 

“Is an IUD right for me?”

This is a question I deal with often, as I counsel frequently on contraceptive methods with my female patients. There are multiple methods, including family planning (“rhythm method”), birth control pills, barrier methods (male and female condoms, diaphragms), the patch, the “shot”, implants, and IUDs.

At my clinic, I place IUDs (intrauterine devices) of the Mirena type, which is a 5 year long, progesterone-releasing method. There are other types of IUDs, such as the copper-T and Paragard that do not contain hormones and last longer than 10 years. IUDs are not only used for birth control, but also potentially to control heavy menstrual bleeding, severe menstrual cramping, and conditions such as ovarian cysts, endometriosis, and other female organ disorders.

The following is the general information I give female patients when they’re considering this method:

We are placing an IUD today, and I hope that you’ve had a chance to review either the brochure or research online about this birth control method. Feel free to ask whatever questions you may have before our procedure.

Benefits

-We hope that you’ll be able to keep the IUD for as long as you want, for up to 5 years. If older than 35years old, it’s a good idea to make sure you include a good amount of vitamin D and Calcium in your diet as the IUD may stop your periods for 5 years, which equals a sort of “early menopause.” These vitamins help protect your bones.

As long as you have not had any ectopic (tubal) pregnancies or recurrent STDs (gonorrhea or Chlamydia), there is little reason notto have an IUD if you want. It does not, however, protect from STDs, so condoms must still be used.

Risks & possible complications

-Anytime ‘outside’ objects are introduced to our ‘insides’, there is always the potential for infection and discomfort. We do our best to keep the procedure sterile (gloves, cleaning solutions, instruments, IUD), but it is possible still. You also should have taken the medicines I have you beforehand to reduce discomfort, which can feel like strong menstrual cramping.

Also, most of the instruments used are metal but not all sharp fortunately. There is the potential for bleeding. The most concerning risk is for the instrument to break through the tissue or muscle of the uterus causing hemorrhage, which is an emergency, for which we call 911.

What to expect after the procedure-

We will make sure you feel ok before leaving Please ask for Tylenol if you feel you need it before discharge. You can expect some vaginal bleeding during the first 24-48 hours afterwards with menstrual discomfort. You can use you Ibuprofen for this every 8 hours as needed. Bed-rest is not required, but I would defer from strenuous activity. Going to work from here is fine.

Some women experience irregular bleeding for up to 3-6months after placement. After than, you’ll join 1 of 3 groups: one-third of women continue irregular bleeding for the duration, the second group continue their normal monthly cycles, and the latter one- third stop having their periods altogether. Everyone responds differently and we don’t know which group you’ll fall into until the IUD is placed. The good news is you can return to have it removed whenever you want.

If you feel back to normal after 24-48hours, resume normal activity, which includes sexual intercourse and tampon use if desired. However, you can also wait to see e at your 1 week follow-up to check the string and make sure thing are stable. Call us here if you have any questions during that week, or problems including fever, severe stomach pain, extremely heavy vaginal bleeding, or foul-smelling vaginal discharge.

Sneaky skin cancers

I’ve been fooled recently. I’ve been fooled by abnormal skin lesions of patients, and I’m not afraid to admit it. I see a good bit of dermatology in my practice, as I’m usually at the front line of diagnosis for my patients.

Here are three recent cases that surprised me.

The first is of a longstanding patient of mine – an elderly white gentleman with a rash on his scalp that we’d frozen lesions off of before, and treated as a combination of “cradle cap” and actinic keratosis, which is essentially sun damaged skin. He returned for evaluation of one lesion on the scalp that seemed to be growing much larger than the others. It was mountainous, yellow and greasy, just like a severe case of cradle cap, and similar to what some babies have.

However, since it was bothersome to him, we decided to take it off by doing an excisional biopsy. We numbed it up and cut it off and sent it to the pathology lab to grow. It returned showing squamous cell carcinoma in situ. This is a precancerous type of lesion that potentially can become cancer. Squamous cell carcinoma in situ has a high probability of becoming true carcinoma. We sent him to a dermatologist for follow up, and he is doing well.

The second patient is an elderly black gentleman I saw with our physician’s assistant. She brought him to my attention for a fairly normal-looking mole on his forehead. He’d had it for years, but it recently started changing in size, shape and color. He had no family history of skin cancers, but due to the recent changes, we agreed to do an excisional biopsy.

Guess what it turned out to be? Squamous cell carcinoma! Not in situ again but true carcinoma. That was truly surprising, particularly since he is African-American, a group that skin cancer doesn’t normally affect, and he had no family history.

The last one is actually a patient of my colleague that he brought to my attention. This is a young, white gentleman who came in for what he thought was “pink eye.” There was a dark spot beginning in the sclera or the white part of the eye, moving into the inside of the lower eyelid. It wasn’t painful, but it was new and had increased over the last couple of weeks. He had no family or personal history of skin lesions or cancers.

The first person that saw him in our practice thought enough to send him to an eye doctor that biopsied the lesion. When he returned to my colleague, guess what it turned out to be? Melanoma!

I never would have imagined skin cancer beginning in the eye. He had no other lesions on the skin that would have sparked the thought of skin cancer. I was able to see the patient and see the original lesion in the eye that was biopsied. I’ll never forget that case, and I’ll now pay even more attention to everyone’s eyes when I examine them.

The point is, skin lesions can be sneaky, and are more often more than meets the eye nowadays. This is not to say every mole, spot or skin tag is cancer, but if there is significant change in color, shape or size over a matter of months, it needs to be evaluated by your doctor. Don’t ignore your body. It may be trying to tell you something.

Dr. C. Nicole Swiner works at Durham Family Medicine, where she treats newborns to elderly patients. She and her colleagues are accepting new patients and can be found at www.durhamfamilymedicine.net.

Deer ticks, and dog ticks, and mites….oh my!

Tick season seemed to start earlier this year than usual. One of my partners in our practice in March said she awoke one morning with a deer tick, and we knew the season was here. This month alone, June that is, I’ve treated 3 cases of RMSF, or Rocky Mountain Spotted Fever, which is one of the common tick‐related illnesses we treat here. Tick‐borne illness is one of the interesting things I’ve learned about since practicing in North Carolina, as these illnesses are more common in the Southeast. But apparently they are an issue all over the US during this time. The illnesses include the above‐mentioned RMSF, Ehrlichiosis, Tularemia, and Lyme disease.

Lyme disease is actually very rare in North Carolina, because the tick that carries the disease is rarely found here. I had to refresh my memory on the different kinds and flavors of ticks, so that I could identify them on patients more easily.

The usual season for ticks is now, during the spring and summer months. The different types of ticks vary from dog ticks to deer ticks to Lone Star ticks. The American dog tick is generally a reddish‐brown color and becomes large and red after it’s attached itself and fed. Deer ticks are usually smaller and darker than dog ticks. The Lone Star tick is also small and reddish‐brown in color but usually also has a white spot on the back. Clear as mud? If confused like I was, you can go to the CDC website (Center for Disease Control and Prevention) to see pictures.

I also have a hard time identifying which is which, so I’ve posted a picture of types in my examination rooms for patients to point them out. Lone Star ticks are probably the most common type in this area, and they cause symptoms such as fever, headaches, myalgias (body aches), and possibly a round, “bulls‐eye” rash where they have bitten. This is the classic rash called erythema migrans, and it’s very helpful to see when trying to diagnose the illness. Not all tick bites will cause the illnesses if caught early enough. The best way to remove them is with tweezers and picking the whole body off, but most importantly the head. If you don’t know whether you’ve removed the entire body, don’t play around with it, have you doctor look at it and remove the rest as quickly as you see it. Don’t use matches or ointments, because they don’t work well all the time.

Once symptoms have been identified, your doctor may go ahead and start treatment, or do blood work. Labs that are affected by tick‐borne illnesses include white blood cell count, platelet count, liver labs, and sodium. There are also antibody tests for RMSF, Erhlichiosis, and Lyme disease. Once I generally have a good idea that a person has been affected, I usually will start treatment with Doxycycline, which is the most common antibiotic that treats all the common types of tick‐borne illnesses. The medicine is prescribed either for 1 or 2 weeks, depending on the severity of symptoms.

Now, to say a word about Lyme disease in North Carolina‐‐‐it’s present, but not very common. In 2008, the CDC reports 16 cases were reported in North Carolina versus 2000‐3000 cases in the upper north states of Connecticut and Minnesota. Because of its long term effects and consequences, such as arthritis and neurologic effects, Lyme disease is taken seriously, but the other types of tick‐borne illnesses are far more common than Lyme disease here in North Carolina. Be careful this summer!

Be Healthy and Be Blessed, Dr. Swiner

*Reference: www.aafp.org (American Family Physician), www.cdc.gov(Center for

Disease Control and Prevention)

Autism and Children’s Vaccines-still puzzling?

One of the joys of being a Family Physician is I have the opportunity to care for the entire family. With this, I care for many babies and children in my practice, giving physicals, providing school vaccinations, and seeing them when sick. So, of course, the conversation arises often of potential side effects of vaccines, and the most recent concern is that of Autism. It’s a difficult and passionate debate to have, and I try to present the information that I know and come to an agreement with the parents of my patients. I’ll try to briefly explain where the debate comes from below.

Autism is a devastatingly difficult mental condition that affects approximately 1 in 150 children per year in the United States (stats from http://www.cdc.gov). It is a puzzling condition for all involved, including the families and caretakers of these children. In fact, if you see the ribbon magnets on the cars of people that advocate research for Autism, it’s in the form of a jigsaw puzzle.

I believe that puzzle represents both the variety of signs and symptoms that can occur with this condition and the controversial factors and arguments that surround the causes and treatment of the condition. Autism is described as a “spectrum disorder” in that it breaks down into 5 different types and can vary from minimal to severe ranges of effects on the human brain and psyche. These types include autistic disorder, Asperger disorder, disintegrative disorder, Rett disorder, and pervasive developmental disorder. Studies haven’t shown a clear cause yet, although a genetic link has been found. Autism in general is usually diagnosed by age 3years old and is 4 times more prevalent in boys than in girls. It spans all socioeconomic and racial lines, and lasts a lifetime for both the patients and their families.

And so begins the debate-There has been a lot of controversy surrounding vaccines and Autism. You’ve probably seen or heard the story of actress, Jenny McCarthy, whose son was diagnosed with Autism and her concern with the administration of shots containing the preservative, thimerosal. The vaccine containing antibodies for measles, mumps, and rubella (MMR) is one vaccine that has received the most blame in the argued link. The MMR shot is given at age 12months during a well child physical, and now recently, is repeated at age 4-6years old for kindergarten physicals. As mentioned above, most children are diagnosed with Autism around age 2 or 3 years old.

Until 2001, thimerosal was used as a preservative for many vaccines, and it is a mercury-containing chemical. After Jenny McCarthy’s story came out, many parents became worried about the effects of this ingredient and how it might affect their children.

I have had this conversation with some parents in my practice and what we discuss is the following. Studies were done and reviewed on thimerosal by the Institute of Medicine. None showed conclusive evidence that the chemical caused Autism. However, even with these favorable studies, after 2001, levels of mercury and thimerosal were reduced if not taken out of most vaccines altogether.

Because we still don’t know for sure what the etiology of Autism is, the best screening tool we have is the monitoring of development of speech and social interaction by parents at home, along with routine well child physicals done with medical professionals. The discussion of vaccines and possible side effects likely will continue for a while between doctors and patients, particularly about Autism. But, it’s a healthy one to be had, as we continue looking for the key and solution to this huge puzzle.

Be healthy and be blessed,

Dr. Price

‘Tis the season: Allergies vs. Sinus Infections vs. Colds

‘Tis the season for pollen, mold, and trees. Yesterday in clinic, I think half of my 20 visits involved complaints of “I think I have a sinus infection”. The answer to my “Why?” included many common truths and misconceptions, ranging from “because I’ve congested for a week” and “because I have green and yellow mucus” to “because this happens every year to me”. The truth is all of these signs of symptoms may be present, but I’d bet money that patients are correct less than 30% of the time when trying to self diagnose themselves with infection versus inflammation. Would you know the difference?

Let’s first review the common cold, which I’ve talked about many times before. A cold is a viral infection, which means there’s no great cure. There are ways we can shorten the duration of symptoms, but if I had the cure to a cold, I’d be a retired millionaire. If you read a medical textbook, it would say symptoms of a cold include, headache, muscle aches, low‐grade fever, runny nose, and cough, which can last for about a week. By day number 7, symptoms generally begin to dissipate. Because it’s a viral infection, antibiotics are not the treatment. Let me repeat myself—antibiotics do not treat colds. I can imagine what the next question might be after the last statement, and the answer is that you’re right. Doctors do and might prescribe an antibiotic when you present with a “cold”. However, this is incorrect and should not be done. This helps to produce super‐bacteria that are resistant to the drugs we currently have and create monsters, such as MRSA or methicillin‐resistant Staph aureus and other resistant bugs. This means it will be harder to treat you if and when you do have a bacterial infection in the future.

I hear the mumblings of the next question—then why do antibiotics seem to work when taken for a “cold”. I put cold in quotes on purpose, because what patients often think is a cold isn’t really a cold. It may be a bacterial sinus infection, walking pneumonia, or Strep throat. Or, what I believe is the most common reason, is that the cold was going away on its own, and it was coincidental that you were taking the antibiotic at the same time. In other words, it probably would have gone away without you doing anything. You just happened to be taking an antibiotic at the time.

What does help and what has been proven in studies to help includes, taking Zinc (such as Zicam) or eating chicken noodle soup at the first start of symptoms to cut your sick time by 2 days. Notice I didn’t say cure but shorten the amount of time you’re sick. After trying to shorter the duration of the cold, we treat the individual symptoms with antihistamines, cough medicine, menthol, tea, salt water gargling.

During the allergy season, it becomes even harder to differentiate, because symptoms are similar. Classic allergy symptoms include sneezing, runny nose, itchy, red eyes, congestion, and headache. Allergies don’t occur with fever and are treated with antihistamines, such as Zyrtec or Claritin. Other important treatments include steam, nasal saline and washes (such as Neti pot or saline spray), and cleaning one’s filters in the house and car. A chronic cough can be caused by allergies.

Another million‐dollar question is “Does green mucus mean I have an infection?”

Yes and no. It could mean an infection, but it doesn’t mean it’s bacterial. It is a sign of white blood cells fighting something, and that something could be an allergy or a virus. A bacterial sinus infection is when one‐sided facial pain, runny nose, fatigue,

congestion, tooth pain, and sneezing begin and is prolonged. Talk to your doctor about concerning symptoms.

Be healthy and be blessed,

Dr. Swiner