Wednesday, April 5, 2017

Wisdom Wednesday: Health Self Advocate

I had a patient contact me by phone two weeks ago with complaints of severe left knee pain and swelling. It was after office hours so he sent me pictures of the leg. One look and I sent him to the emergency room at the local hospital. The leg was twice normal size with edema extending from above the knee to the ankle.

My immediate concern with the possibility of a DVT (deep vein thrombosis). These clots frequently occur in the legs resulting in significant pain, swelling, and will often be warm or hot to the touch.

Despite having all those classic symptoms, an ultrasound at the hospital ruled out DVT. An MRI was performed which was also read as negative. Laboratory testing lead to a diagnosis of “reactive arthritis”. The patient was prescribed an antibiotic and an anti-inflammatory medication and sent home. No advice for follow-up care was given.

I spoke to the patient, again by telephone, over the weekend. I asked what and where was the infection? His response was what infection? I then asked if the test for RA (rheumatoid arthritis) was positive. He responded that he didn’t know any of his lab results. He just knew the ultrasound and MRI were negative.

Reactive arthritis is an autoimmune response to an infection someplace in the body. The immune system overreacts, attacking some joint. In this case, supposedly, the left knee. Testing for RA will be positive and in fact, reactive arthritis is considered a form of rheumatoid arthritis even though it is transient.

I advised him to get his hospital records and see his PCP the first of week. His PCP agreed with both medications but failed to comment on the diagnosis.

Over the course of the week, this patient’s condition gradually improved. However, the symptoms all returned the following week. Another phone call to me and I sent him back to his PCP and asked him to get the diagnosis while he was there.

The PCP gave him a diagnosis of pseudogout and added a steroid pack to the antibiotics and anti-inflammatory meds. Pseudogout is caused by deposition of calcium pyrophosphate crystals and the knee is the most commonly affected joint.

Finally, the beginning of the next week I actually examined this patient in my office. He may have pseudogout or gout (uric acid crystals). Hopefully a review of his lab work will solve the riddle. However, the treatment is virtually the same for both conditions.

I placed him on A-C Carbomide. This is combination of arrowroot and carbomide powder. These alkalizing agents will dissolve the crystals, putting the chemicals back into general circulation.

Later the same day he called to say how surprised he was that his symptoms had resolved within a few hours of starting the supplement.

The Bottom Line:
Physicians, including me, are right about the diagnosis about one-third of the time. In other words, we’re wrong two-thirds of the time. I was wrong about it being a DVT, although it must be ruled out.
You must be your own health advocate – Ask about test results, both positive and negative. Ask for the diagnosis and what conditions have been ruled out. Ask for the rationale behind the treatment.

An antibiotic was not warranted for this patient. Furthermore his history of ulcerative colitis should have kept both the hospital and his PCP from giving him an antibiotic and triggering a new episode. I now have to provide some short term adrenal support to undo the damage caused by the steroid pack.

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