Tuesday, March 31, 2015

Family Medicine: Grieving and Crying With You

"Dr. Jonas, did you see this note yet?"   I look.  Someone died.  A patient of mine.  For 15 years. Gone.  Complex disease.  Complex life.  Complex grief.

Next patient.  Sinus pressure, sore throat, ear pain.

I read the death note again.  Sad. I see his face.  Reflect on our last encounter.
He was thankful.  He was prepared.

Next patient.  Hospital follow-up.  Review meds.  Change one dose.  Review the hospital labs.  Note the intentions of the surgeon.  Clarify preparations for the surgery and timing of follow-up.

Phone call with widow.  I listen to the story.  I respond to her feelings.  We agree a few times.
I hang up.  A wave of sadness comes over me.  A tear starts.  I stand to go to the next exam room.  A staff member asks me a question.  I have to clear my throat to answer.  One tear. One choke. One wave.  Until the next patient.

Look at his name.  Ask another staff if they saw that he died. Reflect again.  Part of doctoring. Intermittent grief.  Loss.  The human condition.  Ends for one.  Starts for another.

Next patient.  Can't get enough breath.  Medication, Ohio, COPD all fight the lungs.  Stop one drug. Start another.

Home.

Now I can cry with them.  For them.

Pray for them. And me.

The blog.  Not the next patient.

Peace.

Sunday, March 15, 2015

Family Medicine: Following Patients with Ehlers Danlos Syndrome by K.M. Babbitt, MSIII and A.P Jonas, MD

Family Physicians follow a lot of patients with rare and unusual chronic disease states.  Wright State University Boonshoft School of Medicine third year student Katherine (Casey) Marian Babbitt has worked with Dr. Jonas on a quality improvement project about one rare and challenging disease. This month we're looking closer at Ehlers Danlos Syndrome to develop a checklist for patient signs and symptoms that helps both patients and physicians.  This will enable Family Physicians to better identify what problem areas and concerns each patient with EDS may have at each chronic disease management visit.  It also reminds patients and physicians to remember multiple aspects of the EDS when managing acute problems.

We'll publish the fifth draft of the checklist to invite comments from patients and physicians to help us fine-tune the document before finalizing it and publishing it online.

What do you think of the current content? (not the format since the Word document didn't load perfectly)  Please make comments, especially hypermobile persons and their families and family physicians.  This is a complex disease and we are complex people, so we start with a complex form.

The patient would have one of these on their cell phone or computer or hard copy and note what symptoms and signs are "leading the way" in a negative sense.  The physician would follow the form inputs from the patient via the patient portal of their EMR or hard copy and add/ subtract/prioritize care based on what seems to be happening.  Etc.



Ehlers-Danlos Signs and Symptom Checklist

Date                ________________

Name             _____________________________________________



Neurological system
New       Old         Stable                                                                                                                                                                                                                                                                                                                  Doctor Use
o                    o                   Y  N             Obsessive Compulsive Disorder                                    o
o                    o                   Y  N             Major Depressive Disorder                                                               o
o                    o                   Y  N              Social Anxiety Disorder                                                                                            o
o                    o                   Y  N              Body Dysmorphic Disorder                                                             o
o                    o                   Y  N              Chiari I Malformation                                                                                                                        o
o                    o                   Y  N             Syringomyelia                                                                                                                                                                         o
o                    o                   Y  N             Tethered Cord Syndrome                                                                                           o
o                    o                   Y  N             Migraines                                                                                                                                                                                                                    o
o                    o                   Y  N             Syncope Dizziness                                                                                                                                          o
o                    o                   Y  N             Paresthesia                                                                                                                                                                                                      o
o                    o                   Y  N             Dysautonomia                                                                                                                                                                         o
o                    o                   Y  N             Decreased Vibrational sensation                                    o
o                    o                   Y  N             Other________________________            o

Musculoskeletal System
New       Old         Stable                                                                                                                                                                                                                                                                                                                  Doctor Use
o                    o                   Y  N             Joint Instability                                                                                                                                                                    o
o                    o                   Y  N             Chronic Muscle Pain                                                                                                              o
o                    o                   Y  N             Chronic Muscle Fatigue                                                                                             o
o                    o                   Y  N             Chronic Muscle Weakness                                                                             o
o                    o                   Y  N             Dystonia                                                                                                                                                                                                                      o
o                    o                   Y  N             Osteopenia/Osteoporosis                                                                                            o
o                    o                   Y  N             Osteoarthritis                                                                                                                                                                          o
o                    o                   Y  N            Bunions                                                                                                                                                                                                                                   o
o                    o                   Y  N             Flat Feet                                                                                                                                                                                                                             o
o                    o                   Y  N             Scoliosis                                                                                                                                                                                                                      o
o                    o                   Y  N             Kyphosis                                                                                                                                                                                                                     o
o                    o                   Y  N             Early Degenerative Disk Disease                o
o                    o                   Y  N                  Herniated Disks                                                                                                                                                                      o
o                    o                   Y  N             Other________________________            o

Cardiac System
New       Old         Stable                                                                                                                                                                                                                                                                                                                  Doctor Use
o                    o                   Y  N              Mitral Valve Prolapse                                                                                                                        o
o                    o                   Y  N             Tricuspid Valve Prolapse                                                                                           o
o                    o                   Y  N              Aortic Root Dilation                                                                                                                          o
o                    o                   Y  N              POTS
o                    o                   Y  N             Other________________________            o

Optical System
New       Old         Stable                                                                                                                                                                                                                                                                                                                  Doctor Use
o                    o                   Y  N             Scleral fragility                                                                                                                                                                       o
o                    o                   Y  N             Corneal deformation                                                                                                                           o
o                    o                   Y  N             Other________________________            o
Vascular System
New       Old         Stable                                                                                                                                                                                                                                                                                                                  Doctor Use
o                    o                   Y  N             Arteriole rupture                                                                                                                                                         o
o                    o                   Y  N             Abdominal Aortic Aneurism                                                  o
o                    o                   Y  N             Neurally Mediated Hypotension                                    o
o                    o                   Y  N             Varicose Veins                                                                                                                                                                       o
o                    o                   Y  N             Other________________________            o

Metabolic System
New       Old         Stable                                                                                                                                                                                                                                                                                                                  Doctor Use
o                    o                   Y  N              Early Lipid Abnormalities                                                                            o
o                    o                   Y  N             Vitamin C Deficiency?                                                                                                           o
o                    o                   Y  N             MTHFR?                                                                                                                                                                                                                    o
o                    o                   Y  N             Drug Sensitivity                                                                                                                                                       o
o                    o                   Y  N             Other________________________            o

Gastrointestinal System
New       Old         Stable                                                                                                                                                                                                                                                                                                                  Doctor Use
o                    o                   Y  N             Irritable Bowel Syndrome                                                                              o
o                    o                   Y  N             Constipation                                                                                                                                                                                        o
o                    o                   Y  N             Gastritis                                                                                                                                                                                                                                   o
o                    o                   Y  N             Gastroesophageal Reflux Disorder            o
o                    o                   Y  N             Delayed Gastric Emptying                                                                             o
o                    o                   Y  N             Other________________________            o


Gynecological System
New       Old         Stable                                                                                                                                                                                                                                                                                                                  Doctor Use
o                    o                   Y  N             Premature Rupture of Membranes                        o
o                    o                   Y  N                  Rapid Labor and Delivery                                                                             o
o                    o                   Y  N             Uterine Rupture                                                                                                                                                                      o
o                    o                   Y  N             Other________________________            o

Dermatological System
New       Old         Stable                                                                                                                                                                                                                                                                                                                  Doctor Use
o                    o                   Y  N             Hyperextensible Skin                                                                                                             o
o                    o                   Y  N             Translucent Skin                                                                                                                                                         o
o                    o                   Y  N             Fragile Skin                                                                                                                                                                                        o
o                    o                   Y  N             Soft/Velvety feel of skin                                                                                             o
o                    o                   Y  N             Hemosiderin Staining                                                                                                             o
o                    o                   Y  N             Stretch Marks                                                                                                                                                                         o
o                    o                   Y  N             Atrophic scarring                                                                                                                                                        o
o                    o                   Y  N             Wound dehiscence                                                                                                                                          o
o                    o                   Y  N             Prolonged bleeding                                                                                                                             o
o                    o                   Y  N              Easy Bruising                                                                                                                                                                                  o

o                    o                   Y  N             Other________________________            o