Friday, June 12, 2020

Family Medicine and COVID-19: Mucous Is the State Bird

"Mucous is the State Bird in Ohio"  I say that to a lot of people in my practice and in some of my holistic health presentations.  A normal adult head makes 2 liters of mucous daily, for many purposes.  Everyone in Ohio seems to have mucous generating allergies at one time of the year or another (or year round for many).  Why are we concerned?


We have to differentiate usual allergic mucous from infectious mucous and further sort out which of the infectious mucous might be a COVID-19 mucous.  One might think that people can tell if they're infected instead of "just" allergic, or COVID-19 instead of "just" a cold.  Unfortunately, it's not that easy.  A lot depends on how individuals sense and know themselves.  That's a challenge that is important as individuals have respiratory symptome, but go to Dot's Market or Kroger or Elsa's Restaurant or schedule an appointment with their Family Physician for their blood pressure or diabetic check-up.  Which mucous might be problematic in those venues?

If the patient is sensitive to what their mucous is saying, it helps a lot.  Many people are too stressed to notice anything about their mucous unless asked about it.  Sometimes it takes several questions from their physician to clarify that they even have extra mucous.  That's why so many medical visits have been shifted to video or phone visits.  They decrease the risk of spreading contagious infections, including, and especially, the COVID-19 infection

Many people sneeze, snort and blow their nose a lot is certain seasons and/or settings due to their allergies.  Many people also have those same symptoms as part of a respiratory infection.

Fever, aching all over, discolored mucous (e.g., green with living microbes or yellow caused by dead microbes) shakes, or chills are indications of infection- but not early in many respiratory infections.  So how do we sort out the people who may have the newest Corona virus, now known as COVID-19?

Usually, we don't sort well since evidence is mounting that millions of people have had the virus already.  The fact that we have over 100,000 deaths related to the virus so far makes us continue to be nervous about this particular microbe.  The statistics people will have to sort out the levels of certainty about the cause of death and the impact of the COVID-19 on life, death and the economy as we move ahead.  They have developed a good idea about who is most vulnerable to succumb to the infection, therefore also have some insights about strategies to protect the most vulnerable populations.  Each state/governor gets to make decisions and policies that apply this knowledge to their citizens.

What about your mucous or your children or your great grandmother in the nursing home?  Initially, notice that you have the mucous by increasing awareness to your "increased mucous"behavior.  Are you using more tissues, antihistamines, vitamins or supplements as you sneeze and cough more?  If you  notice it, look at it in the tissue that you coughed or blew your nose in.  Is it thin or thick?  What color is it (clear, green, brown, tan, yellow)?  If it's green, orange, tan or yellow- that usually means infection (some people with asthma, chronic obstructive pulmonary disease, chronic bronchitis may not have an acute or contagious infection in spite of varying color of sputum- but that's another story).

If your mucous implies infection, you may wish to take your temperature.  If it's 100.4 or above, that's an official fever.  If it seems to be one or more degrees higher than your "usual" (98.6 is just a line on a thermometer- not "normal"- your temperature varies by 1 degree Fahrenheit each 24 hour day).  Many businesses are taking daily temperatures on employees as a screen for undetected infection.  Medical professionals take their temperature daily.  People are often insensitive to a temperature elevation, so it pays to get an understanding about your temperature.  We now have the "scan the forehead" device (not as accurate as a thermometer type device, but there's no mucous involved).

If your mucous changes and/or you have a temperature elevation, reflect on your contacts.  Is anyone you know coughing or sneezing or blowing their nose?  If so, is it more than their usual levels of these behaviors?  Is anyone you know ill, missing work for illness, quarantined, taking antibiotics, going to urgent care or emergency rooms, just discharged from the hospital with pneumonia, just discharged from the hospital for any reason, working in a medical office, nursing home, assisted living, hospital or other high risk job/environment?  Are you exposed to young children such as your kids or grandchildren who may have respiratory signs or symptoms?

Are you infected?  Contagious?  Endangered?  A threat to others?  Just allergic to Ohio or the state where you live?

In a place such as Ohio where I live, where "mucous is the state bird", it's difficult to sort out the usual mucous from the potentially contagious mucous.  Together, we can become mucous sleuths and stay a bit safer.

Sunday, June 7, 2020

Ehlers Danlos Syndrome : A Painful Surprise for Family Physicians

by A. Patrick Jonas, MD, ABFM at Neighborly Family Medicine

Ehlers Danlos Syndrome: Rare? Not so Rare? Not even Rare? Pain, Pain and Pain. It drips with clues to the possible presence of a connective tissue disorder. When I was in medical school, the more likely term was collagen vascular disease. Marfan's Syndrome became the poster child for this group of diseases/conditions. Now it should be Ehlers Danlos Syndrome (EDS).

Coming in at 1 in 100 women (per Dr. Nielson- EDS wizard at the University of Cincinnati, with whom I strongly agree), it races by hemochromatosis and others as a disease to know to provide care for patients in Family Medicine. Every Family Physician has 2-10 patients with this diagnosis that hasn't been made.

The categorization of EDS types was reorganized in March of 2017 for better understanding. The term Hypermobility Spectrum Disorders is added to better understand EDS and that which is between EDS and Marfan’s Syndrome. It will take a while for physicians to get acquainted with the clarification. Most family physicians are not aware of the prevalence of EDS in their daily practices, especially patients with pain syndromes.

What is Ehlers Danlos Syndrome?

From the EDS Society: "Ehlers-Danlos syndromes are a group of connective tissue disorders that can be inherited and are varied both in how they affect the body and in their genetic causes. They are generally characterized by joint hypermobility (joints that stretch further than normal), skin hyperextensibility (skin that can be stretched further than normal), and tissue fragility. (For information about the hypermobility spectrum disorders, please visit “About HSD”.)

The Ehlers-Danlos syndromes (EDS) are currently classified in a system of thirteen subtypes. Each EDS subtype has a set of clinical criteria that help guide diagnosis; a patient’s physical signs and symptoms will be matched up to the major and minor criteria to identify the subtype that is the most complete fit. There is substantial symptom overlap between the EDS subtypes and the other connective tissue disorders including hypermobility spectrum disorders, as well as a lot of variability, so a definitive diagnosis for all the EDS subtypes—except for hypermobile EDS (hEDS)—also calls for confirmation by testing to identify the responsible variant for the gene affected in each subtype."

Most patients with EDS have the Classical EDS (about 10%) for which there is a genetic test or the Hypermobile EDS (close to 90%) for which there is unfortunately not a genetic test. The initial diagnosis is done clinically by the history and physical. The Beighton Score is used to assess joint hypermobility. A Family Physician can assess this aspect of the patient in about one minute. This leads into further consideration of major and minor criteria for making the diagnosis, all of which are found at The Ehlers Danlos Society. A diagnostic checklist for the more common hypermobile type can seem to be confusing, but makes more sense with use.

A Family Physician can add Ehlers Danlos Syndrome to a position high on the differential diagnosis of all women with chronic musculoskeletal pain and start to find the women with EDS. Many are relieved to find that there is a diagnosis that explains their misery and treatments that may alleviate many aspects of their pain.

What are the types of Ehlers Danlos Syndrome?

Chart of Types of EDS with detailed definitions.

Saturday, June 6, 2020

Family Medicine: Human Centered Care in the Modern Era

Respect:  Myself, my office staff, the patients and their families, the system in which we are allowed to engage, the community in which we live and work, the nation in which we reside, the world with which we exist and interact, the biosphere which is amazing, God who is beyond understanding.

Protect:  The patients and persons involved in patient care in and through my office today; their time to express themselves; the objects, air and persons from toxins and pathologic microbes.

Connect: Via an appropriate medium to the patient and their values, goals and dreams.  Our humanity through our respective roles that support exploration via communication.  Our hearts as necessary during our interactions.

Detect:  Our individual and mutual alignment or misalignment with our values, goals and dreams as it relates to the purpose of the interaction today. The "Chief Complaint" and other issues to be considered during the visit and later.  The context in which the patient raises the "Chief Complaint" or purpose of the visit.  The differential diagnosis using a simple and complex model that expands the list of considerations for the cause of the patient's Chief Complaint and other problems/issues.

Inspect:  Information that is available and the patient to clarify the search/ testing strategy that will best explain the patient's problems and possible solutions.

Correct:  The phenomena that cause the patient's misalignment with current or future values, goals and Dreams.  The perspective of me and/or the patient about the context, information, processes, values , goals and dreams of both of us.

Reflect:  On the above in thought and by preserving a record of the interaction in appropriate media and form as desired/ required.  On the continuing connection between the patient and the process of health/ care.

Thursday, June 4, 2020

Thursday in Family Medicine 2020. Technology and People

Wash hands, temperature taken, select mask for the morning, liberal use of hand sanitizer.
Check patient schedule (again, having checked it at the end of yesterday):  Who, What type of visit (video, phone, office), Why are they scheduled? Acute, chronic, preventive focus (although, since I'm a Family Physician, often we cover all three in one visit).  Set up context for the day and first visit.  Make space for two laptops- one for video visit, one for EMR- ,forms/paper space (since I'm a "Geezer", I still write in a paper record as the patient tells their story- suitably illegible at times, but meaningful to me) telephone, and a bottle of water or cup of green tea.

I don't yet have a green screen behind me or a variable background that I noted on a Zoom feed with one of my sons, an academic physician at the University of North Carolina, last week.  Geezers take a while to catch up to cool trends.  I don't have the headset that I would like yet, but the mic in the computer is incredibly good.  It's a start.

Connection difficulties arise with about 20% of patients, especially with the video visits, about issues with sound usually.  Sometimes they can't get the video connection.  There is a software download factor that is a stumbling block for some phones or computers.  My office had some WiFi problems til finally getting a new WiFi and new router.  We're making progress.

The video visits are especially informative about the life of the patient.  Sometimes family members show up as well as pets, art, memorabilia, etc.  We're learning.

More later.