Archive for the 'Progress Notes' Category

All These Gut Feelings: A 10-Year Old With Belly Pain

Today I saw my young adult patient with a distant history of Crohn’s disease and new, chronic abdominal pain. Amitriptyline, 10 mg twice a day, has worked like a charm with no pain remaining, confirming my diagnosis of visceral hyperalgesia.

A few hours later I saw a 10-year old girl who has been to the emergency room several times with belly pain. Her family moved to this area a few months ago and we still don’t have the pediatric gastroenterology records her parents had signed a release for.

This girl has depression, anxiety and maybe more, and quickly established with a mental health provider in the area. She is on several medications. Today’s visit was an emergency room followup with labwork and a CT scan showing nothing abnormal.

Heather will double up with poorly localized belly pain most mornings, many evenings and not infrequently during her school day. The pains start and stop fairly suddenly and can last a couple of hours, sometimes more. Her bowels used to be on the constipated side for most of her life, but someone started her on Miralax and this has helped.

As I talked with Heather and her mother I learned she is often nauseous and pale looking during her attacks. And she sometimes has a very slight headache.

Her mother is on topiramate for migraines. That clinched it for me. I think little Heather has what people call abdominal migraines. I didn’t feel comfortable starting her on topiramate because she’s on the thin side, but as her mother had told me her hay fever wasn’t controlled by cetirizine, cyproheptadine seemed like a good place to start. This lesser known antihistamine is the second choice according to most experts. And for some reason, propranolol is the first choice for abdominal migraines, not topiramate. My thinking was that a nonselective beta blocker might worsen Heather’s depression.

We shall see. Is my gut feeling going to help modify hers? Just like it did for Wanda, who got her diagnosis ten years after I first met her.

The Correct Diagnosis – Ten Years Later

Don’t Eat More of Anything (Until You Decide What to Eat Less Of)

A year ago this week, I made a stir with my post about five common weight loss myths. Today I had a patient conversation I have had so many times before: Someone was trying to eat healthier and lose weight at the same time. They are not necessarily the same thing.

This person was using flavored coffee creamers. I pointed out that they often have harmful fats, like palm and coconut oil, and chemicals that may not be good for humans to consume (corn syrup, trans-fats, milk protein [yet it’s called non-dairy], phosphoric acid [found in Coca-Cola, pesticides and fertilizer], mono- and diglycerides, sodium aluminosilicate [also known as feldspar, a ceramic glaze; it is explosive in powdered form] and proprietary artificial flavors). I even told her about Björn Gillberg, the Swedish chemist who in 1971 washed his shirt on TV with the powdered non-dairy creamer Coffee Mate.

“So what kind of creamer should I use?” She seemed flustered.

“Cream or half and half”, I answered. “They’re not all that good for you, but better than the alternatives.”

I pointed out that most of us want to do both things, eat healthy and achieve or maintain a healthy weight. But salmon, avocado, almonds and olive oil have calories, just like pizza, ice cream and Coca-Cola.

So it helps to prioritize a little. My recent patient, after some thought, wanted to attack the weight first. So my advice was about what to eliminate, rather than what to substitute it with. My point is that it makes little sense to skip the nightly ice cream and start eating yogurt instead if your number one objective is to lose weight. “Eat the real thing that you love, but only do it on the weekend”, I might say.

I scribbled down the math behind the lazy man’s guide to calorie counting, the theoretical 1 lb weekly loss if you eliminate 500 calories (kcal, to be correct) from your daily routine. I do it often enough I might save some time if I created a handout, but I believe in showing the math evolve on the paper as I talk – it’s more like telling a story.

Only after someone who wants to lose weight has eliminated some things do I discuss substitutions in earnest. People want to see results, and giving up ice cream, soda, donuts or beer brings results and makes people believe they can do it. Then, it makes more sense to talk about adding back something with fewer calories.

Like in so many other clinical scenarios, I like to “chunk it down” (see Leveraging Time by Doing Less in Each Chronic Care Visit) and to focus (see The Power of Focus): Reversing a disease process that has been going on for a long time is not usually something that happens quickly.

Five Weight Loss Myths I am Constantly Fighting

Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.



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