A Country Doctor Writes:

I saw three patients the other day that seemed to have new problems. But in each case I found that the diagnosis was, or could have been, made years ago.

Stan Huff had a sore and swollen left knee. Several days earlier it had locked up when he felt some soreness and started to manipulate it. He got it moving again after a few minutes but it swelled up and he had a lingering pain near the upper inside of his patella, or kneecap.

Most of the time a locked knee means a meniscal tear, which causes a pain deep inside the knee or a tenderness along the inside joint line. Stan pointed to the edge of his patella.

“Did you ever have pain, swelling or locking of that knee before?” I asked.

“I don’t think so”, he answered.

I looked him up on Maine Health InfoNet, and there was a report of a left knee X-ray from 2017. It described a loose bone fragment under the upper medial portion of his patella.

He had no memory of this.

“Don’t fool around with your kneecap anymore, and if it keeps hurting or locks up a lot in the future, you’ll need to have that loose piece of bone removed”, I told him.

Sue Moran, a fairly new patient to me, but a long term patient in our practice, came in for tingling of her hands and feet. It happened on and off, and she had neither neck or back pain. She told me she sometimes dropped things because her hands felt so numb. Her exam was pretty normal, maybe just a slightly decreased sensation when I tested it with my monofilament.

“I’ve had this on and off for a couple of years, and I had some testing done, even an EMG, but nothing came of it”, she told me.

I was intrigued and looked her, too, up on Health InfoNet. There was a left leg EMG, done for left sided sciatica. It had some minor, nonspecific abnormality. Looking through her lab tests while asking, “you must have had B12 levels and things like that done”, she nodded “yes”.

But there, a year ago, was a B12 level of 170, clearly too low. I went back to our chart and there was a prescription for injectable B12, once a week for a month and then monthly after that. Sue said she never heard of that or got the solution for us or her to inject.

Her provider had left our practice and she had not been in for about a year, which explained why Sue’s diagnosis fell through the cracks.

Such things happen in medicine, more often than they should.

Glenda Bickford had a long history of heartburn and had even had an upper endoscopy a couple of months ago. It was fairly normal with slight inflammation on her biopsies and a negative test for helicobacter pylori. She was on high dose omeprazole plus famotidine and still had both heartburn and upper abdominal pain after eating. She also felt full after eating a small meal, burped a lot and even regurgitated food sometimes. On top of that, she was more constipated than ever before.

I thought she probably had gastroparesis and asked:

“Did you ever have what’s called a gastric emptying study, where you eat a radioactive meal and the check how long it stays in your stomach?”

“No, I don’t believe I did”, was her answer.

“Did anybody ever think your stomach was paralyzed, gastroparesis?” I asked.

“No”, she said.

“Well, that could be what’s going on with you. We don’t have a lot of options to treat that. The only FDA approved drug for gastroparesis is called metoclopramide…

“I had that before, Dr. Dean put me on it twenty years ago”, she answered instantly.

“And did it help your heartburn?” I asked.

“I believe it did”, she said.

“And why did you stop it?”

“I felt good, I guess.”

“Until the past six months?” I asked.

“Yes, I guess so.”

“So, Dr. Dean and I are thinking along the same lines. Would you be willing to try metoclopramide again?” I asked.

She said yes, enthusiastically, and I went on to explain the newer reports of tardive dyskinesia that was never a concern from its introduction in 1964 until 2009, when the FDA issued a Black Box warning. Glenda was not worried and she was eager to retry the medication.

In only one of my three cases did the patient know about their previously made diagnosis, even though Glenda didn’t remember the name of it. In the other two cases, the information was recorded but the patient did not recall being told what was wrong.

We could and should do better than that.

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Click the tab “A Country Doctor Talks:” or go to hansduvefeltmd.com

https://hansduvefeltmd.com/2021/04/25/a-country-doctor-talks-introduction/?amp=1

He had sores and boils all over his skin and he told me he spent hours every night pulling half inch black larvae out of his painful eruptions.

He was not delusional. He was not on drugs. I had never seen anything like it before. He had already talked to a doctor who gave him his diagnosis: Bot fly infestation. He had also been told there is no real treatment for this.

The only bots I knew of were computer bots that spread viruses.

Bot flies are usually found in Central America, but my patient hadn’t been south of New Hampshire.

The typical treatment, we both learned through computer searches, begins with covering lesions with occlusive topicals. This helps suffocate the larvae, who breathe through small skin openings on their victim’s body. The next, painful, step is removing them, dead or alive, one by one.

When the lesions are infected, antibiotics like clindamycin can be necessary. We used several rounds of it.

As the weeks went by, my patient became run down and frustrated. The wait to see an infectious disease specialist would be another month, he found out, and even longer for a dermatologist. But my reading in The Lancet and elsewhere suggested they really would not have anything more to offer.

My patient one day told me he decided to get healthy. He stopped drinking soda and eating junk food. He began eating more fresh vegetables. He started running and lifting weights.

Two weeks later he had almost no new lesions but the ones he had were inflamed. He asked if I had heard that metronidazole can help get rid of bot flies. I had not, but searching for “metronidazole bot fly” I did see a 2009 case report supporting its use.

I sent in a prescription and one week later my patient said:

“I think I’m cured. And I feel great.”

Almost every day I catch a suspicious fax needing my signature. Often it is an out of state vendor who wants my permission to provide a back brace for a diabetic patient, a continuous blood glucose monitor for a non-diabetic or a compounded (custom made) ointment of some sort that makes no sense from what I know of that patient’s history.

Often, I get a fax appearing to be from Walgreens, just asking me to sign and certify that so-and-so is under my care. Those faxes have Walgreen’s logo, my patient’s correct address and my own DEA and NPI numbers already printed. The problem is that 90% of my patients don’t use Walgreens 20 miles north or south of my clinic, but the local Rexall pharmacy. Once, I called the phone number on the fax and it just rang and rang.

I am convinced that his is just an illicit way to collect physician signatures, so the scammers won’t even have to get my signature on one form at a time. This way it’s like they’ve got their own rubber stamp to use again and again.

I suspect these scams are successful often enough to be quite profitable. I know this because I sometimes sign these forms almost automatically before I catch myself and toss them in the shred box under my desk.

One of the many dirty little secrets in medicine is that doctors get so many papers to sign that there is actually no way we could read them all before scribbling our signature if we still want to see patients, meet clinic revenue projections and match our own productivity quotas.

I used to joke that the only kind of paper in my clinic I didn’t have to sign was the toilet paper. In spite of our computers, we get more papers than ever before to sign. This is probably because everybody else, like the home health agencies, use their computers to generate more and more pages that require our signature.

The really disturbing thing about these scams is that these vendors are billing Medicare for things harried or otherwise inattentive doctors unwittingly “order”. The fact that they can bill Medicare means that they are somehow credentialed to do so.

It must therefore be way too easy to qualify for a place at the Medicare money trough.