A Country Doctor Writes:

A while back I was able to completely stop my mastocytosis patient’s chronic hives, which the allergist had been unable to control.

I did it with a drug that has been on the market since 1969 and is taken once a day at a cost of 40 cents per capsule at Walmart pharmacies.

Hives are usually treated with antihistamines like diphenhydramine (Benadryl). My super drug has a 24 hour duration of effect and is about 800 times more potent than diphenhydramine, which has to be taken every fours hours around the clock.

Histamine is involved in allergic reactions, but it also plays a role in stomach acid production. The allergic response happens mostly through stimulation of Histamine 1 receptors and the stomach acid output is regulated mostly via Histamine 2 receptors. Typical antihistamines are blockers of the H1 receptor, or binding site; they don’t do anything except sit there and prevent the real histamine from attaching and starting the allergic chain reaction. While diphenhydramine sits there for 4 hours, loratadine and the other modern, nonsedating (and less itch-decreasing) antihistamines work for 24 hours. Because there is some overlap between H1 and H2 blocking effects, H2 blockers like famotidine can boost the antiallergy effect of the typical H1 blockers. My mastocytosis patient still had hives on diphenhydramine, loratadine and famotidine combined.

But, wait, there’s more…

A much less well known effect of H1 receptor stimulation happens in the central nervous system. An interesting 2013 article explains:

Histamine is an excitatory neurotransmitter in [the] central nervous system. It plays an important role in the regulation of the sleep-wake cycle. Antidepressants with sleep-promoting effects, for example, doxepin, promote sleep not through a sedative action but through resynchronisation of [the] circadian cycle. The stimulation of the H1 receptor is thought to play an important role in mediating arousal. Doxepin has a high affinity for the H1 receptor, making it a selective H1 antagonist at low dose and it has been shown to display sedating properties. Compared to other sedative antidepressants, low dose doxepin is the only tricyclic drug which has been evaluated by well-designed, randomised, double blind, placebo controlled studies in both adult and elderly patients.

American Family Physician writes “Controlled-release melatonin and doxepin are recommended as first-line agents in older adults.” Yet, at least in this country, trazodone is much more commonly used, even though it is less specific in how it helps people sleep.

Doxepin definitely deserves more attention than it is getting.

The woman had a bleeding ulcer and required a blood transfusion. The hospital discharge summary said to see me in three days for a repeat CBC. But she had a late Friday appointment and there was no way we would get a result before the end of the day. She also had developed diarrhea on her pantoprazole and had stopped the medication. As if that wasn’t enough, her right lower leg was swollen and painful. She had been bed bound for a couple of days in the hospital and sedentary at home after discharge.

She could still be bleeding and she could have a blood clot. There were no openings for an ultrasound until almost a week later. Normally, with the modern blood thinners, we can just start anticoagulation until the diagnosis of a blood clot can be confirmed or disproven. But you don’t do that when somebody has a bleeding ulcer.

The radiology department solved my dilemma by pointing out that the emergency room can order an ultrasound and the department will call in an on-call technician. So that is where my patient had to go. Her blood count was stable and the ultrasound was negative. So now we just have to hope that lansoprazole, which she had taken in the past, but stopped because she didn’t have heartburn, would be effective.

Not long ago, a Friday evening telephone call from a patient with severe nasal pain and a clear discharge after a Covid swab made me think she might have a cerebrospinal fluid leak. She, too, went to the emergency room on my recommendation.

Sometimes I over-explain the reasons I recommend the ER. I will list the types of tests that could help make the diagnosis, the patient only hears “head CT” or “wrist X-ray” and shows up at radiology with no order.

In this part of the country, with sketchy cell phone reception and people not always equipped with land line answering machines, let alone cell phone voice mail, I don’t want to have someone get an imaging test done and be on their way home when I get an abnormal result without being able to reach the patient. I’ve been burned before. And writing “WET READ, PLEASE” doesn’t always result in a call while the patient is still at the hospital.

As so often in medicine, getting the test is only the first step, then there are decisions, interventions and patient education to handle.

I have this irresistible urge to write, in case nobody noticed. I have a fledging Swedish blog under a pseudonym I won’t tell you about, but I finally decided to use Facebook, not just to keep in touch with my family in Sweden and my children, but for people who want to know what’s up in my life. So, under my own name, I do write things about my life, my pets and reflections that don’t fit on A Country Doctor Writes. But, as I wrote in one early post, I don’t want to be friends with a gazillion people because I really don’t have the space to read lots of updates. If somebody wants to know what is going on in the private ruminations of this country doctor, it’s there.

The timeline of a patient’s symptoms is often crucial in making a correct diagnosis. Similarly, the timeline of our own clinical decisions is necessary to document and review when following a patient through their treatment.

In the old paper charts, particularly when they were handwritten, office notes, phone calls, refills and many other things were displayed in the order they happened (usually reverse chronological order). This made following the treatment of a case effortless, for example:

3/1 OFFICE VISIT: ?UTI (where ciprofloxacin was prescribed and culture sent off)

3/3 Clinical note that the culture came back, bacteria resistant and treatment changed to sulfonamide.

3/5 Phone call: Patient developed a rash, quick handwritten addition on left side of chart folder, sulfa allergy. New prescription for nitrofurantoin.

3/8 Phone call: Now has yeast infection, prescribed fluconazole.

Each of these notes took virtually no time to create and you could see them all in one glance.

In one of the EMRs I work with (hi, Greenway, it’s me again), when the culture comes back and I need to change the antibiotic, I open the patient’s chart, go to the medication section and hit the + sign. The system then asks me which existing “encounter” I want to use for my new prescription. Excuse me, I am sending in a new prescription right now, doesn’t the system know what day it is? How could I today send in a new prescription dated yesterday?? So I have to create a new encounter, choosing “medication encounter” as the type and then I’m good to go. Sort of. That type of encounter doesn’t display when I later look at my office notes, because it isn’t classified as an office note.

When the patient later calls to report the rash, that telephone call comes to me as a “task” (oh, how I despise that demeaning word…), which will also not enter the timeline of office notes. I can create a medication encounter when I change the antibiotic again, just like with the first medication change. I can then use the same encounter to document the allergy. But if I want my actions to display in any kind of timeline, I have to use the encounter type “chart update”, which will enter the encounter list.

This is all very fussy and, frankly, reminds me of working with the earliest versions of DOS, which many of my readers are too young to even have encountered.

The time it takes to document the simple clinical scenario I described above in my current EMR – and to review the next time I see my patient – compared to when we did it on paper is 5-10 times longer.

Some progress, huh.

I wish the EMR would know that when I add a medication, I am doing it today and not yesterday.

I wish that it would know that it is a medication encounter when I am adding a medication.

I wish the EMR would display the story as simply as the old paper chart. I’m sure it’s possible. Computers can do amazing things. But of course, it’s a question of whom the holy grail actually serves.

I sometimes explain to patients that shortness of breath is usually one of three things: Bad lungs, bad heart or bad blood. We need the lungs to oxygenate our blood, the heart to pump the blood around and enough hemoglobin in our blood to carry the oxygen. I have sometimes been a little slow in thinking that anemia can be a cause of shortness of breath.

The other day I saw a patient who seemed not fit into either category and he reminded me of Wayne Brown, who died from another condition that can make you short of breath.

I thought of Wayne as I heard the story of Carl, a heavy smoker with severe COPD. He had been to the emergency room half a dozen times since Thanksgiving and had received prednisone with or without antibiotics every time. He had his last chest X-ray in December and it didn’t show anything different from the ones before.

Carl, the man in front of me, made a slight noise with each breath, but it wasn’t quite a wheeze. It was an ever so slight stridor, a sound from higher up in his windpipe.

“I keep telling them it’s not my lungs”, he said, “it’s here”, and pointed to his neck.

Years ago, I remember hearing that same noise as I was leaving the hospital after a meeting one night. My patient, Wayne, was sitting on a bench outside the emergency room. He was waiting for his ride back home after a visit to the ER for breathing problems, diagnosed as another COPD exacerbation. It was a damp, cold evening when you could almost see your breath. He was making this little stridorous noise. He wasn’t hoarse when he talked, but once we got him to see an ear nose and throat doctor, he turned out to have cancer of his larynx. He lived for a while with his tracheostomy, which I helped him manage, and he whispered when we talked for the remaining few months of his life.

Carl had a normal oxygen saturation, a miserable peak flow of 150, poor but clean breath sounds, no cough and no hoarseness. He will of course need a CT of his lungs, because I have seen even large cancers not show on chest X-rays, but he also will need his larynx evaluated.

I hope my hunch is wrong.