Guest guest Posted January 13, 2008 Report Share Posted January 13, 2008 1. I do not know the answers although close to an answer for B Your guy has had a stroke --for preventing stroke if they heve had a TIA I just reveiwed this with an internist and the literature then Aggrenox is indeed recommended having worked at the Va ,while they were annoying, they a re big enough to have people paying attention to EBM. Aggrenox is probably just fine. He has had caroid u/s echo stuff like that? reduction of risk facotrs? 2. Several people in the last two weeks helped me a great deal with my peds question I did it off list becasue I thought i was in the 19th C., lost my confidence due to infrequnce of admits of this stuff+ diffiuclt pediatrican .. IT was great help and i thank all of you esp Chrissie Ott lurking pediatrician ,and Lynnette, kathy, naureen. 3 did you see Gordon's post thing about t he 1-17 phone call, part I dunno, A2 orB3 or rotate part of one call each time or so i should re read it maybe it sounded good i noticed no one answered him. .. about doing clinical stuff on the calls- so there ya go? Clinical Thread? What do you guys think about an ongoing quick (well maybe not quick considering how many points of view there are) question/answer clinical thread on this listserv? Is it too much? I am fighting practice isolation but will desist from posting this here if it takes up too much of the ether. I notice that the volume of posts has been high lately. If it is too much ignore these questions and tell me to desist. I think there are other clinical venues and it doesn't have to be done here. ( I am more fond of you guys than the other lists though.) If it is not too much, here are 3 questions to start off: 1) Surgery/Derm- Can I excise a accessory nipple with a simple punch biopsy for cosmetic reasons ( is there underlying breast tissue, if the person wants to nurse later, will there be milk without an egress point, will it heal up OK?) 2) Neurology- 86 year old man previous CVA on moderate dose ASA, on plavix for 4 years since then, now the VA will now only pay for Aggrenox (dipyridamole and ASA). Plavix costs an arm and a leg and he will have to pay out of pocket. There is a huge trial going on now which may answer this question, plavix vs aggrenox, but it is just enrolling now. Is it safe to switch him? I did it already, but god knows, if he has another CVA, that will be really sad annoying and infuriating. 3) Rheumatology- 51 year old alcoholic female with recurrent episodes past 2 years of high CRP (up to 31) and mildly elevated ESRs during that time, episodes last days to a few weeks then resolve, becomes achy but no objective joint sxs , previous workup about 2 years ago with C3, C4, anti CCP RA anti DNA was not remarkable. A year ago, Parvo virus IgG was quite high, around ?8, IgM was not. Would you send this person to a rheumatologist? (OK Graham, have at it - is this a 'bad referral'?) Thanks! Lynn Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 13, 2008 Report Share Posted January 13, 2008 1. I would think that Aggrenox is fine. In fact, in my neck of the woods, Aggrenox is used after aspirin has failed and Plavix isn’t. Plavix seems to be used only for ACS and s/p stenting. Actually this is #2. 2. I don’t think removing an accessory nipple is at all recommended. I believe it would need to be wide and deep excision. This is #1. 3. I believe being an alcoholic raises ESR and CRP. Most adults will test positive for having had Parvo which is what the IgG elevation indicates. If she is not having objective joint symptoms, why are you measuring CRP and ESRs? What were the symptoms she is having that makes you check? If not having symptoms ignore the tests. It means mild inflammation which could be liver for all we know, no rheumatologic symptoms I wouldn’t refer to rheumatologist. I never treat tests, just people. Kathy Saradarian, MD Branchville, NJ www.qualityfamilypractice.com Solo 4/03, Practicing since 9/90 Practice Partner 5/03 Low staffing From: [mailto: ] On Behalf Of Jean Antonucci Sent: Sunday, January 13, 2008 10:42 AM To: 'lynnhri '; ' ' Subject: RE: Clinical Thread? 1. I do not know the answers although close to an answer for B Your guy has had a stroke --for preventing stroke if they heve had a TIA I just reveiwed this with an internist and the literature then Aggrenox is indeed recommended having worked at the Va ,while they were annoying, they a re big enough to have people paying attention to EBM. Aggrenox is probably just fine. He has had caroid u/s echo stuff like that? reduction of risk facotrs? 2. Several people in the last two weeks helped me a great deal with my peds question I did it off list becasue I thought i was in the 19th C., lost my confidence due to infrequnce of admits of this stuff+ diffiuclt pediatrican .. IT was great help and i thank all of you esp Chrissie Ott lurking pediatrician ,and Lynnette, kathy, naureen. 3 did you see Gordon's post thing about t he 1-17 phone call, part I dunno, A2 orB3 or rotate part of one call each time or so i should re read it maybe it sounded good i noticed no one answered him. .. about doing clinical stuff on the calls- so there ya go? Clinical Thread? What do you guys think about an ongoing quick (well maybe not quick considering how many points of view there are) question/answer clinical thread on this listserv? Is it too much? I am fighting practice isolation but will desist from posting this here if it takes up too much of the ether. I notice that the volume of posts has been high lately. If it is too much ignore these questions and tell me to desist. I think there are other clinical venues and it doesn't have to be done here. ( I am more fond of you guys than the other lists though.) If it is not too much, here are 3 questions to start off: 1) Surgery/Derm- Can I excise a accessory nipple with a simple punch biopsy for cosmetic reasons ( is there underlying breast tissue, if the person wants to nurse later, will there be milk without an egress point, will it heal up OK?) 2) Neurology- 86 year old man previous CVA on moderate dose ASA, on plavix for 4 years since then, now the VA will now only pay for Aggrenox (dipyridamole and ASA). Plavix costs an arm and a leg and he will have to pay out of pocket. There is a huge trial going on now which may answer this question, plavix vs aggrenox, but it is just enrolling now. Is it safe to switch him? I did it already, but god knows, if he has another CVA, that will be really sad annoying and infuriating. 3) Rheumatology- 51 year old alcoholic female with recurrent episodes past 2 years of high CRP (up to 31) and mildly elevated ESRs during that time, episodes last days to a few weeks then resolve, becomes achy but no objective joint sxs , previous workup about 2 years ago with C3, C4, anti CCP RA anti DNA was not remarkable. A year ago, Parvo virus IgG was quite high, around ?8, IgM was not. Would you send this person to a rheumatologist? (OK Graham, have at it - is this a 'bad referral'?) Thanks! Lynn Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 13, 2008 Report Share Posted January 13, 2008 Could it be pancreatitis or hepatitis? No joint signs = no rheumatology referral > > 3) Rheumatology- 51 year old alcoholic female with recurrent episodes > past 2 years of high CRP (up to 31) and mildly elevated ESRs during > that time, episodes last days to a few weeks then resolve, becomes > achy but no objective joint sxs , previous workup about 2 years ago -- Graham Chiu http://www.synapsedirect.com Synapse-EMR - innovative electronic medical records system Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 13, 2008 Report Share Posted January 13, 2008 No joint signs = no rheumatology referral Graham- Darn And i thought rheumatology was almost as good as neurology for all my they must be crazy/ YOU talk to them /i do not have a diagnosis/ folks. Actaully I refer less and less to anyyone but ortho if indeed i can't find it they won't either and if they can treat hem so can I (exceptions humira and other bio -unprbnoucibles) Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 13, 2008 Report Share Posted January 13, 2008 Actually I do get the odd referral which basically says .. I know it's not your field but I don't know what's wrong. Please see and advise! Sometimes I get lucky and can make a diagnosis. > > > No joint signs = no rheumatology referral > > Graham- > Darn And i thought rheumatology was almost as good as neurology for all my > they must be crazy/ YOU talk to them /i do not have a diagnosis/ folks. > > Actaully I refer less and less to anyyone but ortho > if indeed i can't find it they won't either and if they can treat hem so > can I (exceptions humira and other bio -unprbnoucibles) > -- Graham Chiu http://www.synapsedirect.com Synapse-EMR - innovative electronic medical records system Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 13, 2008 Report Share Posted January 13, 2008 Graham- that is nice and straightforward, thank you!I guess this falls nicely into that 'you must be crazy, please see the neurologist basket' for rheumatology.Normal LFTS amylase lipase no abdominal symptoms during these episodes so I am not thinking pancreatitis or hepatitis. Kathy - ESR and CRP go back down to normal when she is still drinking but not having any episodes. I haven't actually been 'treating the lab' since there is nothing to treat/I do not know what to treat, with respect to her recurrent athralgias and episodes of fatigue. Have seen a few women with acute onset and then slow to resolve Parvovirus and joint sxs over about 9 months to a year (not objectively hot red joints but significant arthralgia, or maybe I am just not good enough to 'see' the synovitis), but maybe this is not it. I think this falls into the category of "this is something, but what is it?"It would be great though quite humbling to have all 500+ of you looking at my charts all the time and pointing out the parts that were not quite evidence based. I would settle for a small pod, though, maybe an email group of 5, for running clinical questions around in the group ( I'd obviously better get into a group with a few smart people in it to take up my slack.). I do think the way I am practicing is more isolated than many of you and 500 is probably too big and 1 is too small. I may have to finger 4 of you to see if you would like to be in a small clinical group with me- watch out!I think the clinical question issue on the imp listserv is a great idea for coming up to speed on the big ticket issues (though notice I did not volunteer to take on a topic). However I find that smaller issues like the above are messier and don't fit into the big baskets. Still would like a venue to quickly be able to run the smaller stuff by colleagues, small group as above may work.LynnTo: compkarori@...; From: jantonucci@...Date: Sun, 13 Jan 2008 12:47:22 -0500Subject: RE: Clinical Thread? No joint signs = no rheumatology referral Graham- Darn And i thought rheumatology was almost as good as neurology for all my they must be crazy/ YOU talk to them /i do not have a diagnosis/ folks. Actaully I refer less and less to anyyone but ortho if indeed i can't find it they won't either and if they can treat hem so can I (exceptions humira and other bio -unprbnoucibles) Put your friends on the big screen with Windows Vista® + Windows Live™. Start now! Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 13, 2008 Report Share Posted January 13, 2008 The peer pod is one of our goals in the IMP project as well. We're about to begin some testing of standard evidence based scripting for little videos we can present to our pts on YouTube (more to follow). G At 01:12 PM 1/13/2008, you wrote: Graham- that is nice and straightforward, thank you! I guess this falls nicely into that 'you must be crazy, please see the neurologist basket' for rheumatology. Normal LFTS amylase lipase no abdominal symptoms during these episodes so I am not thinking pancreatitis or hepatitis. Kathy - ESR and CRP go back down to normal when she is still drinking but not having any episodes. I haven't actually been 'treating the lab' since there is nothing to treat/I do not know what to treat, with respect to her recurrent athralgias and episodes of fatigue. Have seen a few women with acute onset and then slow to resolve Parvovirus and joint sxs over about 9 months to a year (not objectively hot red joints but significant arthralgia, or maybe I am just not good enough to 'see' the synovitis), but maybe this is not it. I think this falls into the category of " this is something, but what is it? " It would be great though quite humbling to have all 500+ of you looking at my charts all the time and pointing out the parts that were not quite evidence based. I would settle for a small pod, though, maybe an email group of 5, for running clinical questions around in the group ( I'd obviously better get into a group with a few smart people in it to take up my slack.). I do think the way I am practicing is more isolated than many of you and 500 is probably too big and 1 is too small. I may have to finger 4 of you to see if you would like to be in a small clinical group with me- watch out! I think the clinical question issue on the imp listserv is a great idea for coming up to speed on the big ticket issues (though notice I did not volunteer to take on a topic). However I find that smaller issues like the above are messier and don't fit into the big baskets. Still would like a venue to quickly be able to run the smaller stuff by colleagues, small group as above may work. Lynn To: compkarori@...; From: jantonucci@... Date: Sun, 13 Jan 2008 12:47:22 -0500 Subject: RE: Clinical Thread? No joint signs = no rheumatology referral Graham- Darn And i thought rheumatology was almost as good as neurology for all my they must be crazy/ YOU talk to them /i do not have a diagnosis/ folks. Actaully I refer less and less to anyyone but ortho if indeed i can't find it they won't either and if they can treat hem so can I (exceptions humira and other bio -unprbnoucibles) Put your friends on the big screen with Windows Vista® + Windows Live™. Start now! Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 13, 2008 Report Share Posted January 13, 2008 Lynn, I love the idea of having a small group to run things by. I totally miss that about the group office situation, but I actually think we could do it in a relatively small on-line group. Brilliant idea! Sharon At 10:12 AM 1/13/2008, you wrote: Graham- that is nice and straightforward, thank you! I guess this falls nicely into that 'you must be crazy, please see the neurologist basket' for rheumatology. Normal LFTS amylase lipase no abdominal symptoms during these episodes so I am not thinking pancreatitis or hepatitis. Kathy - ESR and CRP go back down to normal when she is still drinking but not having any episodes. I haven't actually been 'treating the lab' since there is nothing to treat/I do not know what to treat, with respect to her recurrent athralgias and episodes of fatigue. Have seen a few women with acute onset and then slow to resolve Parvovirus and joint sxs over about 9 months to a year (not objectively hot red joints but significant arthralgia, or maybe I am just not good enough to 'see' the synovitis), but maybe this is not it. I think this falls into the category of " this is something, but what is it? " It would be great though quite humbling to have all 500+ of you looking at my charts all the time and pointing out the parts that were not quite evidence based. I would settle for a small pod, though, maybe an email group of 5, for running clinical questions around in the group ( I'd obviously better get into a group with a few smart people in it to take up my slack.). I do think the way I am practicing is more isolated than many of you and 500 is probably too big and 1 is too small. I may have to finger 4 of you to see if you would like to be in a small clinical group with me- watch out! I think the clinical question issue on the imp listserv is a great idea for coming up to speed on the big ticket issues (though notice I did not volunteer to take on a topic). However I find that smaller issues like the above are messier and don't fit into the big baskets. Still would like a venue to quickly be able to run the smaller stuff by colleagues, small group as above may work. Lynn To: compkarori@...; From: jantonucci@... Date: Sun, 13 Jan 2008 12:47:22 -0500 Subject: RE: Clinical Thread? No joint signs = no rheumatology referral Graham- Darn And i thought rheumatology was almost as good as neurology for all my they must be crazy/ YOU talk to them /i do not have a diagnosis/ folks. Actaully I refer less and less to anyyone but ortho if indeed i can't find it they won't either and if they can treat hem so can I (exceptions humira and other bio -unprbnoucibles) Put your friends on the big screen with Windows Vista® + Windows Live™. Start now! Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 13, 2008 Report Share Posted January 13, 2008 Lynn, Sorry but you didn’t mention any symptoms. You just said episodes of ESR and CRP going up and down but not what made you start checking them. So if these episodes of elevated ESR and CRP (how elevated) are associated with joint pain, I would think that makes it rheumatologic. And when they return to normal, is there no joint pain or fatigue? And how normal? Is she post menopausal? Have one patient with climacteric arthritis that responded to hormone replacement. I find the presence or absence of joint effusions to be very user related. I feel boggy, puffy synovium and joints and the rheumatologist says “no” and I see and feel perfectly normal, bony joints and the rheumatologist says “presence of effusion”. I don’t know. Kathy Saradarian, MD Branchville, NJ www.qualityfamilypractice.com Solo 4/03, Practicing since 9/90 Practice Partner 5/03 Low staffing From: [mailto: ] On Behalf Of Lynn Ho Sent: Sunday, January 13, 2008 1:12 PM To: practiceimprovement1 Subject: RE: Clinical Thread? Graham- that is nice and straightforward, thank you! I guess this falls nicely into that 'you must be crazy, please see the neurologist basket' for rheumatology. Normal LFTS amylase lipase no abdominal symptoms during these episodes so I am not thinking pancreatitis or hepatitis. Kathy - ESR and CRP go back down to normal when she is still drinking but not having any episodes. I haven't actually been 'treating the lab' since there is nothing to treat/I do not know what to treat, with respect to her recurrent athralgias and episodes of fatigue. Have seen a few women with acute onset and then slow to resolve Parvovirus and joint sxs over about 9 months to a year (not objectively hot red joints but significant arthralgia, or maybe I am just not good enough to 'see' the synovitis), but maybe this is not it. I think this falls into the category of " this is something, but what is it? " It would be great though quite humbling to have all 500+ of you looking at my charts all the time and pointing out the parts that were not quite evidence based. I would settle for a small pod, though, maybe an email group of 5, for running clinical questions around in the group ( I'd obviously better get into a group with a few smart people in it to take up my slack.). I do think the way I am practicing is more isolated than many of you and 500 is probably too big and 1 is too small. I may have to finger 4 of you to see if you would like to be in a small clinical group with me- watch out! I think the clinical question issue on the imp listserv is a great idea for coming up to speed on the big ticket issues (though notice I did not volunteer to take on a topic). However I find that smaller issues like the above are messier and don't fit into the big baskets. Still would like a venue to quickly be able to run the smaller stuff by colleagues, small group as above may work. Lynn To: compkarori@...; From: jantonucci@... Date: Sun, 13 Jan 2008 12:47:22 -0500 Subject: RE: Clinical Thread? No joint signs = no rheumatology referral Graham- Darn And i thought rheumatology was almost as good as neurology for all my they must be crazy/ YOU talk to them /i do not have a diagnosis/ folks. Actaully I refer less and less to anyyone but ortho if indeed i can't find it they won't either and if they can treat hem so can I (exceptions humira and other bio -unprbnoucibles) Put your friends on the big screen with Windows Vista® + Windows Live™. Start now! Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 13, 2008 Report Share Posted January 13, 2008 Kathy > > Lynn, > > Sorry but you didn't mention any symptoms. You just said episodes of ESR > and CRP going up and down but not what made you start checking them. So if > these episodes of elevated ESR and CRP (how elevated) are associated with > joint pain, I would think that makes it rheumatologic. And when they return I think Lynn was saying " achy " which is not the same as joint pain, and in the absence of clinical synovitis. BTW, not everything needs a diagnosis ... if this were rheumatological, and a patient were experiencing attacks of self limiting non-disabling synovitis eg. variants of palindromic rheumatism, then symptomatic treatment may be all that is required. > I find the presence or absence of joint effusions to be very user related. > I feel boggy, puffy synovium and joints and the rheumatologist says " no " and > I see and feel perfectly normal, bony joints and the rheumatologist says > " presence of effusion " . I don't know. I've had one occasion when an ortho referred me a knee that they said had no effusion. I drained over 50 mls from it. It was so tight there was no " softness " about it. So, I'd go with the rheumatologist in general .. though again I see patients seen by other rheumatologists who say no synovitis and I detect synovitis. And vice versa. -- Graham Chiu http://www.synapsedirect.com Synapse-EMR - innovative electronic medical records system Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 13, 2008 Report Share Posted January 13, 2008 Had 1 too, disabling. Seronegative RA? Not an alcoholic. Could send you "deidentified" rheum review, but note that this pt had neg sed rate too. Matt RE: Clinical Thread? No joint signs = no rheumatology referral :)Graham-Darn And i thought rheumatology was almost as good as neurology for all mythey must be crazy/ YOU talk to them /i do not have a diagnosis/ folks.Actaully I refer less and less to anyyone but orthoif indeed i can't find it they won't either and if they can treat hem socan I (exceptions humira and other bio -unprbnoucibles) Put your friends on the big screen with Windows Vista® + Windows Live™. Start now! Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 13, 2008 Report Share Posted January 13, 2008 Gordon- I wonder if some of this already exists through the series of videos from the Foundation for Informed Medical Decision Making and Health Dialog. I read about it in the Bodenheimer book Improving Primary Care. (You see, if I readjust one book I have to quote from it for forever, don't let me read anything more!) I haven't seen any of the videos but they sound great. Have you, or can anyone else chime in; is that sort of what you meant for the patients?LynnTo: From: gmoore@...Date: Sun, 13 Jan 2008 13:26:29 -0500Subject: RE: Clinical Thread? The peer pod is one of our goals in the IMP project as well. We're about to begin some testing of standard evidence based scripting for little videos we can present to our pts on YouTube (more to follow). G At 01:12 PM 1/13/2008, you wrote: Graham- that is nice and straightforward, thank you! I guess this falls nicely into that 'you must be crazy, please see the neurologist basket' for rheumatology. Normal LFTS amylase lipase no abdominal symptoms during these episodes so I am not thinking pancreatitis or hepatitis. Kathy - ESR and CRP go back down to normal when she is still drinking but not having any episodes. I haven't actually been 'treating the lab' since there is nothing to treat/I do not know what to treat, with respect to her recurrent athralgias and episodes of fatigue. Have seen a few women with acute onset and then slow to resolve Parvovirus and joint sxs over about 9 months to a year (not objectively hot red joints but significant arthralgia, or maybe I am just not good enough to 'see' the synovitis), but maybe this is not it. I think this falls into the category of "this is something, but what is it?" It would be great though quite humbling to have all 500+ of you looking at my charts all the time and pointing out the parts that were not quite evidence based. I would settle for a small pod, though, maybe an email group of 5, for running clinical questions around in the group ( I'd obviously better get into a group with a few smart people in it to take up my slack.). I do think the way I am practicing is more isolated than many of you and 500 is probably too big and 1 is too small. I may have to finger 4 of you to see if you would like to be in a small clinical group with me- watch out! I think the clinical question issue on the imp listserv is a great idea for coming up to speed on the big ticket issues (though notice I did not volunteer to take on a topic). However I find that smaller issues like the above are messier and don't fit into the big baskets. Still would like a venue to quickly be able to run the smaller stuff by colleagues, small group as above may work. Lynn To: compkarorigmail; From: jantonuccifchn (DOT) org Date: Sun, 13 Jan 2008 12:47:22 -0500 Subject: RE: Clinical Thread? No joint signs = no rheumatology referral Graham- Darn And i thought rheumatology was almost as good as neurology for all my they must be crazy/ YOU talk to them /i do not have a diagnosis/ folks. Actaully I refer less and less to anyyone but ortho if indeed i can't find it they won't either and if they can treat hem so can I (exceptions humira and other bio -unprbnoucibles) Put your friends on the big screen with Windows Vista® + Windows Live™. Start now! Watch “Cause Effect,” a show about real people making a real difference. Learn more Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 13, 2008 Report Share Posted January 13, 2008 Very similar, but - along our typical purchase mode - I though we could create our own short ones at no cost, plus we can use our IMP cohorts as potential pods to explore standardization around the evidence. G At 02:15 PM 1/13/2008, you wrote: Gordon- I wonder if some of this already exists through the series of videos from the Foundation for Informed Medical Decision Making and Health Dialog. I read about it in the Bodenheimer book Improving Primary Care. (You see, if I readjust one book I have to quote from it for forever, don't let me read anything more!) I haven't seen any of the videos but they sound great. Have you, or can anyone else chime in; is that sort of what you meant for the patients? Lynn To: From: gmoore@... Date: Sun, 13 Jan 2008 13:26:29 -0500 Subject: RE: Clinical Thread? The peer pod is one of our goals in the IMP project as well. We're about to begin some testing of standard evidence based scripting for little videos we can present to our pts on YouTube (more to follow). G At 01:12 PM 1/13/2008, you wrote: Graham- that is nice and straightforward, thank you! I guess this falls nicely into that 'you must be crazy, please see the neurologist basket' for rheumatology. Normal LFTS amylase lipase no abdominal symptoms during these episodes so I am not thinking pancreatitis or hepatitis. Kathy - ESR and CRP go back down to normal when she is still drinking but not having any episodes. I haven't actually been 'treating the lab' since there is nothing to treat/I do not know what to treat, with respect to her recurrent athralgias and episodes of fatigue. Have seen a few women with acute onset and then slow to resolve Parvovirus and joint sxs over about 9 months to a year (not objectively hot red joints but significant arthralgia, or maybe I am just not good enough to 'see' the synovitis), but maybe this is not it. I think this falls into the category of " this is something, but what is it? " It would be great though quite humbling to have all 500+ of you looking at my charts all the time and pointing out the parts that were not quite evidence based. I would settle for a small pod, though, maybe an email group of 5, for running clinical questions around in the group ( I'd obviously better get into a group with a few smart people in it to take up my slack.). I do think the way I am practicing is more isolated than many of you and 500 is probably too big and 1 is too small. I may have to finger 4 of you to see if you would like to be in a small clinical group with me- watch out! I think the clinical question issue on the imp listserv is a great idea for coming up to speed on the big ticket issues (though notice I did not volunteer to take on a topic). However I find that smaller issues like the above are messier and don't fit into the big baskets. Still would like a venue to quickly be able to run the smaller stuff by colleagues, small group as above may work. Lynn To: compkarori@...; From: jantonucci@... Date: Sun, 13 Jan 2008 12:47:22 -0500 Subject: RE: Clinical Thread? No joint signs = no rheumatology referral Graham- Darn And i thought rheumatology was almost as good as neurology for all my they must be crazy/ YOU talk to them /i do not have a diagnosis/ folks. Actaully I refer less and less to anyyone but ortho if indeed i can't find it they won't either and if they can treat hem so can I (exceptions humira and other bio -unprbnoucibles) Put your friends on the big screen with Windows Vista® + Windows Live™. Start now! Watch “Cause Effect,” a show about real people making a real difference. Learn more Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 14, 2008 Report Share Posted January 14, 2008 I treat a lot of fibromyalgia, so would probably look for tender points, especially during periods of achiness. Also need a thorough sleep history--may be difficult to assess in an alcoholic. Where I am- -Albany, NY- I would look for Lyme disease too. --Padma > > What do you guys think about an ongoing quick (well maybe not quick > considering how many points of view there are) question/answer > clinical thread on this listserv? > Is it too much? I am fighting practice isolation but will desist > from posting this here if it takes up too much of the ether. I notice > that the volume of posts has been high lately. > If it is too much ignore these questions and tell me to desist. I > think there are other clinical venues and it doesn't have to be done > here. ( I am more fond of you guys than the other lists though.) > If it is not too much, here are 3 questions to start off: > 1) Surgery/Derm- Can I excise a accessory nipple with a simple punch > biopsy for cosmetic reasons ( is there underlying breast tissue, if > the person wants to nurse later, will there be milk without an egress > point, will it heal up OK?) > 2) Neurology- 86 year old man previous CVA on moderate dose ASA, on > plavix for 4 years since then, now the VA will now only pay for > Aggrenox (dipyridamole and ASA). Plavix costs an arm and a leg and he > will have to pay out of pocket. There is a huge trial going on now > which may answer this question, plavix vs aggrenox, but it is just > enrolling now. Is it safe to switch him? I did it already, but god > knows, if he has another CVA, that will be really sad annoying and > infuriating. > 3) Rheumatology- 51 year old alcoholic female with recurrent episodes > past 2 years of high CRP (up to 31) and mildly elevated ESRs during > that time, episodes last days to a few weeks then resolve, becomes > achy but no objective joint sxs , previous workup about 2 years ago > with C3, C4, anti CCP RA anti DNA was not remarkable. A year ago, > Parvo virus IgG was quite high, around ?8, IgM was not. Would you > send this person to a rheumatologist? (OK Graham, have at it - is > this a 'bad referral'?) > Thanks! > Lynn > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 14, 2008 Report Share Posted January 14, 2008 I think this falls into the category of " this is something, but what is it? " It reminds me of a PMR patient I saw a few years ago. In that case I tried prednisone 10 mg, worked fast, in 2-3 days. ESR is usually higher and you may have some anemia but not in milder cases. The clue with PMR is that the patient will have sore muscles, mostly neck and hips area but vague location and no particular joint involved. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 14, 2008 Report Share Posted January 14, 2008 Padma Primary fibromyalgia is not associated with raised inflammatory markers. > > > > > > > I treat a lot of fibromyalgia, so would probably look for tender > points, especially during periods of achiness. Also need a thorough > sleep history--may be difficult to assess in an alcoholic. Where I am- > -Albany, NY- I would look for Lyme disease too. > --Padma -- Graham Chiu http://www.synapsedirect.com Synapse-EMR - innovative electronic medical records system Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 14, 2008 Report Share Posted January 14, 2008 That is true, I was thinking the CRP could be a result of inflammation yet to be discovered, and the FMG as the cause of her " achiness " --long shot, but good to look for. But I have quite a few Fibro sufferers with sl. elevated ESR, nothing else, though. > > > > > > > > > > > > > > I treat a lot of fibromyalgia, so would probably look for tender > > points, especially during periods of achiness. Also need a thorough > > sleep history--may be difficult to assess in an alcoholic. Where I am- > > -Albany, NY- I would look for Lyme disease too. > > --Padma > > -- > Graham Chiu > http://www.synapsedirect.com > Synapse-EMR - innovative electronic medical records system > Quote Link to comment Share on other sites More sharing options...
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