So I have a patient with Diabetes which has recently become poorly controlled. She was on Glyburide / Metformin 2.5/500 BID and her blood glucose was in the mid 300s. HgA1C was almost 9. She tells me how she is drinking 6 or so sodas daily and not eating right. I advise her on healthier eating habits and have her double her pills for the next few weeks (2 in the am and 2 in the pm - I don't like for my patients to waste pills every time a dose is changed). She comes back for follow up a few weeks later. I review how she is eating and taking her meds and she has been doing as advised for the most part, however, her accucheck was 400. So I write a script for the higher dose of Glyb/Met (so she no longer has to double her previous script) and give her samples of and write a script for Januvia - another diabetic med.
No sooner is she out the door that we get a call from the pharmacist - her insurance requires prior authorization before filling the Januvia. Basically meaning I have to get permission from the insurance company before I can treat the patient with this med. So my nurse calls Medicaid and answers their 'screening questions' only to be told that they will not cover that until she has been on the glyb/met 5/1000 BID x 3 months. I am livid! They don't even include the past few weeks of her doubling her pills because it didn't show up in their system since it wasn't an official script.
So now she has to run around with blood sugars in the 300-400s for 3 months before they will pay for her med! And if she has to go in the hospital with DKA or hyperosmolar nonketotic diabetic coma, her insurance will have to pay way more for that hospitalization!
I wonder if I can set her up with an appointment for Dr. Medicaid's clinic since they can so easily dictate patient care. What is the point of having doctors if we cannot even treat the patient without permission?
Friday, November 27, 2009
Wednesday, November 25, 2009
My Baby Girl was sick...
Well, my baby girl (20 months old) got sick. Saturday, she started coughing nonstop. Dry, but almost nonstop.
Sunday morning I noticed upper airway noise but listened with my stethescope and her lungs were clear. She was breathing kinda fast. It reminded me of when she had Croup last year. I called one of my colleagues who looked her over and thought she didn't look that bad. We gave her some Prelone syrup. Later that day she got fever 103.
Monday, she was worse. This time the wheezing was all in her lungs and she was retracting some. I was trying to give her her albuterol but she would have none of it - not enough anyway. I took her to the ER (the ER Doc on is a close friend of the fam and I worked with her during my Residency a few times) and we gave her a few updrafts (without officially checking her in and doing lab work, etc as I didn't have my new insurance card with me). She got a little better but was still wheezing some. I figured since she was on steroids, it would continue to get better. I was wrong. Oh, and she was not eating much at all.
Tuesday morning she was worse, wheezing everywhere (I could hear her across the room). Retracting some, breathing fast. Looked ill. So I paged her Pediatrician who happened to be on call. She told me to take her to get a chest Xray and bring her to the office at 10am.
When the Ped listened to her, she had her Nurse Practitioner and Student Doc listen too - her wheezing was so bad. She also had a bad ear infection. Flu and strep tests were negative. She had to go in the hospital for scheduled updrafts, IV steroids and IV fluids.
I don't know why it surprised me that she'd have to be hospitalized. It broke my heart though. They had to stick her 3xs to get a line which came out before her first meds were given, then they had to stick her 3 more times. She ended up having to get it in her foot.
She tested + for RSV, a virus that affects the lungs and in many cases just causes cold like symptoms but for an unlucky few, like young kids prone to wheezing, it can make them very ill - as it did my little girl.
We were there overnight. She was a real trooper. We're home now. She's still sick, but much better. Still on a lot of meds.
Soon as we pulled up to the house and I started getting stuff out the car, she said "Momma! Momma!" and I looked at her and said "What baby?" And she says, "French fries? French fries?" So I get back in the car and head McDonalds. How can I say no to that face?
Sunday morning I noticed upper airway noise but listened with my stethescope and her lungs were clear. She was breathing kinda fast. It reminded me of when she had Croup last year. I called one of my colleagues who looked her over and thought she didn't look that bad. We gave her some Prelone syrup. Later that day she got fever 103.
Monday, she was worse. This time the wheezing was all in her lungs and she was retracting some. I was trying to give her her albuterol but she would have none of it - not enough anyway. I took her to the ER (the ER Doc on is a close friend of the fam and I worked with her during my Residency a few times) and we gave her a few updrafts (without officially checking her in and doing lab work, etc as I didn't have my new insurance card with me). She got a little better but was still wheezing some. I figured since she was on steroids, it would continue to get better. I was wrong. Oh, and she was not eating much at all.
Tuesday morning she was worse, wheezing everywhere (I could hear her across the room). Retracting some, breathing fast. Looked ill. So I paged her Pediatrician who happened to be on call. She told me to take her to get a chest Xray and bring her to the office at 10am.
When the Ped listened to her, she had her Nurse Practitioner and Student Doc listen too - her wheezing was so bad. She also had a bad ear infection. Flu and strep tests were negative. She had to go in the hospital for scheduled updrafts, IV steroids and IV fluids.
I don't know why it surprised me that she'd have to be hospitalized. It broke my heart though. They had to stick her 3xs to get a line which came out before her first meds were given, then they had to stick her 3 more times. She ended up having to get it in her foot.
She tested + for RSV, a virus that affects the lungs and in many cases just causes cold like symptoms but for an unlucky few, like young kids prone to wheezing, it can make them very ill - as it did my little girl.
We were there overnight. She was a real trooper. We're home now. She's still sick, but much better. Still on a lot of meds.
Soon as we pulled up to the house and I started getting stuff out the car, she said "Momma! Momma!" and I looked at her and said "What baby?" And she says, "French fries? French fries?" So I get back in the car and head McDonalds. How can I say no to that face?
Saturday, October 31, 2009
Young Sex
I also work 1/2 day a week in an adolescant / young adult clinic.
"Good morning doc" one of the college kids says to me when I walk in.
Good morning, I am Dr. Blank. What brings you here today?"
"Well, this girl I been messin with got chlamydia so I want to be checked to be sure I don't have it."
"Are you having any symptoms? Pain, discharge?"
"No. It's just that I got a girl back at home and...she even got a man at home...I just wanna make sure I aint got nothin or bringin nothin to my girl."
So I examine him, test him, counsel him on safe sex, and offer him free condoms (which he declines).
I see so many STDs in this population it is like an epidemic. It saddens, angers, and worries me all at the same time. In this case he was acting like it was no big deal at all. *sigh*
"Good morning doc" one of the college kids says to me when I walk in.
Good morning, I am Dr. Blank. What brings you here today?"
"Well, this girl I been messin with got chlamydia so I want to be checked to be sure I don't have it."
"Are you having any symptoms? Pain, discharge?"
"No. It's just that I got a girl back at home and...she even got a man at home...I just wanna make sure I aint got nothin or bringin nothin to my girl."
So I examine him, test him, counsel him on safe sex, and offer him free condoms (which he declines).
I see so many STDs in this population it is like an epidemic. It saddens, angers, and worries me all at the same time. In this case he was acting like it was no big deal at all. *sigh*
Saturday, October 17, 2009
My Mental Week
I called this entry My Mental Week because sometimes patients and their lives can...weigh in on me. This week I had a lot of patients who I spent a great deal of time thinking about.
In Smalltown USA, I see so many people, so many sick people that need help - with no insurance. We have a sliding fee based on income, so we welcome them. This is quite different from Residency. As a Resident, I would be quick to treat a bladder infection with levaquin and not think twice. The vast majority of patients were insured and did not have a problem getting meds. But it is crazy it is to prescribe Levaquin to someone who's husband just lost his job and is struggling to feed 3 kids. Rarely do I prescribe something that is not available on the $4 list and hope that they can get that or treat various ailments with a shot or something available at the clinic or available through a perscription drug program.
Yesterday I saw a man who suffers from chronic pain after having a GSW many years ago. He confessed that he never filled his last script (for Meloxicam and Amitriptyline) because he could not afford it ($30 something dollars). I explained that if he could go to the next town to walmart and they would both be on the $4 list but soon learned he has no way to get to town and does not have $8. So he got a toradol shot. I don't know, I wish I could do more. I then offered him the flu shot and he declined saying "Every one I knows that got the flu shot got sick!" I quickly replied that I got it and I'm not sick (hoping not to jinx myself shortly after I said it). "But you're a doctor!" I couldn't convince him. lol.
Then I saw a lady regarding rapid weight loss - 35 pounds in 7 months! and only 51 years old! She weighs less than 90 lbs and just looking at her I know she has cancer (well, I don't know, but I'm pretty sure). I took a very detailed history. She smokes heavily (lung cancer?) has problems with constipation and bloody stools (colon cancer?) and she still has her ovaries (ovarian cancer?) and has not had a breast exam or mammogram in many years (breast cancer?). She asks me if we can just do some blood work to find out what it is and see if maybe a pill can fix it. She is very pleasant, jovial, and optomistic. As I ponder with how to approach this, I tell her that whenever someone has such rapid weight loss cancer is a definite possibility and she says "Oh, I know! I know! But if it is cancer, I don't want any drastic measures done, just keep me comfortable and let me die!" I counsel her about colon screening and my concerns with her bleeding and she declines. "I don't want to go through a lot of tests! Nothing invasive" I suggest pelvic exam (declines) and a breast exam and mammogram and give her the breast care pamplet as they will pay for that. She says she will think about it. I set her up for a chest Xray which she agrees too and basic blood work. Rapid HIV screen was negative. I will see her next week to review results. I considered ordering tumor markers like CEA, etc, but our lab can't do those and they are very expensive. I don't know if the basic lab will suggest any etiology (like liver metastisis or high alk phos / bone mets) but we shall see I guess. **sigh**
Also, I saw two young girls with Chlamydia. One acted like it was no big deal and the other was so hurt perhaps by her significant other that she could barely speak. I remind them that free condoms are always available here and give them some and encourage them to take care of themselves.
And I found out one of my sweetest patients is a drug seeker. I happened to talk with the ER doc in the next town who I did my Residency with and apparently she is in there several times a month scoring pain meds for various reasons. My nurse confirmed this with two pharmacies. On one visit, she had told me specifically that the ER gave her something for nausea and not pain and I actually believed her and gave her something. She filled a script for Darvocet and Vicoden (from 2 different doctors) at the same pharmacy on the same day!! SUCKER on my head I guess. She has an apt next week and I'll have to tell her no more narcotics from me. I don't know why I am so offended. I guess I thought I was pretty good at detecting drug seekers, but my radar completely missed her. No it's not the first time a patient lied to me, but...idk.
In Smalltown USA, I see so many people, so many sick people that need help - with no insurance. We have a sliding fee based on income, so we welcome them. This is quite different from Residency. As a Resident, I would be quick to treat a bladder infection with levaquin and not think twice. The vast majority of patients were insured and did not have a problem getting meds. But it is crazy it is to prescribe Levaquin to someone who's husband just lost his job and is struggling to feed 3 kids. Rarely do I prescribe something that is not available on the $4 list and hope that they can get that or treat various ailments with a shot or something available at the clinic or available through a perscription drug program.
Yesterday I saw a man who suffers from chronic pain after having a GSW many years ago. He confessed that he never filled his last script (for Meloxicam and Amitriptyline) because he could not afford it ($30 something dollars). I explained that if he could go to the next town to walmart and they would both be on the $4 list but soon learned he has no way to get to town and does not have $8. So he got a toradol shot. I don't know, I wish I could do more. I then offered him the flu shot and he declined saying "Every one I knows that got the flu shot got sick!" I quickly replied that I got it and I'm not sick (hoping not to jinx myself shortly after I said it). "But you're a doctor!" I couldn't convince him. lol.
Then I saw a lady regarding rapid weight loss - 35 pounds in 7 months! and only 51 years old! She weighs less than 90 lbs and just looking at her I know she has cancer (well, I don't know, but I'm pretty sure). I took a very detailed history. She smokes heavily (lung cancer?) has problems with constipation and bloody stools (colon cancer?) and she still has her ovaries (ovarian cancer?) and has not had a breast exam or mammogram in many years (breast cancer?). She asks me if we can just do some blood work to find out what it is and see if maybe a pill can fix it. She is very pleasant, jovial, and optomistic. As I ponder with how to approach this, I tell her that whenever someone has such rapid weight loss cancer is a definite possibility and she says "Oh, I know! I know! But if it is cancer, I don't want any drastic measures done, just keep me comfortable and let me die!" I counsel her about colon screening and my concerns with her bleeding and she declines. "I don't want to go through a lot of tests! Nothing invasive" I suggest pelvic exam (declines) and a breast exam and mammogram and give her the breast care pamplet as they will pay for that. She says she will think about it. I set her up for a chest Xray which she agrees too and basic blood work. Rapid HIV screen was negative. I will see her next week to review results. I considered ordering tumor markers like CEA, etc, but our lab can't do those and they are very expensive. I don't know if the basic lab will suggest any etiology (like liver metastisis or high alk phos / bone mets) but we shall see I guess. **sigh**
Also, I saw two young girls with Chlamydia. One acted like it was no big deal and the other was so hurt perhaps by her significant other that she could barely speak. I remind them that free condoms are always available here and give them some and encourage them to take care of themselves.
And I found out one of my sweetest patients is a drug seeker. I happened to talk with the ER doc in the next town who I did my Residency with and apparently she is in there several times a month scoring pain meds for various reasons. My nurse confirmed this with two pharmacies. On one visit, she had told me specifically that the ER gave her something for nausea and not pain and I actually believed her and gave her something. She filled a script for Darvocet and Vicoden (from 2 different doctors) at the same pharmacy on the same day!! SUCKER on my head I guess. She has an apt next week and I'll have to tell her no more narcotics from me. I don't know why I am so offended. I guess I thought I was pretty good at detecting drug seekers, but my radar completely missed her. No it's not the first time a patient lied to me, but...idk.
Wednesday, October 14, 2009
Heartworms
5 year old girl brought to clinic by grandma because of her chest hurting when she coughs. During the exam, her grandma says "she thought she had heartworms but I told her that only happens in dogs." We both giggle, then the girl says "No granny! I can't have heartworms, I am not a dog! Unless mommy is a dog...or unless daddy is a dog." Grandma says, "Well yes baby, your daddy is a dog, that's for sure!"
Tuesday, October 13, 2009
ADHD and E
I saw a kiddo today who was diagnosed by the local mental health facility with ADHD and was sent to me for monthly perscriptions since he lives close to our clinic. At one point when talking to mom, she said "He went from making A's and B's to making D's and F's" and he quickly and enthusiastically added "And E's!!!"
Wednesday, September 16, 2009
Sex, Lies, and Madness!
Case 1: 24 y/o female presents to clinic for lab review. She had her annual exam and pap smear last week. Very sweet girl, in a long term relationship with her boyfriend of 3 years. On birth control.
Tested positive for gonorrhea.
"I don't understand how that happened..."
Unprotected sex. Case closed.
Case 2: 16 year old female presents to clinic with nausea, vomiting, stomach virus' x 2 weeks. History positive for smoking 1ppd and occasional marijuana use.
Last menstrual period: 2 months ago.
"Do you think you could be pregnant? Did you take a pregnancy test?" I ask.
"I did a few weeks ago and i was positive, but turned negative so I figured I wasn't pregnant."
"Well it is positive today. Congratulations."
She looks at me stunned.
"Do you think you can stop smoking?"
"Yes, I want to do all I can. I don't want to have a miscarriage like last time."
A tear falls from her eyes. I hand her kleenex.
"Is everything okay?"
"Yes it will be, just a little stunned."
"Is the father still in the picture?"
"No we broke up a few weeks ago."
I proceed to counsel her and give her a script for prenatal vitamins and some recommendations for her morning sickness.
Case 3: 55 y/o male presents to clinic with pain during urination. Urinalysis is negative for urinary tract infection.
While getting the basic history, I ask if he is sexually active. He looks down and says, "I lost my wife a few years ago and was not sexually active...until a few weeks ago. I met this girl and we really clicked. I thought we'd be together for a while. We did not plan to have sex but it just happened. Since it wasn't planned, we did not use protection. We are not together anymore. Do you think I may have caught something?"
So we test him for gonorrhea and chlamydia. A few days later he returns for results - he is positive for chlamydia...and treated. "I have learned my lesson" he says. I certainly hope so.
Sex, lies and madness. Sex can be such a beautiful precious thing - but boy can it be dangerous and life altering.
As always, some details are changed to maintain confidentiality.
Tested positive for gonorrhea.
"I don't understand how that happened..."
Unprotected sex. Case closed.
Case 2: 16 year old female presents to clinic with nausea, vomiting, stomach virus' x 2 weeks. History positive for smoking 1ppd and occasional marijuana use.
Last menstrual period: 2 months ago.
"Do you think you could be pregnant? Did you take a pregnancy test?" I ask.
"I did a few weeks ago and i was positive, but turned negative so I figured I wasn't pregnant."
"Well it is positive today. Congratulations."
She looks at me stunned.
"Do you think you can stop smoking?"
"Yes, I want to do all I can. I don't want to have a miscarriage like last time."
A tear falls from her eyes. I hand her kleenex.
"Is everything okay?"
"Yes it will be, just a little stunned."
"Is the father still in the picture?"
"No we broke up a few weeks ago."
I proceed to counsel her and give her a script for prenatal vitamins and some recommendations for her morning sickness.
Case 3: 55 y/o male presents to clinic with pain during urination. Urinalysis is negative for urinary tract infection.
While getting the basic history, I ask if he is sexually active. He looks down and says, "I lost my wife a few years ago and was not sexually active...until a few weeks ago. I met this girl and we really clicked. I thought we'd be together for a while. We did not plan to have sex but it just happened. Since it wasn't planned, we did not use protection. We are not together anymore. Do you think I may have caught something?"
So we test him for gonorrhea and chlamydia. A few days later he returns for results - he is positive for chlamydia...and treated. "I have learned my lesson" he says. I certainly hope so.
Sex, lies and madness. Sex can be such a beautiful precious thing - but boy can it be dangerous and life altering.
As always, some details are changed to maintain confidentiality.
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