I have a patient with very unusual visual symptoms and sense of imbalance that has persisted for more than a year.  She describes very unusual and concerning symptoms including true diplopia, a sense of major visual disturbances like the floor buckling in her visual fields, vertigo, severe sense of imbalance and swaying, headache, memory fog and concentration difficulty. Of note is that her symptoms seemed to start after a cruise.  I ...

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We can now add vitamin B12 deficiency to the growing list of risks of long term use of the proton pump inhibitors (PPIs). The New York Times had an article outlining the evidence that prolonged use of both proton pump inhibitors (PPIs) like Prilosec, Protonix, Prevacid and others, as well as the less potent H2 blockers like Zantac and Pepcid, can lead to vitamin B12 deficiency.  This is in addition to ...

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Early diagnosis, preventative care and aggressive disease management are mainstays of American medicine today.  Proponents argue that early diagnosis and prevention are the keys to healthy living. Skeptics suspect that many of the screening tests for early asymptomatic disease and preventative treatments we undergo lead to overdiagnosis, unnecessary expense, exposure to diagnostic and therapeutic interventions which themselves have risks, and that often cause more harm than good. As a physician and ...

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In Pierce County, Washington, where I work, it is difficult to find a psychiatrist to care for psychiatric cases that are outside the scope of practice of a primary care physician.  Our community is not unusual in this situation.  There is a nationwide shortage of physicians specializing in psychiatry. According to Tom Insel, MD, the director of the Institute of Mental Health in 2011 both the number of psychiatry residency programs and the ...

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The Affordable Care Act (ACA) will make insurers unable to exclude Americans with serious health problems from enrolling in insurance plans. This is among the most popular aspects of Obamacare. It is also the most likely explanation for huge premium increases in plans for individuals not on employer group policies. Persons employed by companies with insurance plans for their employees, usually called group plans, routinely accept all eligible employees, regardless of ...

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What does a modern internal medicine intern do all day (and night)?  It turns out they spend 40% of their time at work using a computer, another 20% on other aspects of patient care that is not in the presence of the patient, 15% in educational activities, 5% on basic needs like walking around and eating, and only 12% in direct patient care. Direct patient care includes interviewing patients, examining ...

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Watchful waiting has become a term often thought of as an alternative to surgery, radiation, or other interventions for early stage prostate cancer. Watchful waiting is actually a viable option for many other conditions too. Most Mom’s know that tincture of time with watchful waiting lets their children have the opportunity to recover without intervention for many minor injuries and illnesses without exposing them to the risks associated with antibiotics or ...

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As a family physician I look forward to the next few years in practice with a sense of uncertainty.  One of biggest of these uncertainties is how to help meet the anticipated demand for primary care I expect.  A number of changes are coming that will alter the supply and demand equation for patients and primary care providers. These include significant projected population demographics, and others that are due to ...

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The price has been in lives.  The capture and killing of Osama bin Laden occurred without loss of any U.S. military lives.  It was hailed as a hugely successful special forces and intelligence operation. Still to believe that the operation was accomplished without the loss of life is both incorrect and naive. The lives lost have been those of polio vaccination workers murdered in the backlash against the use of ...

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I recently read a very good article in the New York Times about a patient found to have the classic incidentaloma, a small mass in the adrenal gland.  This is estimated to be seen in 4% of abdominal CT scans, and is rarely serious but typically leads to recommendations for additional testing and follow up CT scans to assure that it is not either a metastatic cancer from ...

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For as long as I can remember I have tended to develop a bad cough nearly every time I get sick in the cold and flu season. I’m not sure if I have a minor tendency to bronchospasm or if my years of passive smoke exposure as a child somehow damaged my lungs. Who knows, but I seem to have the tendency for every URI become a lingering brohchitic cough. In ...

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Sports fans have heard a lot about football players with Lisfranc injuries recently. Maurice Drew-Jones, running back for the Jacksonville Jaguars and Santonio Holmes, receiver for the New York Jets, have been in the news.  Matt Schuab, QB for the Houston Texans missed last  season from a Lisfranc injury. Many of you may know that a Lisfranc injury is a type of foot injury and that it can sometimes be very serious ...

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Moving from paper death certificates to an online process called the Washington State Electronic Death Registry System, or EDRS. Sounds like a simple 21st century process that should make the process of completing a death certificate faster and easier right?  Oh, the government designed the system.  Oops. I’ve been so frustrated by the unintended consequences of a new state governmental process for completing death certificates. Beginning in early 2012 Washington state started ...

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Linzess is a new drug that received FDA approval by Forest Laboratories for use in irritable bowel syndrome (IBS) with constipation and in chronic idiopathic constipation.  It got my attention because of its biochemistry. Learning about the mechanism of action of new drugs like Linzess reminds me how much more is understood about the molecular biological level of physiologic function of the human body than when I was in med school.  Linzess ...

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E-cigarettes seem to be a very popular product these days, so I thought I’d do a bit of research to figure out what the heck an e-cigarette is and to try to answer the question, “Are e-cigarettes safe?” It appears that the primary reason people use e-cigarettes is to avoid smoking, either as a way to get their nicotine in areas where smoking is prohibited, or as a means to try ...

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I am acutely aware of the obesity epidemic in this country.  I’ve posted previously about how obesity may have surpassed smoking as the #1 preventabe cause of death in the U.S.  Still the FDA approval today of Belviq, a sertonergic drug that brings back memories of Fen-Phen, Meridia and Redux (dexfenfluoramine) over concerns with their association with valvular heart disease, pulmonary hypertension ...

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It seems like every day in the office I see at least one man concerned about testosterone deficiency.  If you look at the symptoms of testosterone deficiency most of us have one or more of these symptoms at least some of the time.  Fatigue, depression, weight gain, lack of energy, reduced sex drive, loss of physical strength, and moodiness are all described as symptoms typical of testosterone deficiency. Making the ...

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Hydrocodone as it is currently prescribed in the U.S. is a schedule 3 drug.  The FDA puts rules and regulations on the prescribing of medications that have a significant potential for abuse, diversion or addiction, and the lower the schedule number, the more the restrictions. Schedule 1 drugs are illegal in the U. S.  They are deemed to have no legitimate medical purpose.  Examples are heroin, LDS, methamphetamine, marijuana (strange but ...

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Does muscle weakness improve after disc surgery? For an NFL fan arguably the best thing that could happen to your team is to sign Peyton Manning and have him perform at or near his pre-injury level.  The corollary is that one of the worst things to happen to your team would be to take a huge salary cap hit to get a Peyton Manning with such weak throwing arm that even ...

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Most OTC products, excepting some medical equipment like crutches and diabetic supplies, now cannot be purchased with flexible spending account dollars without a physician prescription. One of my partners asked last week how I am dealing with this issue.  He has had several patients ask for a long list of prescriptions for OTC products so that they can use their FSP to pay for these things with pre-tax dollars.  This puts ...

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