Agraphia Medical Tragicomedy

16Nov/05Off

Ulcers

I've been in the worst pain of my life for the past few days. I think it's because I've been sitting down so much in class (and, lets be real here... probably also because I haven't exercised in a month or so... been waiting for the iPod to come back. Any excuse works, hey?), but I have had sciatic radicular pain (translate: pain that shoots down the path of the nerve) for the last couple of weeks. It wakes me up at night it's so bad. I can't sit through a full class, have to stand in the back... it's terrible. I saw an orthopedic surgeon who told me that it was nothing to really worry about, and he sent me to PT. An X-ray showed that my secondary lumbar curvature is missing due to lower back spasms because of the pain, but apparently that isn't particularly serious.

Unfortunately the soonest the PT place could get me in is December 1st, and since the treatment course is 3x/week for 3 weeks, that means that I'll be in PT during finals. Which I suppose isn't that bad of a thing to have happen- maybe it'll even relax me during finals- but I'm worried that I won't be able to sit through class up until that point. I've even started wondering if it's the way that I sleep (I sleep on my side- maybe it aggravates it) that's causing the pain. Anyway, it has to stop. I can't make it through class, or sit down to study, without intense shooting pain from my butt down through my knee.

OK, enough whining about me. I got into family clinic tonight!

Family clinic is one of the CUP opportunities we have at U of A (Committment to Underserved People). It's basically a free clinic, manned by the medical students, that is a full-service doctor's visit. We draw blood, perform physicals and medical interviews, diagnose, prescribe, and (hopefully) treat patients who can't afford care elsewhere. My first CUP clinic was the Sight Savers glaucoma one that I did a few weeks ago.

It also moves very slowly. We saw one patient in 2 hours, though we were scheduled for two- our first was a no-show. Anywho, clinic was great. We saw a woman who had come in the week before for right upper quadrant epigastric pain for a follow up visit.

Allow me to proseletyze for one second. Hah.... give someone a tiny bit of knowledge and they want to tell EVERYBODY about it. Anyhow, one of the reasons that belly pain is difficult to treat is that there are, in essence, two ways that you feel pain in your body. One is very sharp and localized (ow, I pinched myself about 2 inches above my belly button), and the other is dull and diffuse (ow, I have [insert malady here] and it's causing me belly pain). One of the things we know is that certain internal organs refer pain to different areas, so when someone comes in complaining of right upper quadrant stomach pain- as opposed to right lower quadrant stomach pain- it narrows things down a bit.

So, our woman was getting worked up against several differential diagnoses. She could have ulcers, gastritis, hepatitis (bad!), gallstones, fatty liver, etc. etc. etc.

Now here's where the uneducated medical student in me comes in. I said that she had come in for a follow up, which means we already had a ton of labs on her. CBC (complete blood count, gives us an idea of your blood composition), BMP (basic metabolic profile, which gives us an idea of your basic body chemistry), and a test for H. Pylori, which is the bacteria that causes stomach ulcers. Most of her labs were completely normal, with 2 exceptions. She was ever so slightly off on her ALT levels, which indicated possible liver damage (possible hepatitis, but only if she's truthful about never drinking... your ALT levels can be raised after a hefty night at the bar as well as for chronic liver damage), but the glaring exception was a hefty antibody titer against H. Pylori. What this means is that either currently or sometime in the past, she has been infected with the bacteria that cause painful peptic ulcers.

A maxim has stuck with me for a while now- "if you hear hoofprints in Texas, don't go thinking zebras". Why? Because it's probably just a horse. Now to me, this positive antibody titer means that her pain is probably from stomach ulcers. The ulcers are my horse. Gastritis (a catch-all for a host of other stomach problems) is my zebra. For that matter, hepatitis is my bloody unicorn.

You may sense that I'm leading somewhere here. We didn't end up diagnosing her with ulcers, nor did we send her home with antibiotics to treat the bacteria causing them. The attending (a family physician in town who generously donates his or her time for the night) even got a GI consulation from a doc on call in the hospital, explained the case, and was told by the GI doc to put her on antibiotics for ulcers.

What did we do? Sent her home and told her to take Prilosec OTC for 2 months, then come back and see us. Why? Because she had been taking aspirin for the pain, which is considered an NSAID (non-steroidal anti-inflammatory drug). Aspirin, Ibuprofen (which I happen to be popping like candy for my sciatic pain) or Aleve can cause thinning of the stomach lining and therefore worsening of gastritis. If she were to have had ulcers in the past, she may still have a positive titer to H. Pylori, and the Aspirin, though she thought it was helping the pain, was actually making it worse.

Thing is, I still think I'm right. That's not to say that she won't come in 2 months from now, still in pain due to her ulcers, and I won't be vindicated. But, that being said, the treatment course for ulcers runs about $100... and that's $100 that she probably doesn't have. Killer thing is, the Prilosec will probably run her $30 or $40 (I'm guessing blindly here) for the next 2 months... and then she'll have to shell out the $100 for the antibiotics anyway. Sum total, $130, and 2 months more of pain than she needed to have.

Anyhow, it was interesting to see that already I have these ideas of what should happen. I don't feel like the attending or my 4th year did the right thing by her. They treated the symptom, not the disease (this, of course, coming from a 1st year medical student with 3 months of schooling, who has never even been to this clinic before). Ulcers keep recurring, too, unless you treat the bacteria (if you're still reading, check this story out- the guys who discovered that ulcers were actually caused by bacteria infected themselves and then cured their "ulcers" with antibiotics... they got the Nobel recently).

So, that's my story. Sorry it's so long, but it's 3:30 AM, I'm in a tremendous amount of sciatic pain, and frankly, I've got nothing else to do. Wonder if anybody actually is interested in what I have to say . You know, frankly, I don't care. I think it'll be fun to look back on this entry as a 4th year and say "hah, hah... I thought I totally knew what I was talking about with that ulcer patient... those are the clinical hallmarks of Hep B. And I called it a unicorn..."

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