Thursday, September 26, 2013

Marijuana

Me: "Do you drink alcohol?"

Her: "Yes, but not since I found out I was pregnant."

Me: "Do you smoke?"

Her: "No."

Me: "Do you use any other drugs?"

Her: "Well, I use marijuana."

Me: "Do you have any plans to quit?"

Her: "I want to, you know, for the baby, but I haven't been able to yet."

Me: "What's holding you back?"

Her: "I'm around a lot of people who do it, so it's always there."

Husband: "All my family members have marijuana cards. Mine is for back pain. It's a big part of my life."

Me: "Did you read the information the office provided about marijuana use during pregnancy?"

Husband: "Yes, and I think they need to do more studies. We both used marijuana for the whole time she was pregnant for the first two girls and there hasn't been a problem with them. Ask them if you think there's a problem. They do well in school. They are geniuses."

Me: "I understand that, but I wouldn't be doing my job if I didn't tell you that we have no idea what long-term effects marijuana may have on your kids. Also that it is illegal for her to use marijuana acquired on your license."

Husband: "So...can you give us a marijuana license?"

Sunday, September 22, 2013

Nephrology

When I first started my nephrology (kidneys) rotation, I was just coming off of surgery. I really enjoyed doing things with my hands and I thought that nephrology would be boring in comparison. Turns out, it's just as easy to kill a nephrology patient as it is a surgery patient, it just takes a few years longer to do it. Nephrology takes quite a bit of abstract reasoning. It's a mental juggle keeping fluid status, electrolytes, drugs, heart function, kidney function,  acid/base status, diabetes, and high blood pressure in the air all at the same time. My preceptor calls it 'glorified' internal medicine, but I haven't seen the glory yet.

Most of our patients have chronic kidney disease that results in gradual decline of kidney function from either high blood pressure or diabetes. A few have acute kidney injuries from drug reactions, shock leading to decreased blood flow to kidneys, or some unexplained process. Since I haven't had any other internal medicine rotations yet, starting off with a specialty of IM means I have a lot of learning to do all at once.

I enjoyed that each patient was different despite having the same diagnosis of end kidney failure. Some would respond well to one kind of medication while another would not, or would have a bad reaction. For one Hispanic patient using a drug called spironolactone was indicated, and his wife translated the possible side effects. One of the possible side effects is growth of breast tissue in men. His wife translated it as a promise that he'd get big pec muscles. I corrected her and when he understood, his eyes got as big as his entire face and opted for a drug of the same class that cost $350 per month. I decided that spironolactone is going to be my go to drug so I can see that face again.

Working as a specialist also means that oddball cases come our way to diagnose. The following case was pending some rare and expensive lab work and imaging to diagnose when I left.

-A thirty year-old male is referred to the clinic for a four month history of gross hematuria. It started abruptly one morning and he can't think of any change in diet, habit, hobby, or exposure that might have caused it. He does have constant pain in his lower back at T11-L2 that wraps around to the front of the abdomen. Nothing makes the pain worse, but he has been taking NSAIDs and tramadol for chronic back pain. Vitals are stable and physical exam is unremarkable. Urinalysis shows 50 RBCs/HPF, no WBCs, or casts. CBC does not demonstrate anemia or leukocytosis. ANA/ANCA are negative. Ultrasound and CT scan do not demonstrate stones, pyelonephritis, or hydronephrosis.-