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Re: WAY overly complex
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Re: WAY overly complex - March 14, 2006 9:57:00 PM
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Randy Dixon
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SJ,
I didn't catch the question. This guy has diabetes though right? and he's drinking a six pack a night?
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Re: WAY overly complex - March 15, 2006 1:19:00 AM
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SJBird55
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From: Michigan
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No diabetes in his history...
The question was - given the info I've provided, any thoughts?
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Re: WAY overly complex - March 16, 2006 12:23:00 AM
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Randy Dixon
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Diabetes?
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Re: WAY overly complex - March 17, 2006 1:39:00 AM
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Sebastian Asselbergs
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even if it is diabetes - first a comprehensive review WITH the patient of all the systems' complexities is needed. HE needs to see in a concise manner, what he expects the professionals to work with....and fix... Then a discussion about expectations and goals. Can normal arm and leg function be expected? And yet, he does NOT want to work? Why not?
Furthermore, I think he can get started with gentle isometrics about the neck and rest of spine, work in a pool and start of some easy cardio. It is not likely that a "single" system is "at fault" here - such a complex mix of so many dysregulated systems.
I have the feeling I would step back and tell the guy that we are at risk of getting lost in the forest of complexity, and that we were going to start with some active therapy, some gentle progressive cardio, some ergonomic/ADL suggestions, and that we would spend a lot of time with education on the aspect of human function and neurology.
But hey, that's me....
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Mundi vult decipi
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Re: WAY overly complex - March 17, 2006 2:34:00 AM
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SJBird55
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Good comments, Bas. I probably spent a good 25 minutes on the medical systems review alone. I also spent a good 20 minutes on just the subjective information form (which isn't attached here).
The patient was concerned about whether normal arm and leg function could occur. (He posed the same question as you, Bas.) I have questions in regard to that also... I requested his operative report and toward the end of it, after the spondylolithesis was reduced in the cervical spine, there is one sentence that indicates that there were no changes in nerve function. (I don't have the report here, so I really don't know what test was performed operatively to determine nerve integrity.) From that report, I have questions of what was the nerve function PRIOR to surgery so I could be more aware of what "no changes" means. I highly doubt that he will have normal arm and leg function - he has a history of spina bifida and he's never had "normal" leg function. The postive lower extremity surgical results are that he isn't falling any longer because of his legs buckling from under him. I have no idea on his upper extremity function - I don't know to what degree nerves were damaged, but he has a lot of deficits in his upper extremities - from both a view of required scapular stabilization with open chain movement and also overall functional strength.
He doesn't want to go back to work for probably a couple of reasons.... he knows that his physical function has substantially declined and he's a male with an ego. He's also in pain quite a bit and always has been secondary to the spina bifida (according to him). I also think that the realization that the degree that he's declined is an embarrassment for him too. My impression is that he's just sick and tired of the crappy body he was dealt. And you know, I really don't blame him.
He already does aquatic exercises independently (has for years).
Well, I asked him if he wanted a new body. LOL I told him that I was pretty sure that there were extra body parts in the closet, but of course no guarantees as to the degree of which they would function or whether they would be better than his current status. LOL
I highlighted my concerns with him regarding the symptoms that I felt should be addressed. I did ask him what he proposed that I do about all the symptoms he just told me about and the fact that his specialists were not aware of all of them... and that some of them were new. He wanted me to communicate to all of his specialists... So... I typed up a generic letter with like 7 or 8 physician Cc'd at the bottom and faxed it off. (What's the point of looking at a medical systems review if no one does anything about it?)
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Re: WAY overly complex - March 17, 2006 4:07:00 PM
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srcase
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From: Michigan
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SJ,
I'll admit I skimmed this thread because my tired brain doesn't want to think anymore. I think you did the right thing trying to alert his doctors to all these new symptoms. Seems like he needs a thorough medical evaluation. One thing that pops into my head is thyroid disease...can account for a lot of his symptoms. Don't narcotics cause constipation? And the drinking could be causing the increased urination too. Maybe part of the problem is that he has too many doctors and not enough communication between them. Is there one primary doc that is managing him and communicating with the others??
Sarah
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Re: WAY overly complex - March 18, 2006 3:28:00 AM
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SJBird55
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From: Michigan
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Sarah, I believe that was one of my points... what should we do as PTs when we get a guy that is definitely complex? Our medical system here in the states kind of sucks. The primary care physician had no idea what psychiatrist he was seeing (and the patient told me who he was seeing and when the primary care physician referred him to the psychiatrist). Meaning... the primary care physician had no consultation notes or any information in the chart that the patient WAS referred to a psychiatrist and DID see a psychiatrist. What's up with that? Why isn't there any communication between any of the involved physicians? And, the biggest bummer - how come there weren't any clinical notes in his medical chart - there wasn't even any consultation notes from the clinical psychologist he sees. Obviously a definite lack of communication to the primary care physician. Lesson learned too though, is that as we as a profession move forward and become really "autonomous," we don't and shouldn't lose the characteristic of communication that we currently have. Direct access or not, the appropriate thing to do will be to always send off either an eval or a consultation note to the primary care physician.
I can't answer your questions, Sarah... I'm not a physician. LOL I am hoping that through faxing a detailed letter and his medical systems review (along with a written authorization sheet to alleviate the HIPPA excuse) that maybe someone will delve into his situation and figure what's what.
I have a lot of questions myself with this particular patient.
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Re: WAY overly complex - March 18, 2006 10:10:00 AM
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Dr.Wagner
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SJ, the patient is an obvious mess with symptoms that span a wide range of disease pathologies.
Alcoholism and narcotic dependence is a HUGE issue with this gentleman. Which of course brings depression DIRECTLY into the picture.
Until those issues are directly dealt with during an intervention, he simply will spiral out of control Obviously there is hope for him, as he still attends PT.
Diabetes is always a problem, but one would have to wonder, if he controls the alcohol use would the some of the symptoms go away?!
To be quite honest, this sounds like every 3rd patient I see in the ER.
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Re: WAY overly complex - March 18, 2006 3:05:00 PM
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SJBird55
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From: Michigan
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He just started PT... he's actually not that difficult to personally deal with, it's just all those other issues.
Off work, no return to work date, smoking history, CA history, narcotics, alcoholism, narcotics, depression, spina bifida...
The biggest question I have is with all the factors stacked against me and my interventions, will he even make any gains? When should I start potentially seeing improvement? When will he reach a plateau? But... I do know that after surgical procedures, we do have a window of time in normal patients to make good gains, so I'd hate to just not treat him based on all of his complexities AND that someone needs to get involved and handle each of the issues.
I honestly believe that he utilizes alcohol for 1) pain 2) coping strategy 3) to just take him away from the issues he has with the crappy body he's been dealt. Can you blame him?
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Re: WAY overly complex - March 19, 2006 1:45:00 PM
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Randy Dixon
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I think you bring up some good points. I saw in the paper the NEJM study that showed something like only 40% of Americans are getting adequate provision of healthcare, largely because of the problems you pointed out: fragmentation, reimbursement issues, lack of communication.
When I first began return to work patients 15 years ago I used to think that social worker and psychologist involvement was fuzzy wuzzy, hand holding, cry baby interventions. It didn't take me long to realize though that every case has a psychological aspect, one that usually has a controlling position over the physical one. Even though I'm not always impressed with psychologists and SW's I think now that they are a necessary part of every workhealth case.
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