The 60+ minute new pt visit

[PMR 4 MSK]

New Pt today - 32 yo f, on Medicare, pain in the:
head - migraines per pt.
neck - multiple HNPs on MRI, no trauma
shoulders - benign xrays, "arthritis" per pt.
forearms.
hands - pain, numbness and tingling. "Arthritis" per pt. BUE EMG normal, xrays normal.
upper back - xrays normal
lumbar - L5-S1 DDD on xray and MRI
hips - normal xrays
knees - normal xray, small meniscal tear on one side, chondromalacia patella on the other on MRI
feet - "arthritis" per pt. No films available.

Yeah, bascially pandynia.

Other Dx's to add to the pleasure - Fibromyalgia, Bipolar, interstitial cystitis, endometriosis, pericarditis (no interventions), asthma. Rheumatology w/u neg for RA, lupus, etc.

Currently on:
Norco 10 mg 3 pills TID, up recently from 2 TID.
Flexeril 10 mg TID
Topomax
Gabapentin 600 mg BID
Lamictal
Frova
Imitrex
Seroquel
Cymbalta
Phentermine
Prempro
Albuterol
Flomax (why?)

Intolerence to Lyrica (sleepy) and Geodon (paranoid)

Exam was as you'd imagine - everything hurts, everything was tender, pain with all joint ROM, all spine ROM. Affect near flat to anxious.

Last pain doc did the following from what I can find in the records:
LESI x 4
LFJI 5 level bilat x 2
SIJI bilat x 3
CESI x 1
B hip inj x 1 each
B subacromial inj x 1 each
B hip bursa inj x 1 each
B knee inj x 2 right, 3 left

Pt reports none of the injections helped for more than a few days.

PT 3 times over the past 3 years "made me worse every time"

Saw spine surgeon, per her report, he wanted to fuse her from T1 to S1. Per his report, he discussed L3-5 lami +/- fusion, C5-7 ACDF, but said he would not do it until she lost weight (BMI was about 46 at that time last year, now around 35).

Here's what I told the pt:
No more injections - they are not going to help you.
Get off the opioids - they are making you worse and are relatively contraindicated for Migranes and Fibro.
Either increase the gabapentin to 1800 mg/day or try going off it.
I don't have any other medication to add in.
Get off the couch and get aerobic exercise. Working towards 30 min per day. Long discussion on that.
Get into counseling. Long discussion on that.

For all that, I'll get maybe about $150 - 200 from Medicare, while the last pain doc probably made $25K plus off her, considering the procedures and MRIs. And in all likelihood she'll just go to someone else in town, who will give her the pills she wants, while she submits to more injections and more tests.

Doing the right thing just doesn't pay. This patient is why our system is going broke.

---

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[stim4u]

New Pt today - 32 yo f, on Medicare, pain in the:
head - migraines per pt.
neck - multiple HNPs on MRI, no trauma
shoulders - benign xrays, "arthritis" per pt.
forearms.
hands - pain, numbness and tingling. "Arthritis" per pt. BUE EMG normal, xrays normal.
upper back - xrays normal
lumbar - L5-S1 DDD on xray and MRI
hips - normal xrays
knees - normal xray, small meniscal tear on one side, chondromalacia patella on the other on MRI
feet - "arthritis" per pt. No films available.

Yeah, bascially pandynia.


Other Dx's to add to the pleasure - Fibromyalgia, Bipolar, interstitial cystitis, endometriosis, pericarditis (no interventions), asthma. Rheumatology w/u neg for RA, lupus, etc.

Currently on:
Norco 10 mg 3 pills TID, up recently from 2 TID.
Flexeril 10 mg TID
Topomax
Gabapentin 600 mg BID
Lamictal
Frova
Imitrex
Seroquel
Cymbalta
Phentermine
Prempro
Albuterol
Flomax (why?)

Intolerence to Lyrica (sleepy) and Geodon (paranoid)

Exam was as you'd imagine - everything hurts, everything was tender, pain with all joint ROM, all spine ROM. Affect near flat to anxious.

Last pain doc did the following from what I can find in the records:
LESI x 4
LFJI 5 level bilat x 2
SIJI bilat x 3
CESI x 1
B hip inj x 1 each
B subacromial inj x 1 each
B hip bursa inj x 1 each
B knee inj x 2 right, 3 left

Pt reports none of the injections helped for more than a few days.

PT 3 times over the past 3 years "made me worse every time"

Saw spine surgeon, per her report, he wanted to fuse her from T1 to S1. Per his report, he discussed L3-5 lami +/- fusion, C5-7 ACDF, but said he would not do it until she lost weight (BMI was about 46 at that time last year, now around 35).

Here's what I told the pt:
No more injections - they are not going to help you.
Get off the opioids - they are making you worse and are relatively contraindicated for Migranes and Fibro.
Either increase the gabapentin to 1800 mg/day or try going off it.
I don't have any other medication to add in.
Get off the couch and get aerobic exercise. Working towards 30 min per day. Long discussion on that.
Get into counseling. Long discussion on that.

For all that, I'll get maybe about $150 - 200 from Medicare, while the last pain doc probably made $25K plus off her, considering the procedures and MRIs. And in all likelihood she'll just go to someone else in town, who will give her the pills she wants, while she submits to more injections and more tests.

Doing the right thing just doesn't pay. This patient is why our system is going broke.

Or you can stop seeing 32yo SSD Medicare patients..... these patients milk the system everywhere in this country. Called entitlements. 90% are looking for drugs.

 

[Tenesma]

and occasionally they have a seronegative arthropathy that needs to be managed with daily hot-baths and gentle eucalyptus foot soaks...

 

[PMR 4 MSK]

I should mention that this patient is also the first one sent by a local PCP who I visitied a month or so ago marketing my practice. I'm guessing this is the classic "test the waters" patient, where they find the most difficult patient they have, and , "Aha, lemme send this one to that guy I just met and see what he can do..."

 

[Mister Mxyzptlk]

It's amazing what can happen if you stop the Seroquel.

IMHO, Seroquel is a major cause of mental illness. I had a patient with CHAOS (Chronic Hurts All Over Syndrome). Her affect was off the wall - crying, etc. I sent her to psych to see if he could get her off the Seroquel the PCP started as a sleep aid (WHY do they do this?). He changed her meds and she called and told me all her pain was gone.

 

[jettavr6]

My .02cents from a psychiatrists perspective -->

The medication regimen is a cluster f---

Cymbalta (Serotonin, Norepi)
Flexeril (basically a tricyclic -- Serotonin, dopamine, norepi)
Seroquel (Serotonin)
Phentermine (All the catecholamines)

If she hasn't had an episode of serotonin syndrome by now, then she's probably ok.

Next, she's prescribed Seroquel which stimulates appetite and phentermine to offset that?

PMRMSK --- excellent recommendations. Less is more in this patients case.

 

[Tenesma]

in my experience this cocktail occurs not because of psychiatric poor care, but rather because of poor communication between practitioners.... these patients typically see their PCP a gazillion times, and then a variety of other specialists including neurologists and rheumatologists who all offer something for the pain without realizing that patient is also getting psychiatric care... and none of those specialists ever cc the psychiatrist with what they are doing..

in fact, this patient probably got
Topamax and Imitrex from one neurologist
Lamictal and Frova from another neurologist
Cymbalta and Flexeril from a rheumatologist...

jettavr6...thanks for your 2 cents, but you forgot the serotonin effects of frova/imitrex...

 

[SSdoc33]

in my experience this cocktail occurs not because of psychiatric poor care, but rather because of poor communication between practitioners

bingo.

this is why i really try to avoid prescribing ANYTHING. if the patients dont know what they are on, how is the myriad of docs supposed to know?

 

[mid|ine]

Poly-pharmacy causes many more problems then it solves. Not even counting the narcotics, but seriously are patients better off on the normal slew of pain meds?

 

[Tenesma]

bingo.

this is why i really try to avoid prescribing ANYTHING. if the patients dont know what they are on, how is the myriad of docs supposed to know?

I am glad that when it comes to pain issues (as opposed to political views) we are on the same page

 

[specepic]

Has anyone actually seen true blue serotonin syndrome? I have not neither my local psych guy.

 

[Tenesma]

i have... hypertonic, hyper-reflexic, hyper-thermic - intubated - thankfully recovered within 3 days....

 

[knoxdoc]

How many of you avoid the combination of tramadol and SSRI meds because of this risk?

 

[jettavr6]

jettavr6...thanks for your 2 cents, but you forgot the serotonin effects of frova/imitrex...

Then it would have been 4 cents! Frova and Imitrex are more of prn type of medication. I have honestly never seen an untoward reaction with patients on Imitrex and an SSRI/SNRI, but that's not to say it can't happen.

In the few cases of serotonin syndrome which I have seen, they were all due to polypharmacy.

 

[bedrock]

How many of you avoid the combination of tramadol and SSRI meds because of this risk?

I second that question. I've never seen or heard of a problem with patients on only tramadol + SSRI (but no other psych meds).

Anybody seen a true serotonin issue with just those two meds?

 

[PinchandBurn]

I second that question. I've never seen or heard of a problem with patients on only tramadol + SSRI (but no other psych meds).

Anybody seen a true serotonin issue with just those two meds?

Obviously these are all "theoretical" risks, that the academics love to throw around.

I've seen plenty of patients on a TCA and Tramadol. Perhaps it's dose dependent. I've never seen patients that were on high doses of each. It was usually just a high dose of tramadol and a low dose of a TCA or vice versa.

 

[Tenesma]

the reaction i saw was tramadol, imipramine, celexa, cymbalta, alcohol, dehydration as set-up... so I agree poly-pharmacy...

the issue is that the pharmacy will call you and document every time you rx tramadol for a SSRI patient - and then if god forbid something happens, you look like an idiot...

and pinchandburn: not all TCAs are equally serotonergic

 

[hyperalgesia]

I avoid tramadol with SSRIs, mostly because I know I'd get fried if there were a problem.

I think we also have to acknowlege the patient's responsibility in CHAOS. Some people can't be helped. I just do my part to educate and tell them they don't have deficiencies in Norco and gabapentin and the rest of the CVS product line. Like a broken record, I tell them but I know that before they put their car in drive, they are wondering about what other molecule God forgot to put in their bodies.

 

[PMR 4 MSK]

How many of you avoid the combination of tramadol and SSRI meds because of this risk?

I try to avoid it, but will try it cautiously. I've never seen a problem with it. There is also the potentially increased seizure risk with them together, more so with SNRIs.

 

[facets]

I have seen seizures with Wellbutrin and tramadol

 

[specepic]

I am not convinced from the 2 examples above. One apparently involved alcohol issues and dehydration ( alcohol withdrawal?) Which provides too much in the way of confounding factors to blame on medications themselves. Someone else mentions a seizure on Wellbutrin and tramadol, how do we know this was serotonin syndrome and not a lowering of the seizure threshold, which we all know tramadol can do unto itself. I disagree with a poster above saying he will get "fried" by prescribing an SSRI plus tramadol ( from a medical legal perspective). I think about half the patients I see are on these 2 medications at some point. I discuss the risk and benefits with the patient and document that if that is a combination I'm going to pursue.

 

[Tenesma]

alcohol withdrawal/DTs are very different from a serotonin syndrome --- although I will agree that the criteria for serotonin syndrome are murky and could easily overlap with neuroleptic malignant syndrome or some weird drug toxicities.

i do prescribe tramadol in combination with other serotonin drugs -but document the risks and warn the patients...

 

[olafa]

so how would that market regimin work out in the long run- I mean if they kept sending patients like this it would totally drain you dry.

Could switch up the ssri/ST/NE mix by adding Savella. Seems to work in some patients.

New Pt today - 32 yo f, on Medicare, pain in the:
head - migraines per pt.
neck - multiple HNPs on MRI, no trauma
shoulders - benign xrays, "arthritis" per pt.
forearms.
hands - pain, numbness and tingling. "Arthritis" per pt. BUE EMG normal, xrays normal.
upper back - xrays normal
lumbar - L5-S1 DDD on xray and MRI
hips - normal xrays
knees - normal xray, small meniscal tear on one side, chondromalacia patella on the other on MRI
feet - "arthritis" per pt. No films available.

Yeah, bascially pandynia.

Other Dx's to add to the pleasure - Fibromyalgia, Bipolar, interstitial cystitis, endometriosis, pericarditis (no interventions), asthma. Rheumatology w/u neg for RA, lupus, etc.

Currently on:
Norco 10 mg 3 pills TID, up recently from 2 TID.
Flexeril 10 mg TID
Topomax
Gabapentin 600 mg BID
Lamictal
Frova
Imitrex
Seroquel
Cymbalta
Phentermine
Prempro
Albuterol
Flomax (why?)

Intolerence to Lyrica (sleepy) and Geodon (paranoid)

Exam was as you'd imagine - everything hurts, everything was tender, pain with all joint ROM, all spine ROM. Affect near flat to anxious.

Last pain doc did the following from what I can find in the records:
LESI x 4
LFJI 5 level bilat x 2
SIJI bilat x 3
CESI x 1
B hip inj x 1 each
B subacromial inj x 1 each
B hip bursa inj x 1 each
B knee inj x 2 right, 3 left

Pt reports none of the injections helped for more than a few days.

PT 3 times over the past 3 years "made me worse every time"

Saw spine surgeon, per her report, he wanted to fuse her from T1 to S1. Per his report, he discussed L3-5 lami +/- fusion, C5-7 ACDF, but said he would not do it until she lost weight (BMI was about 46 at that time last year, now around 35).

Here's what I told the pt:
No more injections - they are not going to help you.
Get off the opioids - they are making you worse and are relatively contraindicated for Migranes and Fibro.
Either increase the gabapentin to 1800 mg/day or try going off it.
I don't have any other medication to add in.
Get off the couch and get aerobic exercise. Working towards 30 min per day. Long discussion on that.
Get into counseling. Long discussion on that.

For all that, I'll get maybe about $150 - 200 from Medicare, while the last pain doc probably made $25K plus off her, considering the procedures and MRIs. And in all likelihood she'll just go to someone else in town, who will give her the pills she wants, while she submits to more injections and more tests.

Doing the right thing just doesn't pay. This patient is why our system is going broke.

 

[ParaVert]

I also use serotonergic drugs in combination. To the contrary of the discussion, I find it very useful. Most "normal" doses of SSRIs, SNRIs, tramadol, flexeril, etc are not all that potent. I think I would be more hesitiant if patient was on something wild like an MAOI or had a potential for amphetamine/ecstacy/PCP/ketamine abuse.

Psychs routinely use these drugs in combination.
Adderal for ADHD
Lexapro for MDD/GAD
Trazodone / Remeron for sleep
Atypical antipsychotic for "neural glue"

I'm much more concerned that a patient will simply abuse the narcotic I prescribe than to suffer serious morbidity from a rare (but potentially harmful) syndrome.


SS is EXCEEDINGLY RARE.


That being said, the patient above is nuts. Wouldn't let her butt warm the exam table before she got the, "Sorry I can't help you. I'm just a simple small-town doctor. Perhaps you'd be better served by seeing that smart doctor in <big city name> at the University, or better yet - the one that is always advertizing on the TV."

 

[PMR 4 MSK]

Psychs routinely use these drugs in combination.
Adderal for ADHD
Lexapro for MDD/GAD
Trazodone / Remeron for sleep
Atypical antipsychotic for "neural glue"

Don't forget that every Adderal Rx needs a Xanax or Valium Rx to balance it out...

 

[mid|ine]

Could switch up the ssri/ST/NE mix by adding Savella. Seems to work in some patients.

Everything and anything work in "some patients". The number needed to treat in practice for most of these meds, even the standards, seems much higher then reported in the literature and side effects more prominent. I really try to avoid my patients being on these cocktails.

 

[hyperalgesia]

Don't forget that every Adderal Rx needs a Xanax or Valium Rx to balance it out...

I had two patients last week referred by different providers, who said they were taking Ritalin to counteract the sleepiness caused by the narcotic. WTF? This just gets better every day...

 

[ghost dog]

New Pt today - 32 yo f, on Medicare, pain in the:
head - migraines per pt.
neck - multiple HNPs on MRI, no trauma
shoulders - benign xrays, "arthritis" per pt.
forearms.
hands - pain, numbness and tingling. "Arthritis" per pt. BUE EMG normal, xrays normal.
upper back - xrays normal
lumbar - L5-S1 DDD on xray and MRI
hips - normal xrays
knees - normal xray, small meniscal tear on one side, chondromalacia patella on the other on MRI
feet - "arthritis" per pt. No films available.

Yeah, bascially pandynia.

Other Dx's to add to the pleasure - Fibromyalgia, Bipolar, interstitial cystitis, endometriosis, pericarditis (no interventions), asthma. Rheumatology w/u neg for RA, lupus, etc.

Currently on:
Norco 10 mg 3 pills TID, up recently from 2 TID.
Flexeril 10 mg TID
Topomax
Gabapentin 600 mg BID
Lamictal
Frova
Imitrex
Seroquel
Cymbalta
Phentermine
Prempro
Albuterol
Flomax (why?)

Intolerence to Lyrica (sleepy) and Geodon (paranoid)

Exam was as you'd imagine - everything hurts, everything was tender, pain with all joint ROM, all spine ROM. Affect near flat to anxious.

Last pain doc did the following from what I can find in the records:
LESI x 4
LFJI 5 level bilat x 2
SIJI bilat x 3
CESI x 1
B hip inj x 1 each
B subacromial inj x 1 each
B hip bursa inj x 1 each
B knee inj x 2 right, 3 left

Pt reports none of the injections helped for more than a few days.

PT 3 times over the past 3 years "made me worse every time"

Saw spine surgeon, per her report, he wanted to fuse her from T1 to S1. Per his report, he discussed L3-5 lami +/- fusion, C5-7 ACDF, but said he would not do it until she lost weight (BMI was about 46 at that time last year, now around 35).

Here's what I told the pt:
No more injections - they are not going to help you.
Get off the opioids - they are making you worse and are relatively contraindicated for Migranes and Fibro.
Either increase the gabapentin to 1800 mg/day or try going off it.
I don't have any other medication to add in.
Get off the couch and get aerobic exercise. Working towards 30 min per day. Long discussion on that.
Get into counseling. Long discussion on that.

For all that, I'll get maybe about $150 - 200 from Medicare, while the last pain doc probably made $25K plus off her, considering the procedures and MRIs. And in all likelihood she'll just go to someone else in town, who will give her the pills she wants, while she submits to more injections and more tests.

Doing the right thing just doesn't pay. This patient is why our system is going broke.

I don't know how it works in the U.S., but in Canadia we are lucky to have
a few docs who run chronic pain management groups. Under the socialized medicine plan (shudder goes through the American crowd), all comers are able to be seen via these groups.

I find that some of the Fibromyalgia crowd respond to this sort of supervised enviroment (i.e. mindful meditation and Tai chi exercise).

As an aside: I absolutely HATE IT when the referring doc sends me a patient on a truckload of daily short acting narcs along with a boat load of benzos. Why do family MDs continue pts on chronic benzos? Worse than useless.

Like Nancy Reagan said: Just say no.

 

[Mattchiavelli]

I had two patients last week referred by different providers, who said they were taking Ritalin to counteract the sleepiness caused by the narcotic. WTF? This just gets better every day...

Was your patient Judy Garland or Neely O'Hara? BTW the original med list was a hot ass mess, I can tell that and I'm just an intern. What I've been most shocked by in my training is the hesitancy to stop drugs someone else started, even when what you're treating may be a well known side effect of a specific drug or drug combo, because "someone started it and it must have been for a good reason." Med school is so good at teaching people to miss the forest for the trees...

I'd wager to bet that the PT made her feel worse because she isn't used to the concept that increased physical activity after being sedentary WILL be painful and that's normal and expected... I wager to bet she wasn't getting a lot of activity with that med combo + CHAOS, however it's surprising she dropped all that weight in the year- would be curious to know how she did it.

 

[ghost dog]

Was your patient Judy Garland or Neely O'Hara? BTW the original med list was a hot ass mess, I can tell that and I'm just an intern. What I've been most shocked by in my training is the hesitancy to stop drugs someone else started, even when what you're treating may be a well known side effect of a specific drug or drug combo, because "someone started it and it must have been for a good reason." Med school is so good at teaching people to miss the forest for the trees...

I'd wager to bet that the PT made her feel worse because she isn't used to the concept that increased physical activity after being sedentary WILL be painful and that's normal and expected... I wager to bet she wasn't getting a lot of activity with that med combo + CHAOS, however it's surprising she dropped all that weight in the year- would be curious to know how she did it.

On a sort of related note (but not really): I was reviewing a treatment plan from a chiropractor which read:

"....short and long-term prognoses were good if she continued scheduled visits, home exercises, and avoidance of aggravating factors".

This being after an inciting injury that occurred more than 1 1/2 years ago, and the patient had received more than 18 months of physio !!!

Way to encourage pain focused / pain amplification behavior buddy.

Note to chiros: patients are not ATM machines.

What a *******.

 

[Ligament]

Flomax for the urinary retention issues caused by the opioids and psych meds.

 

[PMR 4 MSK]

Flomax for the urinary retention issues caused by the opioids and psych meds.

That would make sense.