Dear Doctor Dysphoric:

Very sad news. Well, mixed news. I have decided to leave the United States for part of my "sabbatical." I feel quite mixed about this upcoming leave of absence. IWhile I am quite excited about this trip and adventures ahead, I am sad that Dear Doctor Dysphoric has to fall by the wayside. I really wanted to discuss the recent case in the medical literature of 36 year old Jewish woman who was diagnosed with Pica after chomping on up to six packs of Tic Tacs and Halls within 36 hours. Perhaps we can address this case and diagnosis and treatment of Pica before I leave.

There is a possibility that Dr. D might start a different kind of blog while away. My publicists will post the blog address here, if and when this project is realized. Thank you all for your insightful medical questions over the last month.

Dear Doctor Dysphoric:

In the comments on the last post, you said "don't get sick in July." What are you talking about?

--Worried I may get sick in July


Dear Worried--

"Don't get sick in July" is a joke in the academic medical community. Not a very funny joke, actually. The academic medical calendar generally begins in July. Medical students, Housestaff (interns and residents), and new faculty are promoted. Former junior medical students become senior medical students. former senior medical students become new interns, former interns become new first year residents, and so on and so on. The upshot is that nobody knows how to do their new job. So we warn our loved ones not to get sick until August (or September, even better).

It is just a joke. Everybody in the hospital has supervision, of course. Except I am not supervising them because I am on leave. So maybe don't get sick in Northern Manhattan in July. Oh yes, it's OK, because Dr. Anhedonic will be there for you. If you need critical care, Dr. FEV1 will be there in the ICU. And Bugs and Drugs should be back from Poland any day now. Go ahead and get sick. We'll tell the medical students to stay away from Dear Doctor Dysphoric readers.

Both pics are courtesy of WHO. The pic on the left shows students and Housestaff on ward rounds in the hospital. On the right are medical students talking to women in the "women's ward."

Dear Doctor Dysphoric:

A friend of a friend told me about "Salvia," an herb that you can buy in tobacco shops. Apparently this plant has hallucinogenic effects when smoked. Have you heard of this ? Is it bad for you?

--Trippin' in Brooklyn


Dear Trippin':

I see many complications of substance abuse in my practice. However, up here in Washington Heights we generally stick to the more traditional drugs, such as cocaine, alcohol, and tobacco. I help patch up the organs they destroy (heart, liver, and lungs, respectively). I do not know anything about Saliva, or its effects when smoked. I am always up for learning about new substances for abuse, however. I will search the medical literature and get back to you.

--Doctor Dysphoric

I am sad because yesterday was my last day at work. Or maybe I am relieved becuase yesterday was my last day at work. I am confused becuase yesterday was my last day at work. I slept until 2:30 pm today.

I have been working in a Washington Heights medical clinic for many years. The clinic is over-burdened and chaotic. My patients are elderly immigrants; unemployed, disabled, addicted, screwed-over, and crazy people; and others who have Medicaid or no insurance at all. The majority of my patients are very sick. Most of them have advanced chronic disease. Many have obesity, hypertension, diabetes, congestive heart failure, liver failure, and chronic kidney disease. They shuttle between home, clinic, hospital, and nursing homes. I also take care of a handful of generally healthy working people who are either uninsured or underinsured.

Anyway, to make a long story short, I am burned out by the demands of this work. I was dysphoric before I even started this job, I must admit, but now I am exhausted and dysphoric. Consequently, I am taking a leave of absence from my job.

I saw more than 50 patients last week. I wrote hundreds of perscriptions. I gave them appointments with their new doctors and said my goodbyes. I told at least three patients that they do not qualify for motorized wheelchairs. I wrote my final dozen "medical exemption" letters for jury duty. I renewed home care services and ordered adult diapers, walkers, and canes.

When I told my patients that I am leaving, some burst into tears. A few seemed relieved to be rid of me. Many took it in stride, with comments such as: "everytime I get a decent doctor, they leave after a year or two." I got a lot of presents: earrings, self-help books, candy, make-up, paintings/artwork, an Organizer, a "summer suit," two blouses, skimpy nighties, perfume x many, a "Hello from the Dominican Republic" pen holder, sheets, a "yo amo Jesus" brooch, a faux diamond bracelet, flowers, and a bunch of heart-felt cards. I will miss my patients.

More on my leave of absence later. I mention all of this now as an excuse of why I have been neglecting your questions on Dear Doctor Dysphoric. I will get to them soon, I hope, as I have nothing but free time stretched out in the year ahead.

Dr D.

Dear Doctor Dysphoric:

Is it true that topical dog urine is an effective cure for warts?

--Don't like dermatologists


Dear Don't like Dermatologists:

I understand your dislike of dermatologists. I generally resent them too, because I can never get my patients in to see them. They also have a much better quality of life than we do; they make more money, and they do not have to deal with the stress, headaches, and paperwork that define the life of a primary care doctor. Have you noticed that gay men and heavily made-up women with high heels and fancy purses are overrepresented in the field of dermatology? This is just my observation, of course, and is not based on a scientific analysis of the dermatologic demographic.

Warts are caused by the Human Papilloma Virus (HPV). They are not dangerous. They often will go away without treatment, but it often takes months or even years. For patients who just cannot wait, dermatologists will gladly remove them in exchange for the bulk of your bank account. They freeze them off using liquid nitrogen, burn them off with a hand-held instrument, or cut them off with a blade. Another option is to repeatedly coat the warty surface with a liquid Salicylic Acid (e.g. Compound W).

That is all a tangent, of course, to distract you from the fact that I have no clue how to answer your question. Dog urine on warts? Are you kidding me? They don't teach us this kind of practicality in the fancy upper Manhattan College of Physicians and Surgeons that stole my youth. I suspect we lack well-designed clinical trials that look at this question. I may be able to find the answer in ancient apothecary texts or transcriptions of shaman oral histories. I will look. Until then, please leave your warts alone, or suck it up and go to the dermatologist.

--Doctor D

As you may have noticed, I authorized several Consultants to post on Dear Doctor Dysphoric. These lucky physicians will comment on questions that fall within their particular area of interest. Or maybe they will write about other things. Afterall, Dear Doctor Dysphoric is a space for overly-trained medical folk to discuss medicine with the non-medical public. The exact subject under discussion may or may not fall within the traditional boundaries of academic medicine.

Like Dysphoric, Dr. Anhedonic is a General Internist here in Upper Manhattan. He also has a large pile of knowledge in the areas of clinical epidemiology and evidence based medicine.

Dr. Bugs and Drugs is our lovely Infectious Disease consultant. She is smart and beautiful (not that this matters...). She is out of the country at the moment. We eagerly await her first post.

I plan to solicit the advice of several other subspecialists, including: renal (kidney), cardiac (heart), pulmonary (lung), hematology (blood) and GYN (down there) for your questions as needed. For now, however, I am fighting an ugly black cloud. Stand by.... I may cycle up again some day. Above pic is of my consultant team. Oh? No? No, it is actually "Four Doctors," John Singer Sargent 1905. Sir William Osler (legendary Hopkins bedside clinician and medical educator) is second from right.

The doctor is feeling too dysphoric to post today. If you would like to educate yourself about anhedonia, click here. Or if you don't like that one, clinic here, or here. If you do not have the energy to read all that text, and don't feel like doing anything else either, and everybody is driving you nuts (including yourself), welcome to my world.

William Hogarth "The Rake's Progress," 1735. (Inside the Bedlam Mental Hospital, London, England)

Dear Dr. Dysphoric:

I have a slightly unusual question. Today a llama bit me. It was lying on the ground and I decided to try to ride it. The bite almost proved fatal as the shock of being bitten and the speed with which the llama jumped up nearly caused me to fall off of the side of the mountain. My skin was not broken, but the area is red and swollen. Can you catch rabies from a llama? If so, what should I do about it?

--Not Ready For Rabies


Dear Not Ready For Rabies:

I have to admit that llama bites and rabies are not exactly routine here Washington Heights. In fact, rabies is actually rare now in the United States. But once acquired, rabies is one of the most fatal infectious diseases. According to a 2003 article from the Journal of Clinical Infectious Diseases, there is only one case report of a person who has developed rabies who has actually survived!

Rabies is caused by an RNA virus from the Rhabdoviridae family. The virus is transmitted by the saliva of an infected animal entering a wound. [There have been a few cases of transmission from non-bites, but these were in caves with zillions of infected bats flying around spitting down travelers throats, and other weird stories.] From the bite wound, the virus climbs into peripheral nerve cells. The nerve cells have tails ("axons") which stretch way up to the brain. The virus deposits itself in the brain, the brainstem, and the spinal cord. It eventually spreads via other nerves to the heart, salivary glands, and other organs. [The pic on the above right is the "negri bodies," or collection of virus particles, on a piece of brain tissue stained with H&E. Courtesy of CDC.]

Besides it's impressive fatality rate, rabies causes a horrific clinical syndrome. It has been immortalized in literature for hundreds of years, including the character Tea Cake in Zora Neale Hurston's classic There Eyes Were Watching God. Patients complain of hypersalivation and throat spasms, then become progressively hyperactive and generally nutso. This is topped off by the pathopneumonic hydrophobia (fear of water). Eventually the patient falls into a coma and dies. [The pic on the right is of a rabies patient who required physical restraints. Courtesy of CDC.]

There are two kinds of rabies prophylaxis: pre-exposure prophylaxis (vaccine) and post-exposure prophylaxis. Many travelers are counseled by their doctors to get the vaccine before going to countries where rabies is endemic. If you have not had the rabies vaccine, post-exposure prophylaxis (PEP) is your only option. PEP includes both "active" and "passive" immunization. Active immunization is five gigantic shots of the rabies vaccine into to the deltoid muscle, on days, 0,3,7,14, and 28 after exposure. Passive immunization is a shot of Rabies Immune Globulin (RIG) around the bite wound.

I think we likely agree that PEP is not a walk in the park. In your case, there are several variables to consider when making your decision. First, did you actually have an exposure? If the bite did not break the skin, I think the likelihood is low. Second, what is the likelihood that the llama actually has rabies? Rabies is certainly endemic in Peru, but is usually in bats and dogs, not llamas. Even if llamas can harbor rabies, the likelihood that your llama has rabies is also quite low.

In summary, rabies is both an unpleasant and fatal disease. It can be prevented by post-exposure vaccination, even if you have not had the rabies vaccine prior to the bite. The PEP is an ordeal, however, and you do not want it if the likelihood of rabies exposure is close to nil. My advice is to go to a local doctor and ask about the prevalence of rabies in that part of Peru, and whether they have seen rabid llamas. If the prevalence of rabies in llamas is low, your likelihood of acquiring rabies without a true bite is close to zero. If they have seen a sudden outbreak of rabid llamas at Machu Picchu, you can consider PEP under the supervision of a doctor.

Hope this helps--

Doctor D

The pic of advanced RA (which Sore on Seventh almost certainly does NOT have). Notice how the joints near the fingertips (DIP joints, in Medspeak) on the hand on the right look relatively normal. The DIPS on the had on the left have "swan-necking," which is a common finding in RA. The knuckle joints (MCP joints) are typically the most affected by RA.

By the way, can somebody please tell me the correct usage of affect vs effect? I know I was supposed to learn this in 3rd grade, but apparently I was spacing out that day (or sitting in the corner facing the wall with my dunce hat...).

Dear Doctor Dysphoric:

For the past few weeks, when I wake up in the morning, my fingers and toes are sore. Or, the joints in my fingers and toes are sore. What’s up with that? Is it that I am a nursing mom and my children are literally sucking the life out of me? Am I scaling mountains in my sleep? Or is my grandmother’s arthritis finally making it’s presence known? Isn’t there a pill or something I can take for this?

--Sore on East Seventh St.

Dear Sore on E. Seventh--

Sore fingers and toes are my bread and butter. They are very common, especially in the elderly. Joint pain is called "arthralgia" in Medspeak. If there is also swelling/redness present, we call it "arthritis."

The most common cause of arthritis is just plain old erosion of the joints that comes with old age ("osteoarthritis"). This is probably what your grandmother had. The picture on the upper left is of advanced osteoarthritis in the hands. However, the "Differential Diagnosis" (aka the list of possible etiologies) of arthralgia/arthritis is incredibly wide. Arthritis can be caused by all kinds of infections (e.g. bacteria, viruses), auto-immune processes (e.g rheumatoid arthritis or lupus), crystal-induced inflammation (e.g gout), cancers, and other random, poorly understood diseases (e.g sarcoidosis).

Knowledge of your age, your co-morbidities (other medical probs, in Medspeak), and related symptoms will help me narrow down the list of potential diagnoses. Something tells me that you are an otherwise healthy 37 year old woman with electric blue eyes. Perhaps you look a bit like Meg Ryan from the "You've Got Mail" era? Your lack of other chronic diseases and symptoms (fever, rash, hair loss, chest pain, shortness of breath, weight loss) makes a systemic illness like lupus or cancer incredibily unlikely. Gout is also quite unlikely, given that it generally effects just one joint at a time.

You are, however, in the correct demographic group for rheumatoid arthritis (RA). RA is a fairly common disease. It usually presents in women in middle age (no offense). It starts as morning stiffness in the small joints of the hands. It spares the most distant joints (near your fingertips), but attacks the knuckles and the wrists. The stiffness generally goes away after a couple of hours. The joints swell and get red. Most people will have low-grade fevers, and many have profound fatigue (due to low red blood cell count, aka anemia).

While RA is a possibility, perhaps the most likely cause of your pain is early osteoarthritis (OA). You are on the young side for OA symptoms--it usually comes on after age 50-- but your family history and your frequent use of your hands for activities such as rowing and pic-snapping puts you at higher risk.

In short, my suspician that your symptoms are related to a serious syndrome (like RA or lupus) is low. For now, take 2 extra strength tylenol three times a day as necessary for the pain. You should avoid other pills while you are breast-feeding. If you develop other symptoms, such as fever or profound fatigue, you should see a MD for an exam and lab tests.

Enjoy those beautiful babies and your prodigious talent--

--Doctor D

(ps-- the pic on the upper right is advanced gout. I did not want to post the advanced RA pic, for fear of alarming both you and the casual blog reader.)

Dear Dr. Dysphoric--

My kitty was recently diagnosed with irritable bowel syndrome but is now being successfully treated with prednisone. Just what is irritable bowel syndrome and can i possibly catch it? I'm irritable enough without having to worry about my bowels.


Dear Irritable--

Unfortunately, my network of highly trained consultants does not extend into the veterinary world. Your kitty will have to write in to his own kitty-blog for advice.

In humans, there are two syndromes that are often confused: InflamatoryBowel Disease (IBD), [which includes Crohn's Disease and Ulcerative Colitis], and Irritable Bowel Syndrome (IBS). IBD patients are usually quite ill. They often have bloody diarrhea, fever, severe crampy abdominal pain, and weight loss. IBS is a milder syndome, characterized by bloating, mild pain after eating, diarrhea alternating with constipation. They do not have fever or bloody stool. A colonoscopy is the definitive test to distinguish between the two diagnoses (pic above is a colonic biopsy which shows IBD).

In summary, to answer your questions: (1) your kitty probably has IBD, not IBS (2) if kitty really has IBS, not IBD, he may have a quack-vet (3) neither IBD nor IBS is contagious.
(4) prednisone will make kitty fat and put him at high risk for diabetes. Kitty may need diet.

--Dr. Dysphoric (and irritable too!)

Pills and paperwork are my two closest friends. We hang out every single day at work. In fact, I think they are the closest I will ever get to a long-term relationship. Could this be love? They say it comes when and where you least expect it. I am a bit worried how they will deal with my upcoming sabbatical. Are they going to find a new best friend? Or will they just wallow in their misery, accumulating here in Washington Heights until Northern Manhattan breaks off into the great Atlantic Ocean?

I told many friends and acquaintances that I want to write a medical advice blog. Why aren't you guys sending in your questions? It's not like you don't have them. People complain about their aches and pains to me all day long.

Are you afraid that I don't know what I am doing because I am depressed? I know SSRIs like the back of my hands, of course. Low back pain is my middle name. I can manage diabetes while watching the World Cup. Hypertension is my ball and chain, my bread and butter, my worst enemy. I could answer STD and substance abuse questions before I even went to medical school, dammit.

Plus, if I don't know the answer to your question, I will send out for a consult. My consultants are some of the best trained specialists this country has to offer. Ever heard of New York Presbyterian/Columbia Univerisity? University of Michigan? Nephrology at UCSD? Oncology at Penn? Critical Care at University of Washington? Geriatrics at Mt. Sinai? Endocrine at Havard? I may not be all that, but I got consultants at my fingertips baby. So keep those questions coming... (pic courtesy of NLM)

Here is an interesting health-related question that I received via e-mail this morning:

Dear Dr. Dysphoric:

Every time I go to Brooklyn, I feel sick. I leave Manhattan feeling peachy. As soon as I come up from the 2/3 train, my whole body aches and I feel nausea and tingling all over the left side of my body. Please get back to me ASAP, as the mermaid parade is coming up and I need to know if I should avoid it for medical reasons.

Sincerely,

Poisoned by Park Slope?


Dear Poisoned:

You raise a very interesting question in your letter. I have done a medline search, and found that the medical evidence is really spotty on this clinical question. There are a few observational studies that show Brooklyn indeed effects the health. However, the endpoints in these studies were generally "soft," e.g general malaise, non-specific and unverifiable. not "hard" endpoints, such as mortality data or cadiovascular events (eg. MI, stroke). And there were no clinical trials looking at this question, and not enough studies to do a meta-analysis.

Therefore, I do not think I can advise you either way, using a strict evidence-based approach. However anecdotally I will say to stay away from Park Slope if you are a lesbian and you do not have a baby. You will be the only babyless lesbian, and it will make you feel like shit. Williamsburg should be OK, as long as you have had the hipster vaccine.

Sincerely,

Dr. D

Dear Doctor Dysphoric:

I don't want to do anything. I used to enjoy watching TV, complaining, and eating. Now I don't want to do nothing. I am miserable all the time. What could possibly be the matter with me?


--Depressed in Gotham



Dear Depressed:

You are not alone. Nice day in MAnhattan? Everybody out with their frat buddies drinking pitchers of Bud? Playing frisbee in Riverside park? No wonder you don't want to do it. Who can deal with that torture? Go ahead and try the SSRI your doctor Rxed for you. But don't get them hopes up. Talk therapy kinda sucks too. Sorry, you are just screwed, same as me.

--Dr. D

This Metric CD is awesome. I think I've acquired a bit of a crush on Emily. If anybody ever visits this blog, check out Metric's most recent album Live It Out.

How can I not be...? I am a general internist practicing in Northern Manhattan. I take care of patients with Medicaid, uninsured pateints, immigrants, sick people, old people, and people who are living with advanced chronic disease.

The American Health care system is broken. In almost all practice settings, the demands on primary care doctors are extreme. Most patients are sick and have insurance issues or social problems or psychiatric disease, and/or 10,000 questions. We only have 10-15 minutes for each of you. If you are a primary care doctor and you aren't crazy, depressed or very very out of touch with yourself, please get in touch with me and let me know how you do it.