Help me understand...

[Jarid in Cedar]

Nope. That's a case that I can wrap my brain around and understand where theyre coming from. Yesterday's case was a guy who sees one of our CUFers; today's said that she 'couldnt get an appointment this morning' (i can sort of get this, but offices aren't open yet, so she hadn't tried and she has the day off--I always ask before I give them a clean out...)

Heh, I saw him yesterday morning....before he had picked up the medicine that you had prescribed......and was still complaining that he was constipated. I give up trying to understand the fascination and fixation that old people have on bowel movements/constipation. My wife's Grandma lived with us for awhile and she constantly complained about having constipation and being "bound up". She took probably 5 things a day for this, yet you could hear the "colon spray" hitting everything in the bathroom when she would go in there(it was far too obvious, even with fans on and everything). She also had melanosis coli(a condition from abuse of laxatives).

[ERCougar]

My turn to complain about ERs. Living in this small town, there are no other options after hours. When my son broke his arm 4 weeks ago, I called his primary care, and they said since the Orthos weren't open that day, to go to the ER. The ER doc looked at the x-ray, put a splint that went to mid forearm on a fracture of the radius and told us to see the pediatrician in one week for followup but that the severe bend in my son's arm should straighten itself out.
The ortho isn't in the office till 3 says later, so when we go in an see him and he sees the 26 degree angle in my sons arm he immediately schedules a closed reduction. $15000 later, my son's arm is straight and has a cast that goes beyond the elbow.
Am I within my rights to go kick the ER doc in the nuts?

This is probably a question better directed at hostile, but in reality, I doubt the ER doc's actions (or lack thereof) had much to do with the cost. He obviously should have referred to ortho the next day (I do this on most fractures, even if I'm pretty sure they wont do anything with them), but in the end, you got the closed reduction anyway. I can't see the x ray to fully comment, but children's forearm fractures tend to tolerate quite a bit of angulation in one direction (not so much in the other). A conservative approach, hoping to avoid surgery, doesn't sound too crazy, but that's a decision I would leave to the ortho.

[PaloAltoCougar]

Photophobia and pain are the two things most conjunctivitis don't have that uveitis do....)

Ignoring ER's larger point, I wanted to chime in and offer my services as a consultant on uveitis issues. I suspect I've dealt with this personally far more than anyone else on the board, having had 20-30 bouts of iritis/uveitis (hooray for HLA-B27). My first was at BYU. An optometrist/neighbor diagnosed it as conjunctivitis and gave me a worthless med. A week later, with more pain and redness in the same eye, I saw a BYU Health Center doc who confirmed the original diagnosis and gave me another worthless med. Another week later, my photosensitivity was so bad that when stepping outside, even with my bad eye closed, it felt like a knife was being plunged into the eye. An off campus specialist eventually diagnosed it as iritis, with a synechia to boot. Lucky for me, the problem eventually fully resolved, but I certainly get the fact that lots of professionals simply miss the mark with a diagnosis. P.S. Use a slit lamp.

[PaloAltoCougar]

I give up trying to understand the fascination and fixation that old people have on bowel movements/constipation. M

BYU71 and I would be willing to hold a panel discussion on this should you wish to try again. One of the reasons is that as we age, this is the only activity in which we actually produce something.

[RobinFinderson]

If I hadn't pooped in seven days I might go to the ER.

[ERCougar]

Heh, I saw him yesterday morning....before he had picked up the medicine that you had prescribed......and was still complaining that he was constipated. I give up trying to understand the fascination and fixation that old people have on bowel movements/constipation. My wife's Grandma lived with us for awhile and she constantly complained about having constipation and being "bound up". She took probably 5 things a day for this, yet you could hear the "colon spray" hitting everything in the bathroom when she would go in there(it was far too obvious, even with fans on and everything). She also had melanosis coli(a condition from abuse of laxatives).

Seriously..lol. Help us out, LA. Is this a depression era thing? I have plenty of people complaining simply of constipation. No pain. No upset stomach. Just no bms for a couple of days.

[Pheidippides]

Heh, I saw him yesterday morning....before he had picked up the medicine that you had prescribed......and was still complaining that he was constipated. I give up trying to understand the fascination and fixation that old people have on bowel movements/constipation. My wife's Grandma lived with us for awhile and she constantly complained about having constipation and being "bound up". She took probably 5 things a day for this, yet you could hear the "colon spray" hitting everything in the bathroom when she would go in there(it was far too obvious, even with fans on and everything). She also had melanosis coli(a condition from abuse of laxatives).

Not to threadjack, but what kinds of dangers does constipation present? And is there any danger to eating a ton of fiber as part of a normal diet (i.e. not through supplements)?

[ERCougar]

Ignoring ER's larger point, I wanted to chime in and offer my services as a consultant on uveitis issues. I suspect I've dealt with this personally far more than anyone else on the board, having had 20-30 bouts of iritis/uveitis (hooray for HLA-B27). My first was at BYU. An optometrist/neighbor diagnosed it as conjunctivitis and gave me a worthless med. A week later, with more pain and redness in the same eye, I saw a BYU Health Center doc who confirmed the original diagnosis and gave me another worthless med. Another week later, my photosensitivity was so bad that when stepping outside, even with my bad eye closed, it felt like a knife was being plunged into the eye. An off campus specialist eventually diagnosed it as iritis, with a synechia to boot. Lucky for me, the problem eventually fully resolved, but I certainly get the fact that lots of professionals simply miss the mark with a diagnosis. P.S. Use a slit lamp.

Impressed at your medical knowledge, PAC! I do use a slit lamp on red eyes that aren't obviously conjunctivitis (purulent drainage). Am I still missing some?

Also, what about consensual photophobia? How reliable of a sign is that of uveitis/iritis? Can I rule it out if they don't have it?

[LA Ute]

Seriously..lol. Help us out, LA. Is this a depression era thing? I have plenty of people complaining simply of constipation. No pain. No upset stomach. Just no bms for a couple of days.

I was born 15 years after the Depression era ended ( ) but I do recall it (constipation) being something my parents worried about. I rarely hear that word these days. It might really have something to do with Depression era diets. I remember as a kid having laxatives around the house. There was something called Castoria that my mom would give us "just to keep us regular." Seems to me that since my college days the answer has been plenty of FIBER.

[ERCougar]

Not to threadjack, but what kinds of dangers does constipation present? And is there any danger to eating a ton of fiber as part of a normal diet (i.e. not through supplements)?

I don't even think there's a problem with fiber supplements. Chronic stimulant laxative use is a bad idea, but fiber should be fine.

My hunch is that most constipation could be solved by drinking more fluids and increasing activity.

[Pheidippides]

I don't even think there's a problem with fiber supplements. Chronic stimulant laxative use is a bad idea, but fiber should be fine.

My hunch is that most constipation could be solved by drinking more fluids and increasing activity.

How do stimulant laxatives work? All I know is I took one once the night before a long run and had a horrid detour into the trees a few miles in.

[Art Vandelay]

Impressed at your medical knowledge, PAC! I do use a slit lamp on red eyes that aren't obviously conjunctivitis (purulent drainage). Am I still missing some?

Also, what about consensual photophobia? How reliable of a sign is that of uveitis/iritis? Can I rule it out if they don't have it?

I would assume most anterior uveititis you would see will be first or second episodes (PAC-like patients, know who to call from past experience) meaning they will likely present with mild redness and photophobia and/or non-light related pain far greater than amount of hyperemia. The trouble is getting a good enough view of the cornea and anterior chamber to rule out a corneal ulcer vs iritits (rule of thumb: contact wearer under age of 30, is most likely corneal related. Non-CL related almost always some form of uveititis). The reality is the MD or OD could prescribe an antibiotic (Vigamox or Zymar) in combination with pred-forte (newer, glaucoma friendly steroids, are rarely needed) and treat whatever the problem is 90% of the time. The problem is guessing wrong or mis-diagnosing a herpes simplex related problem. The steroid is like gas on a fire in these cases. Whereas, those who have reoccurring problems will generally experience some neuropathy and a decrease in pain with each subsequent episode. However, with someone like PAC I've seen multiple times for the same condition, I have no problem calling in the steroid and checking them in a day or two.

If there is a competent OD in area (unfortunately, many aren't ), you feel confident in working with don't hesitate to call them. The reason I say OD vs MD is because you are likely get a quicker and friendly response, it makes us feel like "real" doctors when the PCP or ER doc calls with a question. Most of the ophth in my area want to be surgery and are less than thrilled to deal with non-surgical urgencies. I deal with more medical-related eye problems than 95% of all optometrists, yet I'm still happy to talk to someone on the phone and/or squeeze in a patient if necessary. Much like Mos in general, my profession has a HUGE inferiority complex- my partner is particularly guilty of this. Heck if ER, JIC or anyone else wants to ever snap a cell phone pic and text me, I'm more than willing to pass along my number.

[old_gregg]

I know there are worse things to deal with in life, and actually, my job is pretty easy with these. It irritates me on a societal level, much like when I see people on disability for uncomplicated diabetes.

wait you can get disability for uncomplicated diabetes?? i might have to look into that.

[Jarid in Cedar]

How do stimulant laxatives work? All I know is I took one once the night before a long run and had a horrid detour into the trees a few miles in.

Stimulant laxatives(ExLax is the most recognized) work by irritating the nerves in the colon, causing the bowel wall to contract. Overuse of stimulant laxatives cause the nerves in the bowel to stop functioning altogether. Thus that patient now cannot have regular BM's without taking the stimulant. bulking agents(fiber, stool softeners) or osmotic agents(like Miralax) do not cause the same problems as the stimulant laxatives. I recommend those 2 before anything else.

As far as your previous question, constipation is not harmful unless it causes full bowel obstruction(and that is uncommon). It does cause some pain, bloating, and increase in foul gas, so that it the reason that most people try to treat/avoid it.

[ERCougar]

Yup, AV, I want your cell. I'll even call you 'real doctor art'. Our ophtho is really nice and easy to work with, but like all of you wealthy eye guys, spends much of his time in exotic locations.

I'd see HSV/zoster on a fluoroscein stain, no? I usually don't add the steroid anyway, partially because it's a pain to get in the ED, but mostly because of this fear. But maybe the safer thing is to just give everyone steroid.