Vocal cord dysfunction

Vocal cord dysfunction.

What is this?  Feels like throat tightness, not lung/chest tightness.  Starts less than 5 minutes into exercise and recovers within 5-10 minutes from stopping exercise.  These patients do not benefit from beta-agonist (albuterol) challenge like those who have exercise-induced asthma do.  Predisposing factors: allergic symptoms, anxiety, reflux.  Most common patient is a type A teenage female.

How to evaluate?

  • A laryngoscope during exercise.  Yep, this is just like it sounds…This is when the patient rides a bike hard or runs on a treadmill fast and then a scope is introduced into the mouth and down the throat to look at the vocal cords.  The vocal cords SHUT instead of open (!) in vocal cord dysfunction.  This is counterintuitive as during exercise, the athlete needs MORE air.  This makes it difficult for the athlete to inhale as much air as their body would like.


  • Speech therapy!  This is really the mainstay of treatment to help the vocal cords from shutting when they should be open.,
  • treat reflux as if stomach acid comes up the esophagus, the vocal cords may shut in response to this acidic insult to the cords,
  • behavioral treatment to help decrease anxiety.img_2402
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Exercise Induced Bronchospasm

img_2193Exercise-induced bronchospasm, non-physicians may call this exercise-induced asthma.

What is this?

  • It is respiratory distress or wheezing that starts within 15 minutes of exercise onset.
  • Usually it resolves within 15-60 minutes after exercise stops.
  • This can occur in endurance athletes, swimming/pool athletes, ice rink athletes or athletes exposed to cold air.
  • Occurs in 5-10% of the general population without asthma.  EIB occurs in 90% of asthma patients.

Is it active training that causes EIB?  This is a theory in that when elite athletes stop training, most of them do not have EIB. Is it due to a loss of water from the airway that changes airway osmolality and epithelial cell changes?  Or is it thermal and there is a loss of heat from the airway and bronchoconstriction occurs?

What do we  physicians do?

  • Get a good history, is there a pattern of symptoms?  known triggers that bring on symptoms? Is there an asthma diagnosis in the past?
  • We will do an exam.
  • Objective testing then may be done with baseline spirometry and a bronchodilator challenge (the patient is given albuterol and then we see if symptoms resolve and if the spirometry numbers look better).

If testing is positive, then treatment should happen before exercise/ training episodes.

Treatment: Give short-acting beta agonist (albuterol), 15 minutes before exercise.  Tolerance can develop if given daily.  This may not completely help 15-20% of the population.  A second inhaled agent (a steroid) may also be needed.  Leukotriene-receptor antagonists (montelukast) may also be given when taken 2 hours before exercise.  Anything that can help?  pre-exercise warm up and wearing a loosely fitted mask when exercising in cold weather.

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How to coach patients to help them be successful in blood pressure management?

How to coach patients to help them be successful in blood pressure management?  Research shows that in one-year only 50% of patients take their blood pressure medication as prescribed.

One of my roles as a physician is to coach and motivate (!)  my patients.  I am not their mother, daughter, sister, or boss.  I give advice… and the patient has the option to adhere to my advice.  In this manner, I need to meet the patient, wherever they are psychologically.  Often treatments are not successful as they are not followed.  Then, my question to myself is why (?) did they not follow the treatment?

  • Was it too expensive?
  • Did they not understand the instructions?
  • Do they not believe that the treatment will help them?
  • Do they think there will be adverse side effects from it?
  • Did they try it and there were side effects?
  • How can I help?

Lifestyle changes, per the American Heart Association/American College of Cardiology for NON-pharmacologic control of blood pressure includes…

  • Limit sodium to 2400 mg a day.  Do not add additional salt.
  • Read labels on prepackaged foods to estimate sodium intake.
  • Stop using tobacco products.
  • Limit alcohol consumption to 2 drinks per day for men, 1 for women.
  • Measure blood pressure daily at different times of day.  Make a log.  Show your physician this log.
    • The rules to measure blood pressure are to rest for 3 minutes before checking blood pressure, measure blood pressure when arm is at the height of the heart.
  • Exercise 3-4 times per week, 40 minutes per session.
  • Eat a diet rich with vegetables, fruits, and whole grains.
  • Limit red meat and sweets.

There are also peer support programs which may help to promote and sustain healthy behavior.  Research

Let us physicians help you maintain better health.img_2006


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What are “red flag” symptoms for those with low back pain?

img_2327What are “red flag” symptoms for those with low back pain?  When a patient presents to the office or hospital with low back pain, we are looking for the “red flag” (or VERY concerning symptoms) because it reveals that there is a more ominous cause.

  • new inability to urinate,
  • progressive loss of strength in the lower legs,
  • urinary incontinence,
  • a recent invasive spinal procedure,
  • progressive sensory loss (of the anus or near genitals),
  • history of cancer,
  • fever.

If red flags are ABSENT, the guidelines are to NOT perform an MRI, CT or x rays within the first 6 weeks of onset of back pain.  Often back pain resolves spontaneously within 6 weeks, so this is the reason for waiting… unless a “red flag” is present.

I hope this helps.

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Social determinants of health. As a physician am I asking the right questions?

img_2255Social determinants of health.  As a physician, am I asking the right questions?  I recently went to a conference given by Aaron Dieringer MD who is also a Masters in Public Health candidate.  He showcased the ways that I can be aware of environmental differences in patient’s lives.  These issues need to be addressed differently than I have been doing before.

Examples of issues that are biased// juxtaposed to more appropriate questions…

  • “Do not take this medication on an empty stomach.”  //What if the patient does not have access to food regularly (or even daily)?
  • “Go outside to walk every day for exercise.”  //Do you have a safe nearby area to walk?
  • “Come back in the office in 4 weeks.”  //Is there a time or date that works best for your next appointment to help with transportation issues?
  • “See the specialist that I am sending you to.” //If you are unable to get to the specialist’s office due to transportation issues (not on a bus route) let the social worker in my office know and we will work with you to get this fixed.

How to help?

  • Consider immediate postpartum placement of long-acting reversible contraception.  50% of pregnancies are unintended.  The risks unintended pregnancies are that the patient may not be taking a prenatal vitamin or may be using alcohol or drugs.
  • Centering pregnancy.  This is a group prenatal visit.  The first few minutes are one-on-one with a physician and then the rest of the hour is a group learning session about a pregnancy issue.  This form of prenatal visits has decreased the disparity in pregnancy outcomes. https://www.centeringhealthcare.org/what-we-do/centering-pregnancy
  • Student Outreach Clinic.  The University of Nevada Reno has a free medical clinic available to the local underserved population.  One patient example given was a woman seen for asthma exacerbation who needs steroids to avoid worsening in her condition, necessitating an ER visit or a hospitalization.  One question to ask of all patients is  “If I prescribe you medication on the $4 Wal-Mart list, can you afford this?”  Some patients cannot afford this and there are social work workarounds…  Up to 60% of preventable mortality is attributable to social and economic circumstances. Want to know more about our UNR SOC?   med.unr.edu/soc/clinics
  • Project Upstream is a program which accompanies the UNR Student Outreach Clinic.  These Project Upstream volunteers help address the social determinants of health that may affect their treatment (transportation, $4 medications) so that the physician’s advice has a better chance to be adhered to with more optimal care outcomes.

I hope this helps.

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Inflammatory bowel update

Inflammatory bowel update.  Of note, inflammatory bowel includes Crohn’s disease and ulcerative colitis.  Inflammatory bowel disease is not irritable bowel.  I recently attended a lecture by a local gastroenterologist  Here are some of the “pearls” from that talk…

  • Patients with ulcerative colitis flares are at increased risk of blood clots, especially when ill and are sedentary (like when in bed in the hospital).  DVT prophylaxis needed.
  • IBD patients may be more at risk for skin, lymphoma, cervical and anal cancer.  Additionally, colon cancer risk is 2 times higher than the general population.
  • A routine patient (without inflammatory bowel)  is at lifetime-risk of colon cancer is 5-6%.
  • If a patient has pancolitis, colonoscopy should be done after 7 years. Then a colonoscopy every 2 years.
  • Primary sclerosing cholangitis patients get a colonoscopy every one year because their risk of colon cancer can be as high as 20 times the routine population’s risk.

Biologic medicines (that are often used to control inflammatory bowel disease) decrease immune strength and therefore increases the risk of many different kinds of cancers:

  • Melanomas.  These patients should be more sun-aware (sunscreen and spf clothing) and have skin cancer screenings yearly.
  • Lymphoma risk increases with patients on azathioprine.
  • Cervical cancer screening: Consider HPV vaccine, decrease tobacco exposure, get routine pap screenings.
  • Anal cancers are usually squamous cell carcinoma and are more at risk with patients with long standing anorectal colitis or men who have sex with men or HIV patients.  Anal strictures should be biopsied by colorectal surgeon to rule out anal cancer.

What vaccines do inflammatory bowel disease patients need?  Varicella (live vaccine) , Zoster, MMR (live), Tetanus, flu, HPV, hepatitis B, hepatitis A, meningococcal, and pneumococcal (pneumovax).  It is important that patients receive live vaccines before biologic medicines (which can cause immune suppression) are started.  If immunosuppressed, it is suggested that pneumonia vaccines be given before the rest of the population is due (at age 65).  The American College of Gastroenterology (statement offered in 2018) suggests Prevnar followed by Pneumovax 8 weeks later.  Then Pneumovax booster is suggested 5 years later.

Your GI doctor will recheck labs depending on what therapy you are on.  You may need renal function labs, DEXA (bone density) scans, vitamin D or calcium level, comprehensive metabolic panel, tuberculosis test

When to start colon cancer screening in routine-risk patients?  New data shows that first screening should be at age 45, but insurers are not following this yet.  African Americans should get their first screening colonoscopy at age 45.

http://www.cornerstonehealth.org is a great website.

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Intravenous magnesium sulfate helps with asthma exacerbations!

Intravenous magnesium sulfate helps with asthma exacerbations!  I was the attending physician on the hospital service recently and had many children with respiratory distress present to the emergency room.  Many of them had RSV or influenza infections resulting in respiratory distress, but two of them had asthma exacerbations.  A literature review ensued for the most up to date treatment of asthma exacerbations and magnesium sulfate is a new addition to our pharmacotherapy.

It has been found that in an acute asthma exacerbation that has not responded to our first-line therapy (consisting of bronchodilators and steroids) often benefit from a dose of magnesium sulfate intravenous.  I fact hospital admission decreased by 68% patients 18 months to 18 years of age who were given magnesium sulfate.  Of note, the magnesium sulfate was only given if the bronchodilators and steroids were ineffective.  The studies showed no harm caused by magnesium sulfate.  It was a weight-based dose that was given once in the patient’s vein.

I love having one more medication in our arsenal to help asthmatics.

I hope this helps.img_2234-1

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