Weird stuff today that brought up questions

[Reality Check 2]

Strange day here in Family Practice land.....

NUMBER ONE:

Patient denied Life Insurance because a gallbladder ultrasound showed his spleen to be 14 cm. "borderline"

So, now I have to radiate him to get a volumetric CT of his spleen to PROVE he doesn't have a spleen problem.

He doesn't have liver disease, isn't a drinker and doesn't have ITP or Polycythemia or anything like that.

 

Upsets me that I have to radiate him to prove his spleen is normal to get life insurance when clinical discussion just isn't enough for a nonmedically trained insurance reviewer. 

 

The radiologist was sooooo frustrated. He looked at the ultrasound again and says "there is nothing wrong with his spleen".

 

NUMBER TWO:

Another guy - I cannot do a Framingham Calculation on him because his cholesterol is too LOW.

His total cholesterol is 102 - really, it is.

His LDL is 49 and his HDL is 31. 

He is not on meds for cholesterol.

Has controlled BP on solo ARB. 

Over 50

He doesn't smoke. 

Family history shows minimal heart disease all over age 75 in old smokers.

He was told he needed his risk calculated by yet another life insurance company but I can't calculate - every single Framingham calculator throws me out since his total cholesterol is below 130. 

 

 

NUMBER THREE:

Air Traffic Controller trying to avoid discussing his blood pressure because of FAA.

Ummm, seriously? No, dude. You could stroke out or have an MI while guiding my family on a flight.

Ignoring it doesn't make it better and HOW THE HELL did you pass your last FAA physical? He only gets one every other year. 

It's not really questionable - several readings of 160/102 and my own reading of 158/104. And he admits to a history of high readings. 

I can't be an FAA examiner because I am a PA.

Can I report him and to whom?

Am I obligated? 

Oh, and by the way his triglycerides are over 500 and his LDL not calculable. HDL 24......

Not obese, doesn't smoke. Horribly high stress job.

I CAN calculate his Framingham and it ain't pretty.

 

 

Any thoughts from the Peanut Gallery?

[True Anomaly]

Is this where we take potshots at non-medically trained people who work in some field associated with healthcare making healthcare decisions?  Because that's one of my guilty pleasures

[GetMeOuttaThisMess]

Hemochromatosis for scenario #1 (?)

[AliB]

For pt #2, try this one:  

http://reference.medscape.com/calculator/framingham-cardiovascular-disease-risk

 

Or, calculate it yourself using:

https://www.nhlbi.nih.gov/health-pro/guidelines/current/cholesterol-guidelines/quick-desk-reference-html/10-year-risk-framingham-table 

 

Age: 20–34 years: Minus 9 points. 35–39 years: Minus 4 points. 40–44 years: 0 points. 45–49 years: 3 points. 50–54 years: 6 points. 55–59 years: 8 points. 60–64 years: 10 points. 65–69 years: 11 points. 70–74 years: 12 points. 75–79 years: 13 points.

Total cholesterol, mg/dL: Age 20–39 years: Under 160: 0 points. 160-199: 4 points. 200-239: 7 points. 240-279: 9 points. 280 or higher: 11 points.

• Age 40–49 years: Under 160: 0 points. 160-199: 3 points. 200-239: 5 points. 240-279: 6 points. 280 or higher: 8 points.

• Age 50–59 years: Under 160: 0 points. 160-199: 2 points. 200-239: 3 points. 240-279: 4 points. 280 or higher: 5 points.

• Age 60–69 years: Under 160: 0 points. 160-199: 1 point. 200-239: 1 point. 240-279: 2 points. 280 or higher: 3 points.

• Age 70–79 years: Under 160: 0 points. 160-199: 0 points. 200-239: 0 points. 240-279: 1 point. 280 or higher: 1 point.

If cigarette smoker: Age 20–39 years: 8 points.

• Age 40–49 years: 5 points.

• Age 50–59 years: 3 points.

• Age 60–69 years: 1 point.

• Age 70–79 years: 1 point.

All non smokers: 0 points.

HDL cholesterol, mg/dL: 60 or higher: Minus 1 point. 50-59: 0 points. 40-49: 1 point. Under 40: 2 points.

Systolic blood pressure, mm Hg: Untreated: Under 120: 0 points. 120-129: 0 points. 130-139: 1 point. 140-159: 1 point. 160 or higher: 2 points. • Treated: Under 120: 0 points. 120-129: 1 point. 130-139: 2 points. 140-159: 2 points. 160 or higher: 3 points.

10-year risk in %: Points total: 0 point: <1%. 1-4 points: 1%. 5-6 points: 2%. 7 points: 3%. 8 points: 4%. 9 points: 5%. 10 points: 6%. 11 points: 8%. 12 points: 10%. 13 points: 12%. 14 points: 16%. 15 points: 20%. 16 points: 25%. 17 points or more: Over 30%.

[mackjacks]

Regarding patient #3...I had a patient ask me for a few Catapres to "help a friend pass their job physical". NO.

[ventana]

i stopped doing framingham scores with the new guidelines - are you just meaning the newer online calc?

 

as for the air controler - yeah tell someone

 

as for the Life Insurance - #1 - I would write a letter explaining their is no safe dose of radiation to the patient and have them chew on that

 

as for #2 - hummmmm - see #1

and maybe talk to life insurance directly - or just bump up the lab values till he scores - then say his risk is LESS then that as he clearly has better numbers.....

[Reality Check 2]

I used framingham calculator online and followed several hits to cleveland clinic and other reputable sites. Some asked to use BMI and others wanted metrics and labs.

 

What is your favorite?

[sk732]

http://www.chiprehab.com/CVD/index.php?lng=en

 

This is the calculator I use - from McGill University in Montreal.  It's based on the Framingham Score, with a bit more data.  I like it because you can set it up in front of someone and manipulate the numbers and ad data - like changing smoking status, cholesterol and BMI from present to better to show differences.  Haven't used it in awhile, since I work ER now, but still use it if doing military primary care.

 

SK

[Reality Check 2]

The air traffic controller agreed to take fenofibrate to lower his triglycerides, reduce risk of pancreatitis and give me a chance to see what his LDL really is.

Then I might add a statin for the LDL - I am comfortable mixing them at the right doses.

 

My doc stopped using fibrates altogether because they "don't reduce heart risk" but I think I have to use it to even find out what his LDL is and help prevent pancreatitis.

 

Overall, his cardiac risks are high with HTN, lipids and the family history he isn't telling me.

 

Deep Sigh - back to the schedule

[probasestealer]

The air traffic controller agreed to take fenofibrate to lower his triglycerides, reduce risk of pancreatitis and give me a chance to see what his LDL really is.

Then I might add a statin for the LDL - I am comfortable mixing them at the right doses.

 

My doc stopped using fibrates altogether because they "don't reduce heart risk" but I think I have to use it to even find out what his LDL is and help prevent pancreatitis.

 

Overall, his cardiac risks are high with HTN, lipids and the family history he isn't telling me.

 

Deep Sigh - back to the schedule

 

How about a direct LDL? Takes trigs out of the equation.

[Reality Check 2]

Good thought on the direct LDL. The lab does it - his insurance should cover it.

 

Now I just have to get him physically back in the building to check his BP.............

[probasestealer]

Yeah, that is a difficult personality type. Just stick to your guns. Glucose ok?

[Reality Check 2]

Glucose, BMI - everything else ok. Not a smoker, minimal alcohol. 

 

Got a bad deck of genetic cards but doesn't want to deal with it since nothing is tangible.

 

Class for what I deal with.

[dchampigny]

my experience has been that you have to have triglycerides of around 1,000 for the risk of pancreatitis to be real? Anyone had any other experience?

 

It's an interesting conversation to have with a patient when you have to tell them that their job is killing them. Sounds like the case for the FAA employee.