Wednesday, February 11, 2009

Damned if you do

NewFNP feels pretty confident about her diabetes management, her hypertensive skills, her strep throats and all the day to day family practice stuff.

But where newFNP gets a little tripped up is with the more uncommon diagnoses, such as Myasthenia Gravis, a pretty horrible autoimmune disorder in which your body creates antibodies that block its acetylcholine receptors, thus causing muscle weakness.  A gross oversimplification, but it's late and newFNP needs to get out her physiology book to really explain this any better.  End result is weakness because bodies need acetylcholine for muscle contraction.

Anyway, some people have ptosis - or weakness causing eyelid droop.  Others have generalized weakness which frequently causes weakness and fatigue with chewing (a bulbar symptom), neck weakness that can lead to head droop and limb weakness.  Still others have respiratory muscle weakness which can necessitate intubation.  Not so fun.

NewFNP's patient has the generalized, bulbar weakness kind of myasthenia.  She had a thymectomy about a year ago.  It didn't help too much.  She saw her neurologist a few weeks ago and was told to increase her aceylcholinesterase inhibitor - Mestinon - as well as her immunomodulator - prednisone.  She is taking 8-10 tabs of Mestinon daily, as well as 8-12 tabs of prednisone 10mg - a hefty dose indeed.  And her jaw continues to fatigue with chewing.

Because she was worried about her nutrition, she supplemented her diet with Ensure.  Five to six Ensures a day for the past month, in fact.  According to the Ensure website, each Ensure has 350 calories and 22g of sugar.  And because everyone needs a little treat every now and then, she had been indulging in QID mini-doughnuts for about a week or so.  

Anyone who has ever taken prednisone in the past knows that it can make you hungry, even ravenous.  It can also in and of itself tip a heavy prednisone user into steroid-induced diabetes.  Combine that with 1750 kcal/day in Ensure alone and you end up with a random glucose of 236 when you present to your well woman exam.

Frankly, newFNP was surprised that her sugar wasn't higher.  Twice normal is so pedestrian in her clinic!

So then what do you do if you are newFNP?  NewFNP cannot just take the patient off of her prednisone and start her on something else - that is neurology's purview.  She can, and did, encourage her patient to chill out on the Ensure and doughnuts, to call her neurologist and let him know that her sugar is high, and to start taking Metformin.  

Did newFNP mention that this patient is also depressed and was previously abused by her partner?  Then she was diagnosed with myasthenia and had a thymectomy.  And now she has diabetes.  

The whole situation sucks.  

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