Category Archives: Patient Care Notes

When Diet and Exercise is not enough

Mrs. Jones presented to my office approximately six months ago having been told that she had type 2 diabetes two years ago. Her HbA1c was 8.2. This is a measurement of how well glucose has been controlled for the previous three months. Normal is under 5.7 and anything over 7 is typically considered too high. Her number correlated with an average blood glucose of 186 and we know it needs to be under 120 to avoid serious diabetic complications. Since her previous primary care doctor had not been able to adequately help her,  I sent her to an endocrinologist. She returned to my office six months later and was proud to point out her HbA1C which was down to 6.2. Blood_Glucose_Testing_-_Kolkata_2011-07-25_3982She said to me, “I read my records from my previous doctor.  She told me to diet and exercise. That’s all she ever said. She never told me why it applied to my diabetes. Now I understand how increased weight and lack of exercise affects insulin. Why didn’t she tell me those things?” I thought about it. Why didn’t I tell her? I assumed that the physiology and treatment of her condition had been well explained to her and that she was just ignoring her doctor’s advice. Diet and exercise alone as words are not powerful enough for people to understand their importance. Education is more than advice. It includes understanding the significance of the recommendations. 

How many times am I guilty of the same poor communication technique? Doctor comes from the latin docere, to teach. It is part of my job and I hope my patients feel comfortable enough to say, “Hey, I don’t understand that” when I am unclear.  Only by working together can we hope to improve the “outcomes of chronic disease”. And more importantly, my patients will feel better and live longer.


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Medicine X at Stanford–a Patient Experience

Returning from Louisville after the flurry of San Francisco and the MedX conference, I’ve begun to digest some of the information that I was exposed to. A blog post by one of the other participants, Prosthetic Medic (another Louisvillian) summed up nicely where the emphasis of the conference was concentrated on–the patient. In his first post regarding the conference he talks about coming to the understanding that his diagnosis is “chronic”, in other words, his leg will never grow back. Yet as gut wrenching as that fact may be, his diagnosis does not define him. The conference helped him to understand the difference between surviving and living. The epatients at the conference have chosen the latter and they do so with gusto.

To get a sense of what the truly empowered patient can do here are some other terrific posts by MedX’s patient attendee’s:

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Peri-Menopause Aching-the study that’s never been done

“When I have to go to the bathroom in the middle of the night, I walk like an 80 year old woman. Dr. Nieder, I am only 48. There is something seriously wrong!” Lately, this complaint comes one or two times a week from peri-menopausal women. (Peri=around so peri-menopause is defined as around the time of menopause). Similar to my recent Hot Flash post, I started thinking about their complaints from my own experience. It hit me–I don’t ache like I used to. Yes, I exercise more now than in my mid-40’s but not as much as three years ago yet I don’t ache as badly as then. Why?  Research reveals the likely cause of the aches is estrogen deprivation but I cannot find studies that have been done on younger women. And most of the studies are more anecdotal comments about the “anti-estrogen” effect of medications given to women with breast cancer. Many of those patients are unable to tolerate the therapy because their joints hurt too badly[1]. In addition, all the studies on joint pain and estrogen loss have been done on post-menopausal women.[2]

What dawned on me is that the reduction in pain occurred about the same time I started sleeping again and the hot flashes were reduced. An “AH HA” moment indeed. But I’m an “N of one” which means my experience is unique to me and not statistically significant. I am only surmising that my patients will also improve based on my experience and the fact that my older patients are not complaining as much as my peri-menopausal patients are. Let’s hope these studies get done so I can give my patients facts instead of just life experience.

In the meantime, keep walking and staying optimistic. It will get better.


1. Qamar J. Khan, Anne P. O’Dea, and Priyanka Sharma, “Musculoskeletal Adverse Events Associated with Adjuvant Aromatase Inhibitors,” Journal of Oncology, vol. 2010, Article ID 654348, 8 pages, 2010. doi:10.1155/2010/654348

2.Estrogen alone and joint symptoms in the Women’s Health Initiative randomized trial. Chlebowski RT, et al. Menopause. 2013 Jun;20(6):600-8. doi: 10.1097/GME.0b013e31828392c4.

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HOT Flash

This short post is mainly directed at my menopausal patients. It came to me last night about 3 am. As it happened that was the second time I’d awakened for no obvious reason until a few moments later it seemed the room temperature had risen 10 degrees. No wait, MY temperature had done that. FlameV1Having nothing better to do until my temperature normalized (besides kicking off all my covers much to my husband’s dismay) it occurred to me, “this’ll make a great blog post!”

For those women struggling through the peri-menopausal period, better known as the meno-fuzzies, I have good news and bad news. Your cognition issues are real[1]. That’s the bad news. The good news is that this too shall pass and most of your brain function will return. You will also have fewer hot flashes and there will come a time when you will once again sleep through the night. Now that I’ve made it to the other side I can state with assurance that walking into rooms in my house only to discover that I have NO idea why I’m there are fewer now. No longer do I fear bursting into flame in the middle of my office. The bad news? Even though I’m in my late 50’s I still awaken in a sweat two or three times a week. And I have 80 year-old patients that assure me that they too still occasionally flash.

Are your fears about your memory well-grounded? Yes, but it will come back.
Is your insomnia as bad as you think it is? Yes, but you will sleep again.
Are you as irritable as your family says you are? Maybe, but exercise helps.[2]
Are you gaining weight because of the menopause? No, that’s more of the aging process.
Should you take hormones? That’s a very individual question and best discussed with your doctor in the office. Every woman needs to make that choice with her own needs and risk factors in mind.


1. Cognition and mood in perimenopause: A systematic review and meta-analysis. Weber MT, Maki PM, McDermott MPJ Steroid Biochem Mol Biol. 2013 Jun 14. pii: S0960-0760(13)00111-8.

2. Physical Activity, Menopause, and Quality of Life: The Role of Affect and Self-Worth across Time. Steriani Elavsky, Ph.D. Menopause. 2009; 16(2): 265–271.

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A Caffeine-Containing Post

In follow up to an ER visit for a new onset migraine headache, my patient casually asks if caffeine could be playing a part in his headache and blood pressure issue. As we reflected on that possibility he admitted to drinking at least 64 ounces of diet, caffeine-containing sodas daily. WHAT?!?!? Not only can caffeine raise both blood pressure and pulse but if one already has hypertension, caffeine may elevate it even more than in a normal person.[1]  When he  presented to the ER with an excruciating headache and extremely high blood pressure he underwent a head CT scan that was normal and it was theorized that the blood pressure was due to the headache, perhaps a migraine. The problem I had with the diagnosis is that people do not typically present with their first migraine headache in their mid-40s. The ER started him back on blood pressure medication (he had been able to stop it about a year ago with diet and exercise) and sent him back to me for followup. So in my office we began to  explore the biggest question:  was the pressure causing the headache or the pain from the headache causing the blood pressure? In the time between the ER and our office visit he realized that he got a headache if he went a few hours without caffeine. We developed a plan for slowly stopping all caffeine products before ordering any more expensive tests. Since his pressure was still elevated,  his blood pressure medication was increased.

Over the course of a month he brought his exercise level back to 2012 levels (before he let work take over his schedule) . He reduced and came off the caffeine with the exception of one cup of green tea in the morning. He took the bigger medication dose just one day but it made him dizzy. Soon he found the 1/2 dose too much. By the time I saw him one month later his weight was down, his blood pressure was normal and he was completely off medication.

Moral of the story? First of all, caffeine can be beneficial[2] as can working hard. However–all things in moderation. Secondly, what you put in your mouth (or don’t) and how much you exercise you do can sometimes work as well as a pill. And there are no side effects!

1. Hypertension Risk Status and Effect of Caffeine on Blood Pressure. Hartley, Terry R., et al. Hypertension.2000; 36: 137-141.


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Blood Pressure Control

Yesterday a patient presented to my office requesting to be put back on her blood pressure medications. This is a rather unusual request, most patients are trying to stay or get off their medications. However she had been tracking her blood pressures since she stopped medication about six months previously. She was consistently running “bottom number” or diastolic pressures in the high 80’s or low 90’s. Fortunately she realized this was too high over time and came in to get hee prescription refilled.

There are good studies indicating that individuals who check their BPs routinely have better control[1]. I encourage my patients to have their own cuffs to check their pressures both at home and at work. They can bring their cuff to our office and calibrate it to make sure it is accurate. Then they can bring their “numbers” with them when they come in for appointments or just send them to me through the patient portal on, letting me know when they do so.

Together we can keep you healthy!

  1. Agarwal R, et sl. Role of home blood pressure monitoring in overcoming therapeutic inertia and improving hypertension control: a systematic review and meta-analysis. Hypertension 2011;57:29–38.

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Patient Portal Success

“Doctor Nieder, my wife got this new smartphone and she wants to know why she can’t communicate with you using it. Can she?” This coming from a 70 something patient. I’d seen his wife a few days previously and she had a question about her medication. She wanted to know why she couldn’t just email me about it.

We talked a little bit about the insecurity of email and personal health information (PHI in my world). Then I happily explained that,  indeed she could communicate directly with me using her smartphone. I gave him my card with the RelayHealth information on it, directed him to look to the upper right-hand corner of the website and click “register”. This will take her to this page:

Relay Health Sign in


After finishing the registration process, pick a provider – me – and then RelayHealth sends me notification of the registration. After that she can directly communicate with me. He left the office happy to have good news for his wife.

I know many of my colleagues are hesitant to give patients direct access but consistently the portal has saved me more time than cost me. Patients ask thoughtful appropriate questions. If an appointment is needed a staff member calls them. Otherwise I can give an equally thoughtful response on my own time. As they say “It’s a win-win.”


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If it looks like a duck…

If it looks like a duck and quacks like a duck, it’s probably a duck. 32cm Giant DuckThis is a common expression in medicine that simply means, if a patient gives you symptoms that fit a particular disease, don’t go looking for another disease without a good reason. Today a patient presented with low back pain and morning stiffness. She is 80 years old. I thought of osteoarthritis but she was concerned about cancer. She has no history of cancer but she had looked on line and scared herself. After we spoke a little while, she was reassured. She’d spent the nasty winter being much less mobile than usual, then had immediately begun doing hard work in her yard, pulling weeds, mulching and mowing her grass. Of course I was impressed that this 80-year-old woman still did all those things. I was able to reassure her and have her try some walking and water exercises to try to loosen up her back muscles. If it doesn’t get better, we’ll consider other causes. So she agreed to do a little less bending and stooping and pulling until she’d limbered things up a bit with walking. I’ll see her back if necessary in a month. We both agreed that when you hear hoofbeats, you shouldn’t think of zebras.


Interesting–I have no idea why we use so many animal analogies in medicine….

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The Google Pre-consultation

Patients frequently preface a question with “I know doctors hate it when their patients look stuff up on the internet, but…” In typical doctor fashion I interrupt them at this point and say, “No I don’t, I like it when patients do that.” It takes a moment or two for that to take. Then they nod and ask whatever is worrying them that they’ve found on line.

The Google “pre-consultation” is a fact. According to research done by the Pew Research Center, 72% of internet users have searched the internet for health information.[1] Many doctors I know, or at least the ones on social media, will pro-actively ask their patients “what did you read about it online?” This often relieves a couple of anxieties. First, that the doctor will negatively judge the patient for checking on line and secondly, the patient can proceed to ask questions about what is worrying her or him.

So when you come in to see me, instead of the “petit papier” with all your questions, I’ll expect them to be in a list on your smart phone or tablet (the paper is OK too). And if you want to send them in ahead of time, be my guest! Go to, register and send me your questions before your appointment. We can save time and cover more ground that way.

Oh, and when you are researching on the web, be careful out there. You can find lots of wrong information, chicanery and just plain bad advice on the internet. Here are my recommended web sites for disease searches:

If you are looking for patients with similar conditions to yours, there are some great patient communities out there as well:

And always, if you think of a question you forgot to ask please contact me through


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So Dizzy My Head is Spinnin’

It’s a common problem. At least once a month a patient presents to the office with two to five days of a spinning, nauseating sensation. Sometimes it is dramatic, with a miserable individual sitting in her chair, a garbage basket between her knees lest she move her head the wrong way and commence to throwing up.

Bad as these symptoms are, almost 99% of the time the episode will be short-lived and dissipate on its own. Physicians give symptomatic treatment like an anti-nausea pill to help the patient through the worst days but there are no pills that effectively treat  the problem.. The first two to three days are the worst, with milder symptoms that can last up to six weeks.

The problem is called vertigo and its cause is usually due to a disorder of the peripheral vestibular system, the equipment in your inner ear that tells your brain where you are in space. Usually the episodes occur when the patient moves his/her head in a specific direction. The medical term most common for this is Benign Paroxysmal Positional Vertigo (BPPV). Or sometimes we just call it labyrinthitis.

Occasionally this can become chronic and relapsing. There is a maneuver that the Ear, Nose and Throat doctors employ to help resolve severe or persistent cases called the Epley maneuver. Usually patients get resolution of their symptoms after the maneuver. It does tend to cause pretty significant symptoms during the procedure, so if you are already improving on your own, I don’t recommend this.

In the meantime:

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