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The Physical Exam Can Be Pretty Important

I just learned a valuable lesson.

A friend of mine described some fluid build up in her knee, made worse by exercise. She said she had seen an orthopedist who recommended surgery… and she wondered what I thought. Based on her description, I assumed that she had an acute knee effusion – potentially from some recent exercise-induced ligament or meniscal damage.

My friend said that she was concerned about having surgery, and that she was planning to have an MRI first. I must admit that I was a little bit confused as to why surgery was recommended so quickly, without having the MRI results to confirm the cause of the effusion (and that surgical correction was warranted). My knee jerk response was to question the clinical judgment of the orthopedist, and to wonder if he was too “surgery happy” and was leading my friend away from conservative measures (of which I am a great fan).

Several weeks passed, and I finally met my friend in person for a quick look at her knee (she was still waiting for the MRI). Guess what? She did NOT have a knee joint effusion at all. What she had was an almond-sized ganglion cyst on the side of her knee.

I felt pretty silly. Of course the orthopedist recommended surgery (a tiny procedure under local anesthetic) without the MRI. He was indeed offering the appropriate treatment.

Sometimes a picture’s worth 1000 words. And sometimes the physical exam can make the diagnosis – no other studies needed.This post originally appeared on Dr. Val’s blog at

Skin Cream: "All Natural" Isn’t Always Better

I learned something interesting today from Dr. Benabio’s Derm Blog: bacteria love to grow in skin cream. He said that it was kind of like cream cheese – leaving it out at room temperature would cause it to go bad pretty quickly, were it not for the usual preservatives. He described an outbreak of a deadly bacterial infection in a hospital ICU – caused by nurses using “all natural” European (preservative-free) skin cream on their patients.

So there you have it folks – deadly bacteria are indeed “all natural.”This post originally appeared on Dr. Val’s blog at

CBS News: Marine Survives Battle, Dies of Misdiagnosis?

Tonight (Jan 31, 2008) the CBS evening news will be airing a segment about a tragic case of a young Marine who died of melanoma. According to the news transcript, an unusual mole was diagnosed as a melanoma in 1997, but no follow up was scheduled, and no explanation given to the young man about his diagnosis or treatment plan. Eight years later in Iraq he complained to medical personnel of the mole growing larger and he was told it was a wart which would be treated once he returned to US soil. He slipped through the cracks somehow, and tragically died in 2008 of stage IV melanoma.

One interesting issue raised in the segment is that the Marine was not eligible to to sue for negligence in his case.  There is a law, the Feres Doctrine, that denies military personnel the right to sue the government in cases of perceived or real medical malpractice. The rule was established in 1950 after a case was brought to the U.S. Supreme Court (Feres v. United States) in which servicemen who picked up highly radioactive weapons fragments from a crashed airplane were not permitted to recover damages from the government.

While I do understand (in theory) the purpose of this law – if every battle injury allowed soldiers to sue the government, we’d bankrupt our country in the span of a year – it does seem to be over-reaching in this case. The Marine was not injured in battle, but his life was indeed compromised by sloppy medical follow up. In my opinion, the doctor who correctly diagnosed him in 1997 should be held accountable for lack of follow up (if that’s indeed what happened). As for the military personnel who thought the Marine’s advanced melanoma was a wart, that is a tragic misdiagnosis, but hard to say that there was malpractice at play. With limited access to diagnostic pathology services, it is difficult (in the field) to be sure of the diagnosis of a skin lesion. And yes, I can imagine that an advanced melanoma could look wart-like. This is a tragic shame, but since the young man had the melanoma for 8 years prior to the misdiagnosis of the “wart,” in the end I doubt that a correct diagnosis at that point would have changed his terminal outcome.

But I wonder if the Feres Doctrine should be modified to allow for more accountability amongst military physicians in caring for diseases and conditions unrelated to military service? Although I am not pro-lawsuit, it does seem unfair that this Marine was denied the opportunity to pursue justice in his case. What do you think? Check out the segment with Katie Couric tonight and let’s discuss.This post originally appeared on Dr. Val’s blog at

Bruised Finger Nails: How Do You Treat Them?

A colleague slammed his thumb in a door recently and got a black and blue nail.  He told me that he searched for how to treat it on the Internet, and was advised to stick holes in the nail to relieve the pressure.  I gazed at his thumb nail, peppered with tiny little needle divots and cringed as I imagined bacteria being introduced into the soft fleshy part under his thumb nail.  His thumb otherwise looked good – no mallet finger, no swelling – no blood under pressure that I could see.

I decided to do a little research on this issue, since all I’d ever done for a black and blue finger nail before is let nature take its course – it’s painful for a few days, the nail eventually falls off, and a new one grows.

However, in many cases creating a hole in the nail to let the blood escape can significantly relieve pain in the acute phase.  Making the hole is tricky – it has to be large enough to let the blood out, and it has to be done with a sterile instrument so that bacteria are not introduced below the nail.  Most physicians recommend a local anesthetic to ease the pain prior to making the hole.  The hole can be made with a large bore needle (but you have to be careful not to place the needle in too deep) after swabbing with alcohol, or by burning through the nail with the tip of a paperclip that has been heated with a butane lighter.  Creating the nail hole (known as trephination) is best done by a medical professional.

Routine antibiotic coverage is unnecessary. If the nail is loose, split, or a cut extends past the edge of the nail, the nail should be removed,
the cut closed with stitches, and the nail reapplied as a
dressing.  It’s also important to make sure that the thumb bone is not fractured.

Bottom line: black and blue nails (subungual hematomas) are very painful and may be relieved by having a medical professional place a hole in the nail.  But don’t try this at home, folks.This post originally appeared on Dr. Val’s blog at

Healthy Aging – Celebrities In The Spotlight

ABC news created an online photo album of the actors from the movie The Princess Bride.  They display headshots of the actors from 20 years ago (when the film was created) beside a current image.  It was a real eye-opener for me, seeing how these people have changed in appearance over the years – though in all fairness, ABC didn’t choose the most flattering follow up pictures.  Nicer ones are displayed in the link to the movie above.

Nonetheless, this raises the issue of aging – and what each of us will look like in 20 years.  I think a lot of it depends on the little choices we make each day – what we eat, if we exercise, if we’re stressed, if we have loving relationships in our lives… these little things add up and imprint themselves on our faces and bodies for all to see.  What will your body say about you in 20 years?  Mine’s going to have a lot of laugh lines, and probably a good deal of cellulite… ahem.  But I’m going to keep aiming towards the leafy green veggies and regular exercise.  If you’d like to join me, you’ll find some helpful programs right here at Revolution Health.

Bonus Link: My friend Tony Via suggested this link to fake celebrity makeovers (someone took the time to create how they might look as “normal” overweight Americans – thank you, Photoshop).  Quite entertaining – and more fuel for the “eat right and exercise” plan.This post originally appeared on Dr. Val’s blog at

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