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    Primary Care Medicine: A different kind of gate keeper

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    Primary care medicine is often heralded as the “gate keeper” of medicine, meaning that when patients establish with a primary care provider, it is the PCPs role to order screening interventions and decide which patients need referral to specialists.

    For example, does every 27-year-old healthy male need a cardiology evaluation for palpitations? Does every “ugly duckling” mole need a dermatology consult?

    Today, we will explore the concept of the primary care provider as the gate keeper of medicine, but in a different sense. In family medicine and urgent care, it is easy to get into a rhythm of mundane, as winter days can mean many patients with cold symptoms in a row.

    But, there always hides the patient who needs immediate work up and attention. Today’s article will focus on one of these presentations.

    Examples of the above occur sporadically in family medicine and in urgent care.

    One example includes a gentleman in his mid-50s who presented to the family medicine clinic where I was working as a student on rotations. The patient, ironically had minimal complaints. His chief complaint was simply, “Sores in my mouth for two days”. During the day, this patient called in to the office and was scheduled in a 15 minute slot for an acute evaluation.

    As the student, I was asked to get a history and physical from this patient. Upon entering the room, he did not look sick. As I introduced myself and started talking to the man, he stated that he was having very minimal symptoms.

    His history indicated that over the past two days or so, he had noted “black sores” in his mouth which were irritating to him. He reported that he had thought about “seeing if they went away”, but decided to come in for evaluation.

    He denied any pain. He denied any other rash. No tooth problems. He had a very minimal past medical history. He had a recent history of elevated blood pressure, but was not on any medication. There was no family history of cancer, clotting disorders, or heart problems. He smoked a pipe occasionally, did not consume alcohol, and was not under much stress. His review of systems, other than feeling a little “more fatigued”, was positive only for the above “sores”.

    As a student, I struggled to ask more questions. I was not sure what was going on. At times during the history, it felt like pulling teeth. As I have grown in my career, I have found that it is helpful to ask patients directly what their expectations are. Sometimes asking patients what they are fearing the most can help narrow down expectations and provide reassurance. In this case, the man simply wanted to know “whether it was something dangerous”.

    On exam, the man was obviously in no acute distress. He was alert, oriented, and cooperative. His eyes were clear with no erythema. His ear exam was unremarkable. Upon examination of the man’s oropharynx, I appreciated subtle, but significant petechiae on the cheeks and bizarre maroon/black lesions on the tongue. The posterior oropharynx was void of erythema or other abnormality.

    His neck was supple without lymphadenopathy. His heart rate was regular without murmur, and his lungs were clear. His abdomen was soft and non-tender. His skin and extremities did not show any further rash, lesion, or other abnormality. Neurologically, there was no deficit.

    Sometimes in medicine, we are forced to scratch our heads. It can be a very frustrating and challenging to sit in front of a patient and wonder what is causing their symptoms. As we grow into our careers, our differential diagnoses grow and our rolodex of considerations expands. Frustratingly so, there are sometimes patients who have no identifiable cause for their symptoms.

    As clinicians and students, this frustrates us deeply. We are trained to find answers and give solutions. As students, we grow accustomed to there always being an answer. Options A through E, one must be correct. In practice, there is not always a definitive answer.

    My presentation of this patient to the attending was short and sweet. The case could be summed up in a simple sentence: A middle aged man with lesions in his mouth who wasn’t sure why he came in. It was simple, yet unbelievably confusing.

    My suggestions for an assessment and plan considered both a viral illness and rarely, the possibility of a clotting disorder. My attending and I decided to get a CBC given his petechial rash. If anything, we countered, it would be reassuringly normal.

    As I drove home from my rotation, I felt frustrated. This was a patient who came to us for answers, and we offered none.

    As I have grown into my career in medicine, I look back on this case often. Sometimes, patients simply want to know that whatever symptom is present is not a dangerous or life-threatening entity. As long as we can assure them, they are happy.

    Upon arriving at the clinic the next day, I did not think much of the patient from the previous afternoon. Surely there had been other patients with more powerful lessons to be learned. As I discussed morning cases with my attending, he said “Remember your guy from yesterday with the mouth lesions?”

    Of course, I thought.

    “Well, your CBC saved his life. His platelet count was 1,000. The lab paged me on my drive home last night. He’s in the hospital and was diagnosed with idiopathic thrombocytopenic purpura. Good catch”.

    Idiopathic thrombocytopenic purpura, or ITP, is an acquired immunologic destruction of platelets that affects children and adults. In children, it can commonly follow a viral illness and usually results in spontaneous resolution. In adults, ITP is exceedingly rare, accounting for about 3 cases per 100,000 patients.

    The etiology, as it’s’ name elucidates, is vastly unknown but thought to be immune mediated. Medications, including quinidine, gold, penicillin, procainamide, and sulfamethoxazole can be causative (Jana, 2016).

    As with our patient from above, the vast majority of patients are relatively asymptomatic. Most commonly, the disease is discovered via routine CBC. Bleeding can occur spontaneously with platelet counts less than 50,000. In patients with platelet counts less than 30,000, clues include spontaneous ecchymosis, petechiae, menorrhagia, or frequent epistaxsis. Platelet counts less than 20,000 are significantly dangerous for spontaneous intracerebral bleeding.

    In the setting of a patient with the above symptoms and a matching extremely low platelet count, this is usually sufficient for diagnosis. Adults presenting with the above should be screened for hepatitis B, C and HIV.  A peripheral smear, if performed, may show “giant platelets”.

    Patients with signs of active bleeding should be admitted to the hospital. The management of ITP should be performed by a hematologist. The first line treatment for ITP is corticosteroids. Upon initiation of corticosteroids, patients should be monitored for active bleeding. The platelet count is usually monitored for a few days. An additional option includes IVIG. In patients who fail the above, a splenectomy is recommended. If patients have a contraindication to splenectomy, thrombopoietin receptor agonists such as eltromopag or romiplostim are options.

    Despite the significant risk associated with such marked thrombocytopenia, ITP has a good prognosis. The overall mortality rate is about 1%. Up to 80% of adult patients diagnosed with acute idiopathic thrombocytopenic purpura recover within 2 months of diagnosis.

    “Student, you do not study to pass the test, you study to prepare for the day when you are the only thing between a patient and the grave”. –Mark Reid

    Jana, K.K (2016). Idiopathic thrombocytopenic purpura. The Five Minute Clinical Consult.

    This article, blog, or podcast should not be used in any legal capacity whatsoever, including but not limited to establishing standard of care in a legal sense or as a basis of expert witness testimony.  No guarantee is given regarding the accuracy of any statements or opinions made on the podcast or blog.

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    Daniel Champigny, PA-C is a 2016 graduate of The Pennsylvania State University. Prior to attending PA school, Dan worked in pre-hospital medicine as an EMT. Currently, he's in primary care/family medicine in rural Pennsylvania and also works in urgent care. He is a certified impact consultant and is passionate about the management and treatment of concussions. Dan additionally has interests in preventive care, evidence based medicine, and teaching. In his spare time, Dan enjoys running and hiking.