JC - Nepherology Update for WRJ, VT VA

June 4, 2012

I had an appointment with the Neper. at the VA and found out I had a " very rare "

disease! That was the start of his training lesson! When I stopped him and

told him it accounted for 10% or more of the people with resistnt HTN he tried

to pass over it but I didn't let him.

After a little discussion he declaired it wasn't that high at the VA! I

corrected him again and told him I bet it was and that the problem was that

nobody " was smart enough to DX it! " (Sorry ) He pointed out that they

" found my case " so I provided the timeline: Adenoma visable on a 2005 scan,

renin = 0.1 on 2/22/2007 with a note from the lab " PA probable " and put on

Spironolactone on June 2010 and " Proper testing done a month later while on 7 BP

meds including Spironolactone! " I thought they might need to refine the

procedure!

I gave him a copy of the JNC7 reference card on " Prevention, Detection,

Evaluation and Treatment of High BP " from NIH. He actually took 5 minutes and

reviewed it, thought it was pretty good and tried to give it back. I told it

was his to keep and he should start by making sure there was a copy in every

treatment area so the PCP's would understand the importance!

We then talked a little about NIH and he was very interested. He said most of

it wasn't really his responsibility but he would be really intrested in seeing

the results of all the testing. I promised him a copy! (Maybe he can shake

something loose from the inside!)

We wrapped it up with him telling me how much he appreciated having a PTN that

cared enough to do the research I had done. He said I was " really challenging

his memory " ! Probably the best 45 minutes he had spent recently, IMHO. (The

PTNs behind me may not agree since we went slightly over our 20 minute

allotment!)

June 4, 2012

You need to take/send him this article from the VA in CA. They seem to have lots of PA there but they look for it.I have done 2 3 month stints at VA CBOC clinics and found a total of 5 cases in that time. All had been missed by "the system".CE Grim MDOn Jun 4, 2012, at 9:19 PM, wrote: I had an appointment with the Neper. at the VA and found out I had a "very rare" disease! That was the start of his training lesson! When I stopped him and told him it accounted for 10% or more of the people with resistnt HTN he tried to pass over it but I didn't let him. After a little discussion he declaired it wasn't that high at the VA! I corrected him again and told him I bet it was and that the problem was that nobody "was smart enough to DX it!" (Sorry ) He pointed out that they "found my case" so I provided the timeline: Adenoma visable on a 2005 scan, renin = 0.1 on 2/22/2007 with a note from the lab "PA probable" and put on Spironolactone on June 2010 and "Proper testing done a month later while on 7 BP meds including Spironolactone!" I thought they might need to refine the procedure! I gave him a copy of the JNC7 reference card on "Prevention, Detection, Evaluation and Treatment of High BP" from NIH. He actually took 5 minutes and reviewed it, thought it was pretty good and tried to give it back. I told it was his to keep and he should start by making sure there was a copy in every treatment area so the PCP's would understand the importance! We then talked a little about NIH and he was very interested. He said most of it wasn't really his responsibility but he would be really intrested in seeing the results of all the testing. I promised him a copy! (Maybe he can shake something loose from the inside!) We wrapped it up with him telling me how much he appreciated having a PTN that cared enough to do the research I had done. He said I was "really challenging his memory"! Probably the best 45 minutes he had spent recently, IMHO. (The PTNs behind me may not agree since we went slightly over our 20 minute allotment!)

June 5, 2012

They are all smart enough to find anything, the big part of the problem is ego (sometimes ego is less than linear, meaning it's not overt arrogance that is the cause, but more "ignoring" the obvious) and "genetic" in nature in that it is passed down in internships and residencies as "rare" and in terms of PA and hypokalemia- including the infamous "It's JUST a borderline low potassium" for example - that goes untreated or even goes without considering a cause (which even in the face of fatigue and muscle aches they still do not consider the borderline potassium lows) both were brushed aside by their preceptors and senior docs who passed that mentality down to the next crop to come along.

I would guess a lot of docs who worked and trained under Dr G to this day put importance on ruling out or in PA, because Dr G and those around them did consider it and did rule it out or in.

I recall being in the hospital in late 2008 (uncontrolled HTN, rapid heart rate, low K, and a myriad of all the low related things to hyperthyroid too) when the physician assistant made rounds one night (the only night he did) and noted in my chart he'd checked thyroid and told me to "make sure" I talk to Dr Brogan in the am the next day about the hyperthyroidism, which the PA said HE had a hx of and that my case was alot like his own history of HTN. In the AM I brought it up with Dr Brogan who chuckled while telling me "Oh that's not it." And I know now that thyroid was part of it. But even for a prominent cardiologist like he was, and he did treadmills, echos, etc on me in the hospital, he never did a 24 urine or checked renin/aldo or anything related. It was ALL heart and nothing else. He sent me home still high on the BP and with a he didn't know.

From: <jclark24p@...>Subject: JC - Nepherology Update for WRJ, VT VAhyperaldosteronism Date: Monday, June 4, 2012, 9:19 PM

I had an appointment with the Neper. at the VA and found out I had a "very rare" disease! That was the start of his training lesson! When I stopped him and told him it accounted for 10% or more of the people with resistnt HTN he tried to pass over it but I didn't let him.After a little discussion he declaired it wasn't that high at the VA! I corrected him again and told him I bet it was and that the problem was that nobody "was smart enough to DX it!" (Sorry ) He pointed out that they "found my case" so I provided the timeline: Adenoma visable on a 2005 scan, renin = 0.1 on 2/22/2007 with a note from the lab "PA probable" and put on Spironolactone on June 2010 and "Proper testing done a month later while on 7 BP meds including Spironolactone!" I thought they might need to refine the procedure! I gave him a copy of the JNC7 reference card on "Prevention, Detection, Evaluation and Treatment of High BP" from NIH. He actually took 5

minutes and reviewed it, thought it was pretty good and tried to give it back. I told it was his to keep and he should start by making sure there was a copy in every treatment area so the PCP's would understand the importance!We then talked a little about NIH and he was very interested. He said most of it wasn't really his responsibility but he would be really intrested in seeing the results of all the testing. I promised him a copy! (Maybe he can shake something loose from the inside!)We wrapped it up with him telling me how much he appreciated having a PTN that cared enough to do the research I had done. He said I was "really challenging his memory"! Probably the best 45 minutes he had spent recently, IMHO. (The PTNs behind me may not agree since we went slightly over our 20 minute allotment!)

June 5, 2012

Thank-You for that article, I will make sure he gets a copy and share your 2-3

month experience.

I will also share it with the Quality Manager since that looks like the exact

model I was thinking about and had talked with her about. That's easily a

million dollar savings and an enormous QOL issue for the PTN!

>

> > I had an appointment with the Neper. at the VA and found out I had a

> > " very rare " disease! That was the start of his training lesson! When

> > I stopped him and told him it accounted for 10% or more of the

> > people with resistnt HTN he tried to pass over it but I didn't let

> > him.

> >

> > After a little discussion he declaired it wasn't that high at the

> > VA! I corrected him again and told him I bet it was and that the

> > problem was that nobody " was smart enough to DX it! " (Sorry )

> > He pointed out that they " found my case " so I provided the timeline:

> > Adenoma visable on a 2005 scan, renin = 0.1 on 2/22/2007 with a note

> > from the lab " PA probable " and put on Spironolactone on June 2010

> > and " Proper testing done a month later while on 7 BP meds including

> > Spironolactone! " I thought they might need to refine the procedure!

> >

> > I gave him a copy of the JNC7 reference card on " Prevention,

> > Detection, Evaluation and Treatment of High BP " from NIH. He

> > actually took 5 minutes and reviewed it, thought it was pretty good

> > and tried to give it back. I told it was his to keep and he should

> > start by making sure there was a copy in every treatment area so the

> > PCP's would understand the importance!

> >

> > We then talked a little about NIH and he was very interested. He

> > said most of it wasn't really his responsibility but he would be

> > really intrested in seeing the results of all the testing. I

> > promised him a copy! (Maybe he can shake something loose from the

> > inside!)

> >

> > We wrapped it up with him telling me how much he appreciated having

> > a PTN that cared enough to do the research I had done. He said I was

> > " really challenging his memory " ! Probably the best 45 minutes he had

> > spent recently, IMHO. (The PTNs behind me may not agree since we

> > went slightly over our 20 minute allotment!)

> >

>

June 5, 2012