119. Scratch-Itch Cycle

Joanna presents with severe itching and pain in the "groin"--the crease or junction between the thigh and the torso (or more specifically, the vulva).  The area is a bright red patch with superficial excoriations--she has scratched herself so much that there are tiny breaks in the skin, which causes further irritation and more scratching. The goal is not so much to determine the original cause of the irritation as it is to stop the scratch-itch cycle.

But she is fixated on that original cause, certain that it started in a "conversation" tub at a nudist resort in Florida. She wants me to know that she simply accepted the invitation of some friends, not knowing it was "that kind of place."

It looks and sounds fungal but fearing a secondary bacterial invasion I provide both anti-fungal and anti-bacterial meds.  A subsequent culture confirms a bacterial infection.  And most important, I give her the strongest topical steroid that I have, whose anti-inflammatory actions should stop the scratch-itch cycle.

A week later she is doing great, the skin healed and no longer red and tender.  I've already been back in the water, she says, apparently having learned little from the episode.

118. Obamacare

Tubal "ligation" really means "transection"

Last year, at 34, 10 years after the birth of her second child and tired of taking birth control pills, Janet decided it was time too do something permanent.  But when she inquired about an operative tubal ligation, she found it wasn't covered under her insurance; she'd have to pay $6000.

This year she asked again and was told that effective August 1st, the Affordable Care Act requires that eight health care prevention services for women be offered at no cost, including contraception. She's scheduled for Aug 31st.  And that's that.