One of the important aspect of having a primary care in your care team is reduction of risk of adverse events during and after the surgeries.  We provide Pre Op Visits to our patients approximately three to four weeks before the planned date of the surgery. 

It is very important to have this Pre-Op visit with your primary care. We monitor 14 different subsystems and hence are well equipped to asses the risk and then mitigate it through medicine changes, control of lab levels and management of the care plan post surgery.

What happens before the Pre Op?

1. Please book an appointment that is at least three weeks prior to your surgery.
2. Ask your surgeon to send a pre-op request to us (your primary care) ; This request can specify the procedure planned and labs expected.
3. Show up for your Pre-Op appointment. Please let the front office know you are here for the Pre-Op. Do not discuss your other problems during this visit.

What happens during your Pre Op visit?

1. Your primary care physician will assess the procedure planned and agree for the procedure. You can discuss about the procedure and risk and benefits.
2. Our office will do certain labs as requested by the surgeon or your primary care physician
3. We may also send additional referrals if your condition warrants
4. We collect all the information from lab, imaging and consults and your primary care physician assesses if procedure is safe given your condition. Your physician communicates her decision along with risk score for the surgery (calculated if enough data is available)
5. We also make you read our surgery check list so that you can plan a safer surgery and a safer care giving at home
6. You also book an appointment to see us after your surgery (Post Op Visit)

If you need any additional care giver help, we will provide you signed orders so that you can set up additional care (home health, physical therapy) 

Why Pre Op should be done at your primary care ?

1. Your primary care physician knows more about your other conditions than the surgeon who is operating.
2. Your surgeon's office knows less about what primary care is. 
3. Certain medications need to be stopped for adverse events during surgery. They need to be restarted after the surgery. 
4. After the surgery you need more primary care intervention to ensure healing. 
5. Hospital discharges you to a primary care and we need to be prepared to ensure care coordination that may be required.

Can I discuss my regular chronic conditions during pre-op visit?

1. You must not discuss your chronic conditions during your pre-op. Your pre-op is a special appointment to focus on the procedure planned and get risk mitigation done for the procedure.
2. Typically your provider has to spend half an hour going over your procedure plan and make suggestions to reduce the risk. 
3. By keeping your pre -op focused on pre-op you are making sure your procedure has no adverse effects.
4. Pre-op visits also need a coordination work to get your imaging, lab work, EKG etc. So there is hardly any time left to address anything else. 

How can I improve my pre-op visit?

1. Schedule your pre-op from the link below approximately 3 weeks before surgery.
2. At the time of scheduling please have your surgeon write you note describing what procedure is planned and what surgeon wants done.
3. Please upload this note in your visit. When you book appointment online and specify you need a pre-op you will be asked to provide surgeon's request.

This is another true story of a great save. Patient set up care with us because his insurance wanted a letter for annual physicals.  We did annual physicals and noted all the baseline values in the chart and told the patient to see us for health issues. Patient subsequently booked appointment with us following an ER visit for worsening abdominal pain. During this visit, we noted the tell tale signs of something very serious but missed out by the ER. Patient had elevated Lipase in thousands! But ER nurse practitioner forgot to connect the dots for elevated lipase and abdominal pain. 

We insisted that patient go back to same ER and get tests done and provide differential diagnosis so that ER nurse practitioner can fix the earlier miss. They were reluctant to repeat the imaging (Earlier imaging said ulcers) ; When imaging was repeated after we provided the differential diagnosis, the radiologist confirmed pancreatic cancer. 

If you have elevated Lipase make sure you get checked for Pancreatitis. After ER visit or hospital visit, book a follow up appointment with your primary care.

Good primary care treats you for most of the issues. Great primary care puts your interest above that of the third parties  who have infested healthcare in America.  Patient was very reluctant to go back to ER  for talking to them about elevated lipase. But we are glad he changed the mind after our persistence and pancreatic cancer was not missed. 

We are getting reports on the progress of the patient through chemo and surgery and we are glad that our patient is safe. 

Antibiotics are used to treat or prevent certain types of bacterial infection. Antibiotics are effective only against bacteria. They do not work for viral infections. Also we have increased resistance to common antibiotics in our community, so this post.

We do not prescribe antibiotics in following cases.

1. Mild bacterial infections which are likely to get better on their own.
2. Viral infections

This policy has many positives. 

1. By not taking antibiotic when it is not necessary, you are protecting your gut biome. 
2. If you take antibiotic when it is not necessary, in future antibiotics may not work for you. (Antibiotic resistance)
3. Body's immune system can fight small infections and using less antibiotic drugs means your immune system gets a chance to fight infections  

We prescribe antibiotics only when

1. There is strong evidence that your infection is not likely to clear up without antibiotics
2. You are actively infecting others
3. You carry a risk of other serious complications

Please trust our judgment. When we say antibiotics are not required most likely they are not.

When we prescribe antibiotics 

1. We do not shoot in the dark. We get a lab culture done to identify which is the strain of bacteria and we call medicine that works the best for that strain. These days we are using PCR tests to quickly identify the strain and we can often get the results next day itself.
2. We ask you take a probiotic , so that your gut can repair itself. Many a time we prescribe probiotics. However home made yogurt is as effective as probiotic pills. So help yourself to large servings of yogurt. 

If you are on antibiotics,

You may notice side effects such as:

• being sick
• feeling sick
• bloating and indigestion
• diarrhea

Sometime you may develop very serious allergy (anaphylaxis) and may need immediate medical care. So if you are taking antibiotic for the first time, please plan time to watch out for any serious symptoms. 

Angular cheilitis, also known as perlèche, is an acute or chronic inflammation of the skin and contiguous labial mucosa located at the lateral commissures of the mouth. It typically presents with erythema, maceration, scaling, and fissuring at the corners of the mouth. Lesions are most often bilateral and may be painful.

Angular cheilitis is caused by excessive moisture and maceration from saliva and secondary infection with Candida albicans or, less commonly, Staphylococcus aureus . Angular cheilitis may occur at any age without sex predilection but is especially common in older individuals wearing dentures. Predisposing local factors include wearing orthodontic appliances or ill-fitting dentures, sicca symptoms (dry mouth), intraoral fungal infection, poor oral hygiene, and age-related anatomic changes of the mouth due to reduced vertical facial dimensions 

Diagnosis

Dr. Kamat will do the clinical diagnosis after looking at your skin. In some instances to rule out candida or other infections, we may take a swab and send it to the lab.

Treatment

In our community we have observed that one of the contributing factors is vitamin deficiency. So we ask patients to take multivitamins. Patients must also avoid smacking the lips. Patient can also  start using topical aloe vera, sun protection (hat),  topical hydrocortisone. If drooling is a contributing factor, please use vaseline before going to bed. Typically your inflammation must resolve in a week of treatment.

Prevention

1. Continue taking multivitamins
2. Improve oral hygeine
3. Use moisturizer to avoid dry lips
4. Improve denture  fit and cleaning(if using) 

Patient Questions:

1. Where do I find a good Aloe Vera?

There are many Aloe Vera creams in the market. Look for something that has purer Aloe Vera and no fancy chemicals or mineral oils. Aloe vera is a moisturizer. Alcohol dries the skin. So if the product lists out alcohol along with Aloe Vera, it may not be very effective.   

You can get Aloe Vera at H-Mart in Aurora. You may also get this from other Asian and Mexican Markets.

If you buy Aloe Vera you can make Aloe Vera Gel at home following instructions from WellnessMama. (We have requested permission to share this link)