MCPN Hoffman Heights

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MCPN Hoffman Heights

• Theresa Medina
• John Perna, MD
• Lea Casperson, MD

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Whats coming?

• What is MCPN?
• Who does it serve?
• What services does it provide?
• What is wrong with Maria?
• Who is part of the community that is involved in
  her care?

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What is MCPN metro community provider network?

• MCPN is a nonprofit organization that provides
  medical services and health education to the
  underserved since 1989.
• Developed to provide primary health care services
  for people without access to health care.
• Serves the largest number of underserved
  individuals in the State.
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• There are clinics in Jefferson, Arapahoe, Adams
  and Park Counties and the City of Lakewood and
  Aurora.

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MCPN Hoffman Heights
Hoffman Heights Shopping Center 6th and Peoria,
Aurora, CO
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Who are the patients?

• 73 of MCPN patients are at or below the poverty
  level

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Overview of health services provided

• At each clinics there is a limited pharmacy and
  lab support, staffed by a quest diagnostics
  employee.
• There is a staff dedicated to helping patients
  work through medical financial aid program
  applications.
• The Reach Out and Read Program promotes childhood
  literacy by giving books to every child at each
  well-child visit.

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Promoting Health Education

• Maternal child health
• Diabetes groups
• Smoking cessation classes
• Walking clubs

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Maternal child health classes

• Childbirth education
• Breastfeeding support and education
• Gestational diabetes classes
• Doula services
• MCPN walking clubs

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Diabetes education

• New diabetic workshop
• Diabetes self management education
• Diabetes support group
• MCPN walking clubs

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Maria O. 35 yo G2 P1

• Maria presented to University L/D at 39 weeks
  EGA.
• She was complaining of painful oral ulcers
• She had a max fever of 39 C (102.2 F)

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Was this a case of HSV?

• The decision was made to do C/S on suspicion of
  primary herpes simplex virus outbreak and treat
  her with acyclovir
• Serology later showed
• HSV IgM AB Screen not detected
• HSV IgM AB Titer not detected
• ESR 36 (ref range 0-20 mm/hr)

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Herpes Oralis
Buccal Mucosa
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1 week post partum

• Maria was seen by Dr. Perna, baby was still in
  the hospital
• She did not think it had improved
• She had numerous ulcers and swelling inside her
  mouth
• Her gingiva and gums were infected
• She was treated with shot-gun approach of
  doxycycline and a nystatin suspension

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2 weeks post-partum

• Maria was seen by Dr. Perna and myself, noted to
  have 3 lb. weight loss.
• She states the sores are getting better but have
  not gone away
• There were multiple sores on both sides of the
  buccal mucosa, palate and sides of her tongue
• She was told to finish doxycyclin/nystatin

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3 weeks post partum

• Maria says that the oral sores and pain have
  returned, an additional 6 lb. weight loss
• She also complains of painful bullous lesions on
  her arms, back, abdomen, chest, groin.
• She has a positive Nikloskys sign

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Dr. Perna now suspected she may have
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Pemphigus Vulgaris

• Auto-immune disease
• IgG antibodies against surface antigens on
  stratified squamous cells
• Causes disintegration of epidermis and blister
  formation
• Incidence is 0.1 0.5 in 100,000 in US

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Diagnosis and Treatment

• Punch biopsy of erupted vesicle and adjacent
  normal skin confirmed the diagnosis
• She was started on 80g of prednisone QD
• She was referred to dermatology but was denied

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Follow up visit

• Maria was extremely happy to have a diagnosis
• Even more so she was relieved to be free from
  pain and the bulla
• Her weight had returned to the same as her first
  visit
• The prednisone was reduced by half and will be
  tapered slowly until a maintenance dose is
  established

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Who will take care of Maria?

• Maria needed/needs care from several providers
• Dermatology
• Dental
• Psychiatry
• PCP
• nutritionist

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The downside of public health

• Maria exemplified the patient population at MCPN
• The standard of care for patients is generally
  less than the guideline recommendations
• Many patients are denied access to the
  specialized care they need because of their
  financial situation
• Maria probably will not receive the follow-up
  care that would be considered standard if she had
  insurance