Diary from a Week in Practice



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Am Fam Physician. 2002 Jan 1;65(1):49-50.

Monday

God appeared at my office today. Based on appearance alone, you might not have guessed it was the Almighty. She looked to be in her mid-70s and was a bit disheveled. She rocked back and forth on the examination table and fingered the white paper covering it.

“I am the Lord,” the elderly woman announced. “I am God,” she repeated, speaking to no one in particular. When I last saw this patient in my office two months earlier, she proclaimed to be the King—Elvis Presley, not God. Despite her dementia, she was clearly moving up in stature. So far, the woman's delusions have not resulted in harm to her or anyone else, so I decided to continue her on a low dose of risperidone. I cannot help wonder who she will believe herself to be the next time she visits my office.

Tuesday

Needing to catch up on telephone messages, medication refills, and lab results, my “lunch” today consisted only of a chocolate bar and can of soda (so much for setting a healthy example). A voice from the waiting room bellowed, “Hurry. I've got a sick guy here.” I saw a pale man dripping with sweat, propped up by a co-worker. Clutching his chest in agony, my 46-year-old patient could barely articulate his complaint, “I feel like I need to have a 500-lb belch.” After receiving aspirin and sublingual nitroglycerin, Kent was transported to the emergency room. An ECG showed an acute inferior wall myocardial infarction. He received thrombolytic therapy and did quite well.

It turns out that the patient had been experiencing chest pain for a few months before his heart attack. With the help of a medical manual, his wife correctly diagnosed his symptoms as angina. Not satisfied with the diagnosis his wife made, Kent sought an alternative one. Scanning the same home medical guide, he discovered a diagnosis in the chapter on stomach disorders—a classic hiatal hernia. I am still not sure whether the patient's diagnosis was a classic case of denial or just plain wrong. It is clear, however, that his angina, masquerading as a hiatal hernia along with its 500-lb belch, offers proof that the way to a man's heart is through his stomach!

Wednesday

It has been said that when people lose the use of one of their senses, they sometimes develop an enhancement of one of the remaining four or compensate for the loss in other ways. That certainly seems to be true of Homer, one of my patients I saw today. Homer has been legally blind since the age of 35 as a result of retinitis pigmentosa and glaucoma. In spite of his blindness, the 64-year-old man walks all over town with the assistance of only a cane. Despite my admonitions, he continues to use his riding mower to cut the grass in his yard. Homer has even been spotted climbing onto the roof of his house to clean leaves out of the gutters. How he accomplishes these feats (and manages to survive them) remains a mystery. Perhaps Homer—blind as a bat—has also evolved a system of echolocation. Maybe he possesses some undiscovered internal global positioning system. While the rest of us are bumping into doors and tripping over curbs, Homer continues to navigate his world with what seems the greatest of ease. Homer's resiliency and courage are humbling. This blind man sees that when we abandon our fear, nothing is impossible.

Thursday

I often have a difficult time convincing some patients of the necessity of taking prescription drugs. I can understand their concerns about costs and potential side effects, but some patients simply have a hangup about taking prescription drugs. Consider the following examples from today's office visits.

An older woman refuses to use an inhaled drug for her COPD. Of course, she won't stop smoking, either. She has heard that inhalers are habit forming, and she opposes putting unnatural chemicals like medicines in her body. The irony of both statements is obvious to everyone but her.

A male patient's blood pressure is 170/98—again. He is unwilling to begin antihypertensive therapy because he has heard a lot of “bad stuff” about taking blood pressure pills—lack of energy, impotence, and the need to eat bunches of bananas. He is working on lifestyle modifications; I'm working to convince him that I'll find a drug that won't bother him.

Another female patient refuses to take any drugs in capsule and liquid forms. As if her options are not already limited, she also has a preference for the color of tablets. Blue is out; pink is best; and white is fine (except after Labor Day). Her tastes in prescription medicines give new meaning to the term “designer drugs.” Together, we conclude all her office visits by perusing photographs of pills in the Physicians' Desk Reference.

Friday

About five years ago, a male patient in his 60s made a reasonable request, “As long as I'm already in the office, would it be all right to get a chest x-ray, too?” We were making small talk while waiting for his leg to be x-rayed following a fall. Although Clarence had quit smoking cigarettes two years earlier, he had averaged more than two packs a day for about 45 years. He denied having any respiratory tract symptoms. There was no real indication for obtaining a chest x-ray except for screening purposes and the patient's obvious interest in having one. He said he thought a chest x-ray “might be a good idea.” You have probably already guessed where this story is headed. The x-ray of his leg was negative for a fracture, but his chest x-ray revealed a 1.5-cm nodule in the right upper lobe. A CT scan confirmed a spiculated mass. He underwent thoracotomy and right upper lobectomy for a poorly differentiated but localized adenocarcinoma.

At today's office visit, Clarence reported feeling great. We are both keenly aware of how his simple request five years ago probably saved his life. He still maintains that the idea to request the x-ray “just popped into my head,” but I believe that he knew something just wasn't right. It seems that intuition can work equally well for patients and physicians.

Saturday/Sunday

I was shopping at a local discount store when a woman stopped to say hello. Although she looked familiar, I could not recall her name or even how I knew her. We chatted briefly and then went separate ways. The woman, who was not especially attractive, had a large mole on her left cheek with a thin brown hair emanating from it. Suddenly I remembered how I knew her. A few years ago, while making hospital rounds one Sunday morning, a confused elderly man in a geri-chair began yelling. A thoughtful young nurse quickly sat down next to him, held his hand, and spoke soothingly to him. Within seconds, he was calmed. As she gently wiped the remnants of breakfast from his face, the man lunged at the nurse's head. I moved toward the man, concerned that he was attacking her. But he only wanted to touch her mole. The nurse moved her head away and kept the nevus out of harm's way. She continued comforting the patient with the compassion and interest one might show their father or child. I feel ashamed that I did not recognize that wonderful nurse because, I now remember, that she was one of the most beautiful people I have ever seen.

In 1995, after 12 years in solo private practice, Dr. Tony Miksanek joined the St. Mary's Good Samaritan Hospital system. He is the medical director of and sole physician in the hospital's Benton, Illinois rural health clinic, which also employs a full-time physician's assistant. Dr. Miksanek sees all kinds of patients, and many of them are elderly.


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