Diary from a Week in Practice
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Am Fam Physician. 2002 Mar 1;65(5):833-835.
Misdiagnosis. The very word is an anathema to physicians. It connotes error, failure, and, perhaps, a threat. There is little comfort in the knowledge that all physicians make mistakes. When we make an incorrect diagnosis, it can haunt us—even when no harm befalls the patient. Two weeks ago, a middle-aged woman came to my office with epigastric pain and symptoms of acid reflux. JW had been taking a nonsteroidal anti-inflammatory drug for shoulder pain. There were no “red flags” such as weight loss or dysphagia to suggest any ominous process. We agreed to treat her symptoms with a proton pump inhibitor with the understanding that if the pain did not resolve, further diagnostic testing would be required. Today, the epigastric pain belongs to me. Shortly after JW's initial visit, the pain worsened. An electrocardiogram demonstrated dramatic ischemic changes, but an acute myocardial infarction was ruled out. Cardiac catheterization studies revealed severe single-vessel disease. She underwent PTCA and successful stent placement. This patient did not have even one risk factor for coronary artery disease and, retrospectively, her symptoms did not sound like angina. JW is doing well. I am dealing with the error I made. Fortunately, we can all learn from our errors, especially with the help and understanding of our patients. The best lessons are sometimes the hardest to accept, but they are also the lessons we take to heart.
Sometimes it's the little things that matter the most. I was reminded of that when DK, a sturdy 37-year-old man, came in for his final follow-up visit today and announced, “I'm 100 percent better!” It was only eight days ago that he dragged himself into the office saying, “I've never been this sick in my life.” Clammy, weak, and wheezing, his self-assessment seemed right on the mark. DK had left-lower-lobe pneumonia and appeared ill enough to hospitalize. He elected to slug it out at home and in the office. Over the course of a week and a half, we threw just about everything at his infection—two antibiotics, three inhalers, cough syrup, fluids, rest, and, of course, the obligatory chicken soup. I saw him in my office every other day. Between visits, I fretted over his condition and called him at home in the evenings to check on him. Today, DK looked like his old self again. Before leaving the office, this tough guy made a comment I didn't expect, “I've never before been called at home by a doctor. I just can't tell you how much that meant to me.” Sometimes physicians make the biggest impact on their patients' lives with the smallest gestures.
I smelled trouble the moment I entered the examination room. A stench filled the air, and even AH's heavy perfume could not mask the odor. I had not seen this 61-year-old woman in more than four years. She came to share a secret that she had been harboring for almost one year. A small lump that AH discovered in her left breast had grown into a mass during the past few months. She could no longer hide or disguise it. It wasn't the size of the tumor or even its constant drainage that forced her acquiescence, but rather the terrible odor emanating from the site. Blood and exudate stained the paper gown that I gently uncovered to examine what remained of her breast. Much of it had been replaced by a large, ulcerating, malodorous mass. At that moment, I was not sure what disturbed me more—the cancer, the smell of rotting flesh, or the notion that AH had knowingly nurtured the malignancy for so many months. AH repeated her dislike for going to doctors and her inability to afford medical care. We sat there for some time, even after agreeing on a course of action. All the while her tumor continued weeping through the paper gown as I struggled to hold back my tears.
One of the hardest things for a physician to do is nothing. RO is a 79-year-old woman who is dedicated to remaining healthy. She eats right and exercises religiously. She has already logged more miles from her daily walking regimen than most of us will ever aspire to. I was mildly surprised when she came into the office with low back pain radiating down her left leg. “I've got a doozy of a back ache, and my leg kind of tingles. I just don't have time to be sick,” she announced. There was no history of injury or strain. Her examination was similarly unrevealing. Thoughts of obtaining lumbar spine radiographs, a complete blood count, sedimentation rate, and urinalysis flashed through my mind, but I knew RO would have none of that. I suggested we simply treat her symptoms and see what happens. Before I could finish scribbling a prescription for nonsteroidal anti-inflammatory drug and codeine for breakthrough pain, Ruth informed me that she would take acetaminophen and call back if she didn't feel better. Forty-eight hours later, she telephoned me asking if the patches of blistering rash on her left buttock and leg might be an allergic reaction or insect bites. RO is back to walking three miles a day, waving to everyone she sees, and not one step slower since her bout with shingles. Time is often our ally. We just need to know when to enlist it.
On most autumn Friday nights, a revered ritual takes place in southern Illinois—high school football games. For at least one evening, half of the small towns in our region can claim bragging rights to the best team and, by extension, the best city. On one memorable night, a single play made a game of football both tragic and insignificant. RB is a tough 16-year-old athlete who had a helmet-to-helmet collision with another player. When he reentered the defensive unit's huddle, his teammates noticed he was unsteady, his speech was slurred, and the left side of his face was drooping. RB admitted he had a bad headache and that his left hand felt numb. As the ambulance transported him to the hospital, the crowd never considered or would have believed that this healthy teenager had just suffered a stroke on the football field. Yet his evaluation confirmed a right-sided, middle-cerebral artery hemorrhagic stroke secondary to a right carotid-artery dissection. Thanks to RB's grit, determination, loving family, and the resiliency of youth, he has achieved a personal victory that inspires all who know him. He has recovered sufficiently to participate in another high school sport. He now plays on the golf team where he hits a small ball with the same ferocity he once tackled opposing football players. And, if anything, the cheers for RB are louder than ever.
One of the nuances of practicing medicine in a small town is that I do not get many “drug seekers.” When I do stumble across the occasional person searching for prescription drugs, it is not narcotics or benzodiazepines that they usually want. Rather, it is antibiotics. Many people believe that antibiotics will cure just about any ailment. Even if this class of drugs turns out to be inappropriate or ineffective, folks still seem to derive a sense of security from knowing that a bottle of their favorite antibiotic is in their medicine cabinet. “While I'm here, would you mind writing a prescription for sulfa just in case I happen to get a bladder infection like I had last year?” a young woman requested. “Doc, how about giving me a couple of refills on that amoxicillin…so I don't have to bother you the next time I get a sinus infection?” a middle-aged man asked. “My husband has the same thing that I do, but he won't come in to see you. Would you mind writing a prescription for him also?” a woman pleaded. It's often difficult to convince patients that they do not need antibiotics. And when I refuse to give some patients what I consider unnecessary antimicrobial agents, they clearly don't understand that I am trying to protect them.
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, Ill., 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.
Copyright © 2002 by the American Academy of Family Physicians.
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