Diary from a Week in Practice
Am Fam Physician. 2002 May 1;65(9):1795-1796.
The events of September 11 have affected all of us in many different ways. Physicians are especially aware of the toll that terrorism has exacted. Some people now refuse to fly on airplanes. Others fear opening their mail. Suddenly ciprofloxacin (Cipro) has emerged as a more valuable drug than sildenafil (Viagra). My concern is that the threat of terrorism has eroded the innocence of our youth. Today, a normally rambunctious 10-year-old boy was brought to the office by his mother. His symptoms included a low-grade fever, nasal congestion, and nonproductive cough. The examination suggested a viral upper respiratory tract infection. I was surprised by his unusual stillness and attributed his reticence to probably feeling lousy. Before leaving, the boy broke his silence with an unexpected question, “How do you feel if you've got anthrax?” After clearing the large lump from my throat, I reviewed the symptoms of anthrax with him and reassured the child that he absolutely did not have the disease. Our country will recover from the terrible acts of violence perpetrated on us recently, but we better not forget about our children in the process. Our nation's youth will have to be brave and informed to live in this new world.
Life is a balancing act, and nowhere is that more evident than in the care of patients with congestive heart failure (CHF). Although 92 years old, Millicent was an avid gardener who found it hard to ever sit still. When dyspnea and increasing fatigue resulting from CHF began to affect Millicent, her vitality and indomitable spirit appeared to slip away. She tired easily and was embarrassed by a frequent need to urinate, caused by diuretic therapy. Millicent's solution to the problem was not unique—she lowered the dose of furosemide and sometimes even stopped taking it on her own. On one occasion, her “solution” nearly resulted in her demise. I worried that she might not make it through the winter. She grudgingly accepted the use of a wheelchair and home oxygen. Months passed and Millicent somehow hung on. Spring has finally arrived and many of the perennials around here—roses, irises, and peonies—are showing signs of blooming. Amidst that group of flowers, one seems to be flourishing beyond all others. Smiling and adorned with makeup, Millicent sprouted out of her wheelchair today and announced that she was ready to start working in her garden. We exist in a state of fragile equilibrium, and I am always grateful to be a part of it.
Diagnoses are sometimes made in the most unusual circumstances. A high school junior injured his left middle finger during a football game when it was smashed by an opposing player's helmet. He came to my office seeking advice on how to care for his broken finger. I observed only mild tenderness and swelling of the injured finger without any bruising, bony deformity, or limitation of range of motion. “Why do you think your finger's broken?” I asked. “I don't think it's broken,” he replied looking at me as if I were incompetent, “I know it is.” He reached into his pants pocket and produced three tiny dental radiographs, each one roughly the size of a matchbook cover. Sure enough, the miniature x-rays demonstrated an oblique fracture of the proximal phalanx. Because I was not at the game where he was injured, this football player improvised and settled for the next best thing—the local dentist! In our small town, there's no such thing as false advertising. “Full service” dentistry is just that.
It's wise to be careful what you tell people…or at least how you tell them. Your words just might come back to bite you. Today, the wife of a patient reminded me of my utter failure as a prognosticator 10 years ago. At that time, her husband was 46 years old and had just had a second myocardial infarction (MI) within two years. Unfortunately, he had not learned his lesson from the first one. He remained overweight, continued to smoke cigarettes, failed to closely follow up with his physician, and seemed to have little interest in modifying any of his many cardiac risk factors. Outside the intensive care unit, the man's wife asked me a reasonable question, “What does the future hold for my husband?” Without thinking, I uttered what was on my mind but absolutely should never have been said aloud. “I'm worried that you might end up a young widow.” The moment I blurted it out I regretted saying it. To this day, I have never forgiven myself for making such a crass statement. I'm happy to report that the man is still alive even though he has recently experienced a third MI. Some things are better left unsaid except perhaps “I'm sorry.”
Have you ever noticed that the sickest patients usually walk into the office at about 4:45 p.m. on Friday afternoons? I met a 77-year-old woman for the first time after her husband coerced her into seeing a doctor. It had been at least 20 years since she last saw any physician. Her husband provided the woman's chief symptom, “She's really sick.” His assessment was succinct and accurate. She was dyspneic and appeared nearly cachectic. Abnormal findings on examination included decreased breath sounds, tachypnea, rapid atrial fibrillation with a ventricular rate as high as 170, splenomegaly, and a right-sided abdominal mass. After admitting her to the hospital, the lab notified me with a “panic” result. Her white blood cell count was a whopping 587,000 per mL with 95 percent lymphocytes. Subsequent venipunctures during her hospital stay continued to yield leukocyte counts in excess of half a million. A bone marrow biopsy confirmed the diagnosis of chronic lymphocytic leukemia. Despite her record-setting blood count for the hospital, hematologist, and her family physician, the patient was unimpressed. “It's been so long since I've seen a doctor, I guess I just saved everything up until now,” she drolly commented. Thank heavens for nice patients with a sense of humor…and the subspecialists who assist us in caring for them.
Ernest is a middle-aged banker with hyperlipidemia. He was good with numbers in all ways but one—he never could manage his lipid levels. When his cholesterol level hit 315 mg per dL and his triglycerides soared above 1,600 mg per dL, I told him it was time to write a prescription for a statin agent to lower his lipids. “Put that pen down,” Ernest commanded, “I'll fix them without taking any medicine.” He had not previously shown much interest in losing weight, exercising regularly, and following a healthy diet. I was skeptical he could do it. However, Ernest was not just insistent but supremely confident that he could “work the numbers” in his favor. You can imagine how impressed I was a couple of months later when this banker's investment in his health paid off handsomely—his cholesterol was reduced by more than one half to 140 and his triglycerides were down to 165. And along the way he had lost 30 lb. Sensing my amazement at his remarkable achievement, Ernest pointed out, “You've not known me as long as I have.”
Determination is a valuable trait, and we should help our patients discover and nurture it. Some of them, like Ernest, have already unlocked their potential despite their physician's initial lack of faith.
Copyright © 2002 by the American Academy of Family Physicians.
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