Diary from a Week in Practice
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Am Fam Physician. 2002 Aug 15;66(4):597-598.
“Her other medical problems include methadone treatment of heroin addiction, hepatitis C, seizures, and chronic depression. Plus, she is under a lot of stress at home because her teenaged son is in a gang,” reported CG. The second-year resident was describing a woman in her late 30s whose chief complaint was chronic low back pain, which began after a car accident more than 10 years earlier. The patient was demanding a prescription for a narcotic pain reliever. Various other treatment modalities that had been tried in the past included nonsteroidal anti-inflammatory drugs, muscle relaxants, and physical therapy, but none of these had helped much and the patient was unhappy. CG discussed the patient at length with the faculty. Together they came up with a treatment plan, which included increasing her antidepressant medication and referring her to family counseling. She also received a long overdue Papanicolaou (Pap) smear. DE, the faculty member, commended CG for remembering to perform routine preventive services on such a complex, demanding patient.
During nursing home rounds, KS and PM, the second-year resident, were informed that one of the residents had a two-day episode of vaginal bleeding. The 60-year-old woman had sustained a severe head injury 25 years earlier, and she had been in long-term care ever since. She was completely bedridden and dependent in most activities of daily living. The patient was able to speak with some difficulty and always maintained a cheerful demeanor, despite her limitations. KS had taken over her care four years earlier. “As far as I know, she has never even had a Pap smear,” KS remarked to PM. She went on to explain that ordinarily frail nursing home patients do not benefit from regular Pap smears, because of their limited life expectancy. Instead, the nursing home physician focuses prevention efforts on improving or maintaining quality of life. But this particular patient had been stable for many years, and she could be expected to live for many more. “It seems to me that we ought to at least do a pelvic exam and make sure she doesn't have an obvious cause for the bleeding. After that, we will decide if anything else needs to be done,” KS suggested.
Determining a patient's prognosis can sometimes be challenging. KS was examining a frail woman who was suffering from the complications of longstanding diabetes. Earlier this year, she had been hospitalized because of diabetic foot ulcers. Now she had been readmitted to begin kidney dialysis. Having always been independent, she had insisted on returning home, despite her debilitation. Things had not gone well at home, and she needed to enter a long-term care facility. Her sister, who lived in a different state, was trying to decide if she should come for a visit. She had her own share of health problems, but wanted to see her sister before she died. KS had learned from experience that she was often wrong in predicting outcome in such cases. Her patient clinically looked worse than could be explained by her medical problems. KS knew how much she dreaded the thought of going into a nursing home, and she sensed that her exhausted patient was giving up. As KS spoke to the sister on the telephone, she advised her to come as soon as possible, even though the patient might live several more weeks, or even months. It would mean so much more to both of them if the ill sister were still able to converse and enjoy the visit.
“How wonderful to have been married 70 years!” exclaimed TA. She was seeing one of her favorite couples in clinic that morning—patients whom she had been treating for more than 10 years. Both had enjoyed good health all the way into their mid-80s. Sadly, the husband had been diagnosed with Alzheimer's disease two years earlier. His increasing forgetful-ness and behavior problems were becoming more than his wife could manage, and on the previous visit TA had broached the topic of long-term care in a nursing home. Since that visit, the couple had celebrated their 70th wedding anniversary, and the wife described how lovely the reception had been. TA quietly figured out that her patients had been teenagers when they married back in 1932. They never had any children, and were very devoted to each other. TA knew how the wife dreaded the prospect of moving her husband out of their home. She made a note to call the home health agency to get more information about how the couple was managing and to try to get them as much assistance as possible. If she could delay moving the husband to a nursing home for even a few months, it would make a big difference.
One of the second-year residents called KS from the emergency room to discuss a 70-year-old woman whom they both had seen many times. The patient had longstanding diabetes with complications, including chronic renal failure, congestive heart failure, and foot ulcers. She had a central line catheter because she was receiving home intravenous antibiotics for the treatment of osteomyelitis. The resident reported that although the patient looked fine and had normal vital signs, she was extremely anemic, with hemoglobin of 5 gper dL (50 g per L) and hematocrit of 17 percent. The patient complained of diarrhea for the past several days, and the resident postulated that she was losing blood from the stomach. Admitting orders included the transfusion of several units of packed red cells. When KS went to evaluate the patient, she found her sitting up in the examination room, complaining about lunch. Her vitals remained normal, she was not pale, and her conjunctivae were pink. In other words, she did not look severely anemic. KS decided to repeat the blood work, and was not surprised when the results came back with hemoglobin of 11, and hematocrit of 34. The nurse sheepishly recalled that the lab had been drawn through the central line and had been artificially diluted. KS and the resident were both reminded of the adage, “Treat the patient, not the lab!”
KS passed one of the third-year residents in the hallway. Noticing that he looked completely exhausted, she commented that he must have had a difficult night on call. “I wish I had been on call,” he exclaimed. “My wife is in labor and delivery is being induced for the third time. Neither one of us has had any sleep for two weeks!” Later that day, KS made a point to look for him in the delivery suite. The resident was standing by the nurse's station looking very excited. His wife was finally making progress and was already about 6 cm dilated. “I am a nervous wreck,” he admitted. “I have delivered nearly 50 babies and never paid much attention to the father's experience. From now on, I intend to include them in my discussions a lot more often.” He went back to his wife's side, having learned a more valuable lesson than any faculty or textbook could impart.
Kathy Soch, M.D., is a clinical instructor with the Corpus Christi Family Residency Program, affiliated with the University of Texas Health Science Center in San Antonio. This community-based program, which employs nine full-time faculty and 36 residents, primarily serves low-income, uninsured patients.
Address correspondence to Kathy Soch, M.D., 2606 Hospital Blvd., Corpus Christi, TX 78405. Reprints are not available from the author.
In order to preserve patient confidentiality, the patients' names and identifying characteristics have been changed in each scenario.
Copyright © 2002 by the American Academy of Family Physicians.
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