Diary from a Week in Practice
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Am Fam Physician. 2002 Oct 15;66(8):1426-1429.
PC, a second-year resident, was examining an eight-year-old boy who complained of nasal congestion and cough that had lasted for three days. Aside from a red throat, PC noted the presence of darkened, velvety skin around the child's neck and elbows. canthosis nigricans is commonly seen in school-aged children in south Texas. This condition can be a marker for insulin resistance, indicating that the patient is at increased risk for developing type 2 diabetes. Most of these children are overweight, and one or both parents have already been diagnosed with diabetes. This particular boy weighed in at well over the 95th percentile, and PC was chagrined to notice that he was drinking a 20-oz soda. The treatment for acanthosis nigricans is diet and exercise. PC explained to the mother that the boy had an upper respiratory infection that would resolve without treatment. But more importantly, he discussed the significance of the black spot on the back of her son's neck. He recommended that the whole family learn about the components of a healthy diet and made a referral to the dietitian. “I keep telling him to scrub behind his ears,” the mother admitted. “It never occurred to me that a dirty neck could be a sign of diabetes.”
Even when patients have completed an advance directive and durable power of attorney, decisions at the end of life can be difficult. KS was examining a 74-year-old woman who had been her patient for nearly 10 years. The woman had always been in excellent health, except for well-controlled hypertension. Two days earlier, she had an intracerebral hemorrhage, and she was now unresponsive. She would occasionally open her eyes, but she exhibited no purposeful movement or awareness of her environment. Her husband was devastated. He knew that his wife did not want treatments to keep her alive if there was no hope of a good recovery. She had told her physician and her family that she did not want a ventilator or feeding tubes “just to keep me alive.” KS explained to the family that the chance for improvement was very small. Both the family and the physician wanted to give the best care, while at the same time honoring the patient's wishes. After several discussions, they decided to try tube feedings for two weeks. If there was no improvement, they would discontinue the feedings and let her die peacefully.
“Do you remember that cute, six-month-old boy who cocked his head to the side?” CCG asked third-year resident RD. Both residents had examined the child several weeks earlier when his mother brought him in for treatment of bilateral otitis media. At first, CCG thought that the cheerful little boy (smiling despite obvious ear infections) was just being playful. She examined his neck, which was supple and flexible, but the minute she stepped away he tilted his head back to the left side. She questioned the mother, who replied that her son just seemed to prefer that position. Puzzled, CCG asked RD to take a look. He watched the child for a few minutes, then took out a pen-light and checked the child's papillary light reflexes. They were obviously asymmetrical. The two residents concluded that the little boy had strabismus and that he cocked his head to the side so the world did not look double. The child was referred to ophthalmology, and he was found to have a congenital superior oblique palsy of the eye with anomalous head position. There was no evidence of amblyopia, so they decided to observe him until he is about one year old, and then plan strabismus surgery.
A 78-year-old woman presented for an annual examination. She was in excellent health, except for osteoarthritis affecting both shoulders. She remained extremely active as a volunteer in her church and various social organizations. On the last visit, just over a year ago, the patient had mentioned that she was concerned about memory loss. She was writing lists nearly every day to keep track of her many activities, and she felt somewhat overwhelmed. Her husband and children felt that her memory was completely normal “for someone her age.” KS had administered a Mini-Mental State Examination, and the patient scored 28 out of 30 points. Although the score was in the normal range (normal is 25 points or higher), KS had recommended that she repeat the test in six months. The woman laughingly admitted, “I am glad to say that I remembered what you suggested. I was just afraid to think that I might be developing Alzheimer's disease, so I avoided coming back.” Explaining that there is good treatment available for Alzheimer's dementia, KS encouraged her to repeat the test. They were both relieved that the repeat score was a perfect 30. “I must have been nervous the last time!” the patient declared.
“Doctor, don't you think this supplement is a lot safer for me than the medicine you prescribed for my high cholesterol?” asked the 54-year-old woman who presented for follow-up of hypertension and hyperlipidemia. She held a bottle of pills in her hand that contained an herb with which KS was not familiar. The patient had started a CoA reductase inhibitor about one year earlier, with excellent reduction in low-density lipoprotein cholesterol levels. Her liver enzymes remained normal, but the patient was concerned that she had to have regular blood tests. The clerk at the health food store had assured her that the herbal medicine was safe and effective for lowering cholesterol levels. “He certainly didn't recommend any lab tests, so I'm sure this drug must be safe,” the patient insisted. KS explained that she could not provide such reassurance, because supplements are not subject to the same testing as prescription drugs. She reminded her patient that checking liver enzymes twice a year and discontinuing the drug if abnormalities occurred would protect her from the slight risk of hepatotoxicity. But the woman was not convinced. KS finally decided to repeat the lipid panel to determine if the supplement actually worked. After a trial period with the supplement, the patient's cholesterol was very high again. Only then did she agree to return to the prescription drug.
Sometimes KS has to bite her tongue so as not to chuckle out loud. She was evaluating a woman in her 30s who complained of being tired all the time. The patient had no specific complaints and was not depressed. The physical examination and laboratory tests were completely normal. KS asked her patient to describe a typical day, and the response was just what she expected. A single mother of two, the woman woke up at 6:15 a.m., barely in time to get the children to school and herself to work. She ran errands at lunchtime, picked the kids up at 5 p.m., shuffled them to various activities, made dinner, helped with homework, and somehow found time to drop in on her elderly parents. She dropped into bed exhausted at 11 p.m. “It's no wonder you feel tired all the time!” KS observed. The two discussed ways to lower the young mother's workload—perhaps by limiting the children's activities or getting outside help with housework.
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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