Diary from a Week in Practice



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Am Fam Physician. 2002 Nov 1;66(9):1645-1646.

Monday

Once in a while, we all need a hug. Margaret, a 73-year-old woman, had developed the sudden onset of difficulty speaking. Everything she attempted to say came out garbled and fragmented. A noncontrast computed tomographic scan of the head was negative, but the following day a magnetic resonance imaging scan of the brain demonstrated an acute infarction in the dominant speech territory of the left cerebral hemisphere, including Broca's and Wernicke's areas. Margaret's left internal carotid artery was completely occluded at its origin. She was treated with intravenous heparin and, later, warfarin. Speech therapy and physical therapy occupied much of her time in the hospital. She became frustrated by how little progress she had made. “Stick with it,” I implored her. “Show me what you can say today.” I felt more like her coach than her physician. Like so many poststroke patients, Margaret seemed on the verge of depression, but the promise of going home lifted her spirits. As I reviewed discharge instructions with her and her family, I gave Margaret one last pep talk. “You've done a good job. Keep working hard at home with your speech therapist.” Her eyes welled with tears and she gave me an unexpected hug. “Ank ou,” Margaret answered. It was my turn to be speechless, because I could not recall ever receiving a more articulate expression of gratitude.

Tuesday

Chalk up another possible hazard of the Internet. “My leg has really been aching for the past few days,” Garrett informed me as he rubbed the back of his left leg up and down. “Crazy thing is, I don't remember hurting it. I just turned 50 last week, and I'm already falling apart.” Garrett's left calf was tender, it measured one-half inch more in circumference than his right calf, and Homan's sign was positive. A venous Doppler study confirmed a deep venous thrombosis of the left leg. Once we made the diagnosis, both Garrett and I wondered why a healthy man would form a clot. He had no obvious risk factors or precipitating events like recent travel, trauma, prolonged bed rest, or malignancy. It was Garrett himself who offered a plausible explanation. “I love surfing the Web and spend lots of time at home on my computer. I sit with my legs propped up on the computer desk and sometimes fall asleep in that position for two or three hours. Do you think that might have something to do with it?” His theory, “computer clot,” was as plausible as my explanation, idiopathic thrombosis without provocation. They say life begins at 50, but for Garrett, so did a blood clot and a most unusual type of computer glitch.

Wednesday

Jeremy is an 11-year-old boy with a history of mild asthma. In the past few months, he has experienced three episodes of gagging and even choking while eating meat. His mother made sure he ate slowly, chewed each mouthful of food 30 times, and washed it down with a bolus of water or milk. “I just know something's wrong with him,” Jeremy's mother lectured me. “Find out what it is.” Her child sat on the examination table looking like a picture of health with nary a care in the world. A barium swallow and upper gastrointestinal (GI) series of x-rays were normal. His mother was pleased with the results but remained unsatisfied. I referred him to a gastroenterologist who specializes in children, and Jeremy underwent an upper GI endoscopy procedure. Marked esophagitis was present and confirmed by histology. Jeremy was treated with lansoprazole (Prevacid), and to this day he has not experienced any further episodes of dysphagia. Not surprisingly, his mild asthma virtually disappeared with acid suppressive therapy. At first, the moral of this encounter might appear to be that if something just doesn't seem right, it probably isn't (regardless of the results of the barium swallow study). Yet, the true lesson learned remains a familiar one—mother knows best.

Thursday

Peter is an easy-going 41-year-old man who took up rock collecting. Or, to put it more accurately, rock collecting sort of discovered him. He became so tired of experiencing renal colic that he finally decided to submit to something that he considered only a little less painful—a trip to the doctor. “I don't mind so much making kidney stones,” he told me at our first-ever office visit, “but I sure as heck hate trying to pass them.” He handed me evidence of his predicament—three tiny calculi carefully wrapped in toilet paper. Chemical analysis revealed they were all calcium oxalate stones. In the past two years, Peter had recovered seven kidney stones that he had passed. “Ouch,” was all I could say to describe these experiences. His total serum calcium was 11.8 mg per dL, ionized calcium 6.8 mg per dL, and serum phosphorus 2.7 mg per dL. Urine calcium was elevated at 665 mg per 24 hours, and the parathyroid hormone level was also elevated. I referred him to an endocrinologist for further management of his hyperparathyroidism, and Peter subsequently underwent parathyroidectomy. At surgery, a single enlarged right upper parathyroid gland was removed. It was an adenoma that weighed 3.5 g. Since his surgery, Peter has given up both rock collecting and, more fortunately, stone making.

Friday

Lillian is an 80-year-old woman with advanced chronic obstructive pulmonary disease, type 2 diabetes mellitus, and coronary artery disease, to name just a few of her afflictions. The problem list in her chart resembles the table of contents of Harrison's Principles of Internal Medicine. Despite wearing two hearing aids, she answers all of my questions with “Huh?” Much of Lillian's poor health can be attributed to her long and heavy history of cigarette smoking. After much prodding and pleading, I finally managed to convince her to quit smoking about four years ago. Or so I thought. Every time I meet with Lillian, she still smells like cigarette smoke. This day was no different. “Are you smoking again?” I asked her. “Huh? . . . Oh, no,” she replied. She seemed so sincere I believed she could probably pass a polygraph test. Meanwhile, Lillian's adult granddaughter, who was standing behind her, furiously signaled me and mouthed the words, “she's lying.” At the conclusion of our office visit, I reminded Lillian for the umpteenth time of the health hazards of cigarettes and asked her to avoid cigarette smoke. She nodded her head in agreement and smiled. Trust is the cornerstone of the doctor-patient relationship. I trust that when she returns to see me, Lillian will still smell like she was drenched with cigarette smoke. And she can trust that I will still encourage her to stop smoking at every visit.

Saturday/Sunday

There are some things they never taught in medical school, and at the top of that list is how to break bad news. Louise, a normally vibrant 69-year-old woman, returned from vacation feeling run down, nervous, and twitchy. By the time I examined her in the office, she had widespread fasciculations involving her arms and legs, atrophy of her left thigh, and nystagmus in all directions of gaze. “What do you think is wrong with me, doctor?” Louise asked. What I feared was wrong with her was amyotrophic lateral sclerosis (ALS), but I hemmed and hawed and told her that we needed to run some tests. Was it clinical uncertainty, pity, or cowardice that prevented me from expressing my opinion? “You suspect something though, don't you?” she pressed me. Clutching her hands between my already sweaty palms, I slowly explained to her the signs and symptoms of ALS, other conditions that might mimic the disorder, and how we needed to proceed. “I understand,” was all Louise finally said. And I think we both did. Her nerve conduction studies demonstrated diffuse denervation. A muscle biopsy confirmed neuropathic changes in a pattern consistent with denervation. A neurologist prescribed riluzole (Rilutek), but Louise died eight months after her ALS was diagnosed. How we take care of our patients who are dying speaks volumes. Yet, how we break the news to them resonates just as loudly.

Dr. Tony Miksanek is a family physician in a solo private practice in Benton, a town of just under 7,000 people in rural southern Illinois. He sees a variety of patients, and many of them are elderly.

Address correspondence to Tony Miksanek, M.D., 712 Old Orchard Dr., Benton, IL 62812. 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.


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