Diary from a Week in Practice
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Am Fam Physician. 2003 Jan 1;67(1):58-60.
We shouldn't treat children as if they were simply miniature adults, but there are occasions when such a perspective might assist in establishing a difficult diagnosis. Ten-year-old Emily sat quietly, without her usual smile. She was experiencing mid and lower back pain that kept her awake at night. There was no history of trauma, fever, or urinary symptoms. Nothing relieved her pain. She was mildly tender over the area of the thoracic spine. Her white blood cell count was 15,200 cells per mm3, and a sedimentation rate was 40. A urinalysis was normal. Plain x-rays of her spine revealed fractures of the T6 and T9 vertebra. A nuclear bone scan and magnetic resonance imaging of the spine confirmed compression fractures of those two vertebra. While I fretted over diagnostic possibilities like osteomyelitis and malignancy, I failed to consider an etiology that would have topped my list if Emily had been an adult. After referral to a pediatric orthopedist, she was diagnosed with idiopathic juvenile osteoporosis. Secondary causes of osteoporosis were ruled out. Fortunately for Emily, the onset of puberty should result in recovery. For now, she is wearing a back brace as needed and taking calcium and vitamin D supplements. At age 10, Emily is one youngster already well ahead of her time.
Who wants to be a millionaire? If you guessed “everybody,” then you obviously don't know Penelope, a 40-year-old woman who just joined that exclusive group with a platelet count of 1,191,000 per mm3. For the past few years, Penelope's platelet count has ranged between 490,000 and 814,000 per mm3. She was previously diagnosed with reactive thrombocytosis in response to iron deficiency from heavy menstrual bleeding. Since then, she has had a hysterectomy and is no longer iron deficient. Her current white blood cell count, hemoglobin, hematocrit, and red blood cell indices are all normal. She has no evidence of malignancy, inflammatory disease, hemorrhage, or chronic infection. I asked Penelope to take 325 mg of aspirin daily while awaiting further evaluation. In patients with reactive thrombocytosis, the only therapy usually required is correction of the underlying disease. Asymptomatic patients with essential thrombo-cythemia who are younger than 60, with platelet counts of less than 1.5 million per mm3 and no history of cardiovascular risk factors or previous thrombotic events, often can be observed rather than treated with cytore-duction agents. Today, a young woman learned she is “making seven figures,” and all she can think about is how to make less.
An 80-year-old man presented to my office today, worried about a rash on his face. “Good heavens,” Mr. Dorian said, “I look like a teenaged boy!” He paused for a few seconds before qualifying his chief complaint. “But I sure don't feel like one.” Mr. Dorian is a fair-skinned man with facial erythema, telangiectasias of the nose and cheeks, and inflammatory papules and pustules. We discussed the diagnosis and treatment of rosacea. I instructed him about good skin care, proper diet, and the avoidance of precipitating factors. I recommended the application of metronidazole cream (Noritate) once a day and a short course of doxycycline (Vibramycin). Mr. Dorian seemed to have something else on his mind as I was about to exit the examination room. Never one to beat around the bush, he looked me directly in the eyes and confided, “You know, doctor, I really wouldn't mind feeling like a teenager either. What do you think about Viagra?” I guess the old adage is true: You're only as old as you feel!
I am reminded once again just how quickly time passes, because all my last-minute preparations for Christmas are suddenly replaced by the need to remove the tree and put the holiday decorations away. As I glance one last time at the cards received from family and friends, an attractive card stamped in gold ink with “Seasons Greetings to a Special Doctor” catches my eye. It is from a thoughtful patient named Ada, whom I met a few months ago when she presented with a four-week history of vaginal itching. On examination, she had vulvar erythema and a curdy vaginal discharge. A potassium hydroxide preparation demonstrated budding yeast and pseudohyphae. Her previous health history was unremarkable—no chronic illnesses or current medications. Her review of systems, however, turned up recent blurred vision, increased thirst, and a burning sensation of her tongue. Her blood glucose was 323 mg per dL, and her glycosylated hemoglobin A1C was 13.3 percent. Ada was treated with a small dose of glyburide (Micronase) and a micon-azole (Monistat) dual pack, and she was scheduled for diabetic education and diet instruction. Six weeks later, her fasting blood sugars were in the range of 96 to 114 mg per dL. I feel fortunate to care for such a considerate patient, even though I can proudly claim that she is not nearly as “sweet” now as when we first met.
There are times when we just don't know what's best for ourselves. Or if we do, we can't force ourselves to admit it and accept it. Terence was a middle-aged man with “a plumbing problem,” as he liked to call it. There was nothing “benign” about his prostatic hypertrophy; he suffered from all its symptoms. Despite considerable interference in the quality of his life, Terence was adamant about avoiding surgery for his BPH. “I know some guys who had prostate surgery, and boy do they regret it now,” he lectured me. So, we pushed medical therapy. First, he tried terazosin (Hytrin), and then I substituted tamsulosin (Flomax). Next, we added finasteride (Proscar), even though I explained to him that the combination of these two drugs might not produce results better than either one alone. Terence managed to get by until late one afternoon, when he rushed to the office with an inability to void, suprapubic distention, and enough misery to conclude “I feel like I'm about to have a baby.” Insertion of a Foley catheter “delivered” Terence from his suffering, and a few days later, a urologist performed a transurethral resection of the prostate. Just before hospital discharge, the man who was so determined not to have surgery eloquently summed up his experience. “I don't know if you doctors saved my life, but you sure as heck saved my sanity.”
Doctors tend to be a curious bunch. We are not just interested in people—we're also fascinated by them. While I was making hospital rounds, two strangers walking down the hall caught my attention. They were laughing hysterically. One was a boy whom I guessed to be about nine years old, and the other was a man probably in his early 30s. The boy was using arm crutches to ambulate, and his short legs moved in a wide and awkward manner that suggested he was sweeping the floor with his feet. I wondered whether he was a visitor or a patient and just exactly what his diagnosis was. His companion was a muscular man who looked like a bodybuilder. Somehow, I knew that the two of them were father and son, despite their discordant physical appearances. It was obvious that they were connected by more than genetics. I imagined they shared a love of life, the love of father and son, and the belief that the future held much promise for both of them. The affection that these two people demonstrated for each other generated enough human warmth to melt the snow that gently fell outside the hospital. I was eager to get home. I knew my youngest son would be waiting to nail me with a snowball the instant I stepped out of the car. What he didn't know was that I couldn't wait to playfully chase him around our yard in praise of fathers and sons everywhere.
Dr. Tony Miksanek is a family physician in solo private practice in Benton, a town of just under 7,000 people in rural southern Illinois. He sees all kinds of patients, and many of them are elderly.
Address correspondence to Tony Miksanek, M.D., 712 Old Orchard Dr., Benton, IL 62812. In order to preserve patient confidentiality, the patients' names and identifying characteristics have been changed in each scenario.
In order to preserve patient confidentiality, the patients' names and identifying characteristics have been changed in each scenario.
Copyright © 2003 by the American Academy of Family Physicians.
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