Diary from a Week in Practice
Am Fam Physician. 2003 Jan 15;67(2):289-290.
Linda, a 40-year-old woman, presented this afternoon to review a recent computed tomographic (CT) scan. The scan was obtained to further evaluate a six-week history of abdominal pain. The pain was crampy, located in the left upper quadrant, and initially associated with constipation. Diet changes and a stool softener resolved the constipation but not the pain. An antispasmodic and a proton pump inhibitor didn't help either. On examination, she became progressively tender. CSJ and Linda agreed that the pain had gone on long enough; they chose to schedule a CT scan and then anticipated colonoscopy. To their great surprise, the CT scan revealed a large mass involving the descending colon, with evidence of enlarged retroperitoneal lymph nodes and liver metastases. CSJ had already discussed the case with her supervising physician, who in turn contacted a gastroenterologist (Fortunately, AJ practices with us!) and surgeon. AJ spoke with Linda and her husband in our office that day, and a plan of action was developed. While stunned, scared, and overwhelmed, Linda took the news relatively well. With the support of her family and health care team, she prepared for the next step in evaluating her disease.
RKT was evaluating a young boy this evening when his mother, Susan, mentioned some right flank pain she continued to have. The pain had started eight weeks earlier and had been evaluated by CSJ, her gynecologist, and urology. RKT asked CSJ for the details, and together they reviewed her chart. Because of hematuria, bacteriuria and pyuria, Susan had been treated for a urinary tract infection with possible pyelonephritis. An intravenous pyelogram revealed a 3-mm stone on the left. She had started a second course of antibiotics Monday, when her urine still contained evidence of infection, including blood. Although she had been advised to return in 10 days to ensure clearance of the hematuria, she was becoming more uncomfortable. Considering development of a stone on the right, RKT and CSJ ordered a limited CT scan to further evaluate. Susan was relieved to hear that another study could be done and that she was right to have mentioned her persistent pain! While sometimes add-on patients can be disruptive to our schedules, we can work together to take better care of them.
Mrs. Peterson was seen two weeks earlier for “lumps” in her neck, but by the time she came in, they had disappeared. Now the lumps were back. CSJ found large, tender cervical nodes on the left and no other palpable lymphadenopathy. A complete blood count was normal. A chest x-ray revealed a slightly widened mediastinum and slightly uncurled aorta. CSJ discussed the possibility of lymphoma with Mrs. Peterson, and a CT scan was arranged. Mrs. Peterson, however, did not seem worried. She was more concerned about her son, Dan, whose appointment was next. Dan was a 33-year-old man who had been feeling bad for several weeks. He'd been seen for sinusitis and epididymitis but was still feeling exhausted. He reported dizziness, rapid heart rate with even minimal exertion, and shortness of breath when he tried to lie down. He was obese, with a blood pressure of 200/100 mm Hg and heme-negative stool. An electrocardiogram showed tachycardia and down-going T waves in the anterior leads. The chest x-ray revealed mild cardiomegaly. The white blood cell count was 12.8 × 103 per mm3, hemoglobin 4.9 g per dL, hematocrit 15.8 percent, and platelets 53,000 per mm3. RKT promptly admitted Dan for a blood and platelet transfusion and additional evaluation.
This morning, the results of Dan's bone marrow were in: acute myelogenous leukemia. He was getting ready for chemotherapy to begin, and he was feeling perky after multiple transfusions. But, the news kept coming. Linda's colonoscopy had gone well, but an apple core lesion was located at 35 cm and was nearly obstructing her colon. AJ and the surgeon were putting her on the schedule next week. Susan's CT scan report showed a small mass in the right kidney that was suspicious for malignancy. Mrs. Peterson's scan revealed multiple sites of lymphadenopathy within the chest, indicating lymphoma. CSJ discussed each patient with RKT—which tests needed ordering, which subspecialists would be contacted, how each patient might accept the news. They identified the next step for each case, and RKT gave CSJ reassurance and advice for her upcoming follow-up visits with each one. CSJ knew the calls were ominous to receive—“CSJ asks that you come in to discuss the results” and no more information offered.
CSJ greeted Friday's schedule with apprehension. The day's potential was enormous. Each visit was different. Each patient took the news differently. Both Linda and Susan were shocked, confused, and scared. And both cried. CSJ answered all the questions she could. Few were asked, which was fortunate because few answers were available. The conversations were frank and open. Mrs. Peterson found a way to smile and found strength in her faith. Susan needed more time to process and think. CSJ asked RKT to call Susan in a few days to offer more support. CSJ and RKT discussed the experiences of the week. How unusual and difficult to have four cases of malignancy in one week, especially two in the same family!
In 1997, RHS was in L'viv, Ukraine, as part of a medical mission team. The team consisted of nurses, an optometrist, a dentist, a physician, and other support persons; together they operated a daily clinic out of a small church. The economy was terrible, and the national health care system was in shambles. Modern services and drug therapy were almost unobtainable. One afternoon, a neat, attractively dressed 60-year-old woman presented with a complaint of right knee pain. She was short in stature, and she walked erect and without apparent difficulty. It was customary for Ukrainians to bring their own medical records to each visit. The records contained progress notes, prescriptions, and laboratory reports, including miniature copies of x-rays. This patient's record contained a posteroanterior (PA) view of her right knee and a PA view of her pelvis. The knee film showed moderate osteoarthritis, but the pelvic x-ray was most informative. The hip trochanters were at about the level of the iliac crest. The acetabular sockets were empty, and the femoral necks faded into soft tissue, well above the acetabuli. No femoral heads were visible. This patient had walked all her life without hip joints as the result of untreated congenital dislocation of both hip joints. RHS could only give her some nonsteroidal anti-inflammatory drugs and admire her spunk. Despite all its flaws, let us be thankful for our U.S. health care!
Robert H. Shackelford, M.D., is one of five physicians at Mount Olive Family Practice in Mount Olive, North Carolina. Dr. Shackelford and his colleagues, which include three physician assistants, provide all types of care (except obstetrics) to patients of all ages in their rural community.
Address correspondence to R.H. Shackelford, M.D., Mount Olive Family Medicine Center, 238 Smith Chapel Road, Mount Olive, NC 28365 (e-mail: firstname.lastname@example.org).
In order to preserve patient confidentiality, the patients' names and identifying characteristics have been changed in each scenario.
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