Diary from a Week in Practice
Am Fam Physician. 2003 Mar 1;67(5):975-976.
“I'm a mess,” Gwen confessed. Struggling to hold back her tears, this 54-year-old woman described a recent history of feeling nervous, shaky, and hot. She had unintentionally lost 12 lb, even though her appetite was good. Lately, she'd been experiencing palpitations. Less than one year ago, Gwen had been at the office for a checkup and laboratory work. At that time, everything looked fine. Now, her examination revealed a fine tremor, mild tachycardia, increased deep tendon reflexes, and the explanation for all her symptoms—a small, diffuse nontender goiter. Gwen's thyroid-stimulating hormone (TSH) level was less than 0.1 μU/mL, and her total T4 was 14.8 μg/dL. A repeated TSH was 0.03 μU/mL. Nine months ago, her TSH and thyroxine levels were normal. Radioactive iodine uptake was now elevated at 60 percent. Gwen's thyrotoxicosis was probably secondary to Graves' disease. Her symptoms improved with propra-nolol, and she was then treated with radioactive iodine. She understands the need to monitor her thyroid function closely for the development of hypothyroidism. Gwen is still bewildered about how her thyroid status could have changed so quickly and disappointed to learn that normal laboratory tests are not guaranteed. In Gwen's case, it didn't even come with a one-year warranty.
Rocky, a large 44-year-old man who tended to be suspicious of doctors, didn't exactly sit on the examination table; he overwhelmed it. “I just can't catch my breath, and it's getting worse.” Rocky described a syncopal episode yesterday that failed to hurt him. He appeared weak, pale, and clammy. His pulse was 112 and blood pressure 110/80 mm Hg. I noted tachypnea and heard inspiratory crackles in his chest. His feet were swollen with no calf tenderness. He denied chest pain. An electrocardiogram showed only sinus tachycardia. A chest x-ray demonstrated car-diomegaly. His oxygen saturation was 90 percent on room air. I was puzzled. He might have congestive heart failure or pneumonia not yet apparent on chest x-ray, but neither diagnosis was a good fit. I admitted Rocky to the hospital, uncertain about the diagnosis but not the severity of his illness. Almost as an afterthought, I added a final admitting order: stat ventilation-perfusion lung scan, which turned out to show a high probability of pulmonary emboli with multiple perfusion defects in the right lung. A Doppler study identified a deep venous thrombosis in the right leg. Rocky was treated with intravenous heparin, oxygen and, eventually, warfarin. It pays to be suspicious—clinically speaking, of course.
It certainly helps to have nine lives … especially if you're going to spend three of them. Ninety-five-year-old Magdalene was brought to the emergency room in respiratory failure because of pulmonary edema. A vibrant woman, Magdalene had cultivated her longevity the old-fashioned way—she earned it. She had worked hard every day of her life, until recently. In the past few years, she had fractured a hip and had two brushes with death: a myocardial infarction and a severe episode of congestive heart failure. “Ever since I turned 90, I've just gone to pieces,” Magdalene lamented. Now she was unresponsive and critically ill. Her family reminded me that she had a living will, with an emphasis on “living.” Magdalene had made it clear that she wanted everything done to prolong her survival. She was intubated and placed on a ventilator. Almost miraculously, she was extubated a day later and soon talking non-stop, albeit with a slightly raspy voice. “I'm doing great, Doc. Can I go home?” Five days later she was discharged, seemingly unfazed by her close encounter with death. “At my age,” she informed me, “you have to be prepared for anything.” Magdalene may be down to six lives, but she believes she has ample mileage remaining on her first.
Not everyone likes surprises. Consider Irene, a health-conscious, 60-year-old woman who exercises daily, adheres to a diet low in salt but high in fruits and vegetables, does not smoke or drink, and has a body mass index of 25. She has no family history of cardiovascular disease. Her checkups have always been normal. Irene figured she was about the least likely person to develop hypertension. Surprise! While sitting in my office and describing a recent nosebleed, Irene's blood pressure was 210/110 mm Hg. Three additional readings were about the same. She felt fine, and her examination was otherwise normal. Laboratory studies and an electrocardiogram were normal. Treatment with long-acting nifedipine failed to lower her pressure, so atenolol, then hydrochlorothiazide, and finally lisinopril were added. Her blood pressure barely budged, hovering around 190/92 mm Hg.
Substituting other antihyperten-sive agents made little difference. This prompted me to search for secondary causes. I was able to rule out a pheochromocytoma and aldosteronism. Renal angiography demonstrated fibromuscular dysplasia of the right renal artery, which was successfully dilated. With the renovascular component of her hypertension stabilized, it is no surprise that Irene's blood pressure is currently well controlled.
Doctors and their patients are known to disagree about many things. Little did I imagine that the definition of “normal” was one of them. Like many of the generally healthy elderly women I see in my practice, 85-year-old Maude was very interested in knowing her cholesterol level. When I received the results of her lipid profile, I was concerned that she would be disappointed or perhaps even alarmed by the figures. Her total cholesterol level was 349 mg per dL with a low-density lipoprotein cholesterol level of 258 mg per dL. Her reaction to hearing the test results was unexpected. Maude was not the least bit impressed by the news. “My normal cholesterol reading is 343,” she told me, “so 349 is just barely high for me. Why don't we just check it again in a year?” I am not sure that Maude will agree with me that if she chooses not to treat her elevated cholesterol levels, we probably need to quit checking it. She has, however, convinced me that while definitions of normal may vary, “ordinary” and “average” just aren't as soothing as “usual.”
This morning, I received a telephone call from Mrs. Lear. Her husband is bedridden with advanced Parkinson's disease and dementia, and now has a blistering rash associated with a fever. Immediately, a differential diagnosis begins to take shape in my mind: cellulitis, herpes zoster, drug reaction, or maybe pemphigoid. I will need to inspect this rash, and the family is unable to bring him to my office. “How about I come by later today?” I ask. “You mean a house call?” Mrs. Lear replies, with either a hint of astonishment or faint recollection in her voice. Now trapped in a near useless body, Mr. Lear yells and spits, and I feel almost as helpless as he does. The rash turns out to be small areas of skin irritation. I think the fever is from pneumonia, and I prescribe oral suspension ciprofloxacin, because he can no longer swallow pills. I discuss a DNR status with his wife and suggest enrolling her husband in our hospice program. I feel right at home visiting with his wife, daughter, and grandchildren, who are all taking excellent care of Mr. Lear. On my way out, I find myself carrying a homemade chocolate pie in one hand and my black bag in the other. I feel more appreciated than any human being has a right to be. Yet, there is little I can offer my patient any-more, except to be there for him and his family. Apparently, that is what matters most.
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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