Diary from a Week in Practice
Am Fam Physician. 2003 Mar 15;67(6):1229-1230.
Lately, I'm fielding questions about the smallpox vaccine. Misinformation abounds. Some believe that they retain immunity to smallpox no matter how long it has been since they were originally vaccinated. Others fear that the rate of serious adverse reactions from the vaccine is 50 percent, rather than the actual estimate of complications in first-time recipients of less than 50 persons per 1 million. “What do you think about the smallpox vaccine?” Catherine quizzed me as we were concluding the elderly woman's visit for her diabetes and neuropathy. “Do I really need one? You know I had a vaccination years ago.” I sensed the answer Catherine desired was “No,” and she appeared more distressed than interested by the question, so I probed a little deeper. “In 1940, my 13-year-old sister died of encephalitis after receiving a smallpox vaccination. How safe is it for me to be revaccinated?” We spent some time chatting—Catherine shared memories of her sister with me, and I shared what I knew about smallpox with her. “If and when a time comes that mass vaccination is recommended, I believe you'll be safe in getting another one,” I summed things up for her. Doctors may not have all the answers, but that does not stop patients from asking the questions. And patients are sometimes grateful for an answer that originally they didn't think they wanted.
Randall was at my office after enduring pain “below the belt” for the past five days. The pain was provoked by eating and was accompanied by decreased appetite, weakness, and nausea without vomiting. He denied any urinary symptoms or change in bowel habits. The 75-year-old man had a history of diverticulosis and had undergone a colonoscopy two years earlier. He appeared jaundiced and mildly dehydrated. His abdomen was quite tender over the right upper quadrant, but he pointed to the lower abdomen as the location of his worst pain. An ultrasound of the abdomen revealed a gallbladder completely full of calculi. Although afebrile, Randall's white blood cell count was 21,000 per mm3. Amylase level was 656 IU per L, total bilirubin count was 5.0 mg per dL, and aspartate transaminase level was 266 IU per L. In the hospital, he received intravenous fluids and intravenous piperacillin-tazobactam (Zosyn). When his clinical status improved, Randall underwent laparoscopic cholecystectomy. He had an uneventful recovery following surgery. Everything about his cholecystitis with cholelithiasis and pancreatitis was “textbook” except the location of his most intense abdominal pain. I wonder if Randall doesn't wear his belt a lot higher than the rest of us.
“I feel lousy,” Dolores greeted me as I entered the room. “I have no energy, hurt all over, and can't sleep.” She also was experiencing anhedonia, decreased appetite, and difficulty concentrating. My examination failed to turn up any physical abnormalities except that she wasn't as perky as usual. “Is it possible you might be a little depressed?” I asked, putting the question as gently as possible. “I have no reason to be depressed,” she replied. “No, it must be something else.” Although I was convinced of the diagnosis, Dolores needed proof. When laboratory studies came back normal, she grudgingly accepted a prescription for an antidepressant. The dosage was gradually increased. The prescription was changed twice. Her symptoms remained the same. I referred Dolores to a psychiatrist who tried different combinations of antidepressants and counseling. She was still no better, so I suggested she consider electroconvulsive therapy (ECT). She balked. Then her symptoms progressed to what she described as “a complete breakdown.” She was ready for ECT. After completing her treatments, Dolores felt “good” for the first time in many years, and her affect was clearly brighter. Most of the patients I see who suffer from depression don't announce “I feel depressed.” For some of them, like Dolores, both the diagnosis and its treatment come as a bit of a shock.
Isn't it nice when a patient can leave your office with something special instead of the usual written prescriptions? Carrie, a 26-year-old elementary school teacher with no children of her own, called this morning requesting an appointment to be seen for “whatever it is that's going around.” She listed her symptoms as low-grade fever, lightheaded-ness, nonproductive cough, head congestion, and mild nausea. Other than a temperature of 37.2°C (99.1ÞF), nasal congestion, and shotty cervical lymphadenopathy, Carrie's examination was normal. The diagnosis seemed obvious—an acute viral upper respiratory tract infection. Wait a minute. When I asked her how things were generally going, she happened to mention that she and her husband were interested in having a baby and recently had stepped up their efforts. Her last period ended 26 days ago, but she had experienced some increased urinary frequency and breast tenderness. A urine pregnancy test done in the office was positive. Carrie was elated and couldn't wait to tell her husband. It really is true that if you listen carefully to your patients, they'll often tell you their diagnosis. I thought I already knew “what was going around,” but I just saw a woman who came in with a cold and left my office with the knowledge and joy that she is expecting a baby.
Fatigue is a common complaint in my office. Its differential diagnosis, however, is lengthy and includes familiar problems (anemia, hypothyroidism, infectious mononucleosis) as well as an occasional surprise. Olivia is a thin, 56-year-old woman who felt “unplugged”—both her energy and strength were sapped. She denied weight loss, anorexia, or nausea. She was admitted to the hospital after a syncopal episode. Her blood pressure was 88/60 mm Hg sitting, and 78/50 mm Hg standing. Laboratory tests were noteworthy for a sodium level of 133 mmol per L, potassium level of 5.7 mmol per L, and random serum cortisol level of 2.3 mg per dL. A repeat early morning cortisol level was 1.26 mg per dL. Cosyntropin-stimulation test was abnormal. Thyroid function studies and a prolactin level were normal, but a plasma corticotropin level was markedly elevated at 1,460 pg per mL, supporting a diagnosis of primary adrenal insufficiency. Treatment was started with prednisone, 5 mg every morning and 2.5 mg every evening, along with fludrocortisone (Florinef) 0.1 mg daily. She was advised to increase the amount of salt in her diet. Olivia cannot believe how much energy she now has. She jokes that she is taking steroids to pump herself up. I am reminded how even the most mundane of complaints can occasionally have an extraordinary explanation.
Constance was a firm believer that things have a way of working themselves out. So when her light-headedness and difficulty with balance did not resolve after falling down some stairs over a month ago, Constance's daughter had to twist her mother's arm to get her to visit me. The 73-year-old woman denied any loss of consciousness or headaches. Her physical examination was unremarkable except for mild difficulty with tandem gait. “I can live with a little dizziness,” Constance said, “because I don't want to take any medicine, and I doubt there's much you can do about it anyway.” She paused and then laughed. “It's probably all in my head.” She grudgingly consented to a magnetic resonance imaging scan of the brain. A heterogeneous mass in the pituitary gland measuring 2.8 × 2.0 × 1.5 cm was present. Thyroid function tests and levels of early morning serum cortisol, serum prolactin, and Somatomedin C were all normal. She underwent an extensive ophthalmology evaluation. Because she was not experiencing any visual problems and there was no evidence of endocrine dysfunction, the neurosurgical consultant felt there was no need to resect the large pituitary adenoma. We are closely monitoring it. Constance's dizziness has resolved on its own. I have to hand it to her: she was right. It was all in her head (literally), and there's nothing we're going to do about it (hopefully).
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.
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