Diary from a Week in Practice
Am Fam Physician. 2003 Apr 15;67(8):1709-1710.
“I have good news and bad news,” TA reported to her 45-year-old patient. “The good news is that your lipid profile looks fantastic. The bad news is that you'll have to continue your diet.” For more than a year now, she had been treating this patient for severe hyperlipidemia, with triglyceride levels well over 1,000 mg per dL. The patient had been hesitant to combine two different medications because of the possible risk of side effects, but he could not get his triglyceride levels below 500 mg per dL on one drug alone. Finally, with a combination of gemfibrozil and a CoA reductase inhibitor, his triglycerides were reduced to 245 mg per dL. On his last visit, six weeks earlier, his triglycerides had been 380 mg per dL, on the exact same dosage of medications. He had vowed to follow a strict diet and exercise plan, and finally had met with great success. “Now that I am convinced that following a low-fat diet really works,” he said, “I intend to stick with it.” He thought for a minute about how much he missed eating fried food and then said with a smile, “That really is good and bad news!”
“Her sister had her stomach stapled last summer, and she has lost over 100 pounds,” MJ, a third-year resident told KS, who was the attending that day. His patient was a 33-year-old woman who weighed well over 300 lb. She was in the office that afternoon to follow up on diabetes and hypertension, both of which were only moderately well controlled. MJ had seen the patient regularly during the past two years. They had discussed diet and exercise at every visit, and he was pleased to note that she had not gained any weight in more than a year. But they both were discouraged about her inability to lose even a modest amount. Several years earlier, KS would not have considered a referral for weight reduction surgery. But, in the past few years, new operative techniques have been developed, and stomach stapling is making a comeback. The future seems so bleak for young women like this patient, who have a severe weight problem that is complicated by diabetes. In 20 years, she no doubt would develop many of the terrible sequelae of longstanding diabetes mellitus, such as nephropathy, heart disease, and retinopathy. “I would make the referral,” she advised the resident.
In the morning mail, KS received a newspaper clipping sent by the daughter of a patient who suffered from progressively severe Alzheimer's dementia. The article described how a major research center was investigating the use of positron emission tomography (PET) scanning to diagnose dementia in its early stages. KS thought about her patient. Once a very successful businessman, he could no longer manage to prepare a simple meal or dress himself. He had been diagnosed eight years earlier, and the symptoms stabilized for a year or so with medication. But, as expected, his cognition had steadily declined, and the family was facing the fact that he would soon need long-term care. In retrospect, it was clear that he had had symptoms for several years before the diagnosis was made. In a sense, thought KS, the brain is the last frontier in medicine. There are computed tomographic scans, magnetic resonance imaging scans, nuclear scans, and complicated laboratory tests available to evaluate disease in every other organ system. But, for higher brain function, doctors still rely on simple office tools such as the Mini-Mental State Examination. If new tools such as PET scanning can diagnosis cognitive impairment at earlier stages, surely better treatment regimens will follow.
“Whatever is in that little pill, it makes me feel wonderful,” declared the 68-year-old woman. KS could not have been more pleased by the news. Her patient, ordinarily a very independent, active person, had broken her hip a year earlier. After surgery and rehabilitation, she had done very well. Then about six weeks ago, she slipped on some wet stairs and almost fell again. This near-miss experience was so upsetting that she became very depressed and was fearful of leaving the house. She resumed physical therapy, but she just could not get her confidence back. KS recommended a low-dose selective serotonin reuptake inhibitor. Like many people, her patient refused to try the medication, worrying about “becoming dependent on drugs.” KS suggested that she enroll in tai chi classes at the local YMCA to help her with balance and strength training. Two weeks later, KS again suggested antidepressant medication, and this time her patient agreed. Now, she reported being much less fearful and had resumed her volunteer work at the local art museum. Although the patient attributed her progress to the medication, KS explained that participating in an exercise program was even more beneficial in preventing future falls.
JP looked around the house. His patient's hospital bed was situated right in the center of the living room, next to a sunny window. The television set was on one side of the bed, and a radio/CD player was on the other side. Three of the elderly woman's five daughters welcomed him, and they gathered around the bedside explaining the daily routine. JP, a third-year resident, had arranged to make this home visit when the patient was hospitalized 10 days earlier with dehydration secondary to gastroenteritis. The patient had been bedridden for several years because of multiple strokes, and although her speech was slurred, any one of her daughters could understand her easily. These remarkable women were devoted to their mother and took turns staying with her around the clock. When JP asked how they managed, each one looked genuinely surprised. “Mother dedicated her life to us,” explained the eldest daughter, who was in her late 60s. “Now it's our turn to care for her.” JP had little to add to their excellent care. When the women thanked him repeatedly for making the house call, JP felt that he had done very little. But, he did have a much better picture of the challenges facing this family, and knew he would feel much more confident helping them in the future.
Every so often, a patient makes a remarkable turnaround. A year ago, this 54-year-old man nearly died while hospitalized in the intensive care unit for diabetic ketoacidosis, hypertensive emergency, and near end-stage renal failure. He had not seen his doctor for more than a year and had run out of his medications months earlier. After weeks of fatigue, polyuria, polydipsia, and weight loss, the patient finally became critically ill. Once he recovered, vascular access was placed in his right arm in anticipation of dialysis in the near future. In one last attempt to manage his blood pressure and glucose, KS agreed to follow the patient if he promised to see her in the office every week. Now, one year later, his glycosylat-ed hemoglobin was 6.3 percent, his blood pressure was normal, and his creatinine clearance stayed exactly the same. KS still sees him once a month. “Getting that shunt scared me,” he admitted. “I guess I never believed that my kidneys were as bad as the doctors said.” Family practitioners treat asymptomatic conditions in nearly every patient. Our challenge is to convince patients to believe us and to motivate them to change.
In order to preserve patient confidentiality, the patients' names and identifying characteristics have been changed in each scenario.
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