Diary from a Week in Practice



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Am Fam Physician. 2003 May 1;67(9):1911-1912.

Monday

Eileen, a 37-year-old factory worker, is one of those rare people whom everyone likes the instant they meet her. She described having a wonderful life except for one large problem. Standing 63 inches tall and weighing 273 lb resulted in a body mass index of 48 for Eileen. Despite walking three miles a day and limiting her diet to 1,400 calories per day, Eileen's weight barely budged. She had tried taking sibutramine (Meridia) but stopped it. Later, she took orli-stat (Xenical) but discontinued it as well. Neither medication in conjunction with her exercise program and diet produced significant weight reduction. We discussed the risks and potential long-term complications of bariatric surgery. Screening for endocrine problems was negative, and she passed a psychologic evaluation. Eileen underwent Roux-en-Y gastric bypass surgery for morbid obesity. Six months later her weight is down to 167 lb. “Have you experienced any side effects from the operation or the 108-lb weight loss?” I asked her. “Only one,” Eileen replied with a big smile as she tugged on the elastic waistband of her slacks. “The need for a whole new wardrobe!” Eileen is little more than half the woman she once was, yet her loss of size is dwarfed by the health benefits she has gained and the joy she has realized.

Tuesday

Hermann came to my office complaining of extreme weakness, a burning sensation in his chest, and abdominal pain. The middle-aged man looked almost as white as the paper covering the examination table. A stool sample tested positive for occult blood. An electrocardiogram and chest x-ray were normal. Hermann's hemoglobin was 7.9 g per dL, and his red blood cell indices were consistent with iron deficiency anemia. An upper gastrointestinal x-ray revealed a duodenal ulcer. His anemia, and possibly his pain, might be attributed to that finding. Because of his age and symptoms, I recommended he have a colonoscopy to complete his evaluation. Hermann balked at that suggestion. He was more than satisfied that we had already established a good diagnosis.“Why do you have to look for something else wrong with me?” he wanted to know. It was a reasonable question. Was I merely “going by the book” and being thorough, or was it intuition that had me prodding and pleading with this patient to undergo one more test? Hermann grudgingly consented to having a colonoscopy. The test identified an early adenocarcinoma. His colon cancer was resected and his ulcer treated medically. There are times when it doesn't pay to be satisfied with just one diagnosis, especially when your “gut” feeling tells you otherwise.

Wednesday

Anymore, it seems as if every patient I see has had sinusitis at one time or another. So, when Beverly showed up at my office with a headache, facial pressure, a fever as high as 101.2°F, and purulent nasal drainage streaked with blood, the diagnosis of acute sinusitis was as obvious to her as it was to me. “I feel awful,” she said. “I'd just as soon be sick with almost anything other than this.” Be careful what you wish for! I prescribed amoxicillin-clavulanate (Augmentin) for her infection. Beverly telephoned a few days later to report an upset stomach, so I had her switch to cefuroxime axetil (Ceftin). One week later she was back at my office, minus her sinus symptoms but now with lower abdominal cramping and profuse nonbloody diarrhea. A stool sample for Clostridium difficile toxin was positive. When I informed Beverly that the treatment of pseudomembranous colitis required stopping the cefuroxime and taking yet another antimicrobial agent, she looked at me as if I had lost my mind. “You've got to be kidding,” she retorted. “Isn't it obvious by now that antibiotics don't like me? I can't say I care much for them either.” Nevertheless, she graciously accepted a prescription for metronidazole (Flagyl), trusting that her doctor finally got it right.

Thursday

Alongside every great man is a great woman. Sam was in the office today, accompanied by his wife, and I hardly recognized either of them. A few months ago, this 38-year-old, overweight man with well-controlled hypertension on losartan (Cozaar) had screening laboratory work done. He was dismayed to learn that his fasting blood glucose level was 204 mg per dL and total cholesterol level was 255 mg per dL. “If I plan on sticking around awhile, I guess I'd better get serious,” Sam decided. And did he ever. He met with a dietitian who instructed him on a low-cholesterol, American Diabetes Association diet. He began exercising five days a week. To date, Sam has lost 39 lb, and his waist size has gone from 41 to 37 inches. His fasting glucose levels at home range from 75 to 103 mg per dL. He looks and feels like a new man—greater self-esteem, increased energy level, and more in control of his life. Sam's most recent glycohemoglobin A1C level was 5.8 percent and total cholesterol level was 162 mg per dL. What I didn't anticipate was the effect of Sam's diabetes on his overweight wife. In an effort to encourage her husband, she followed the same diet and exercise regimen prescribed for Sam. Guess what? She lost 40 lb. There's no limit to what people can accomplish once they decide to try.

Friday

Off-balance. Unsteady. Lightheaded. Woozy. These are just a few of the ways that patients describe their sensation of dizziness. Fifty-seven-year-old Joan had her own unique description: “I keep getting a whooshing sensation in my head. At times I feel like things are moving when I know darn well that they're not.” Talk about empathy for a patient. The longer I listened to Joan, the dizzier I became. With a medical history that included hypertension, a myocardial infarction, carotid artery stenosis, and depression, the differential diagnosis of Joan's dizziness was daunting. Her physical examination, an electrocardiogram, and blood work were normal. A magnetic resonance imaging scan of the head showed changes of mild microvascular disease. For no apparent reason, I recalled the case of another patient whom I had seen two years earlier—a man who complained of feeling “cloudy” and “spacey” and turned out to be suffering from a seizure disorder. Might lightning strike twice? Joan's electroencephalogram was abnormal and demonstrated left anterior temporal epileptiform activity. It's amazing how treatment with levetiracetam (Keppra) has helped Joan's “dizziness.” Patients are our finest teachers, but it helps if we remember the valuable lessons they teach us. Joan owes a debt of gratitude to a man whose name she'll never know. And, so do I.

Saturday/Sunday

Even when it's the setting of a serious accident, there's just no place like home. Seventy-four-year-old Miriam caught her foot on a rug at home, fell, and fractured her left hip. Surgery went well, and she made considerable progress with physical therapy. After discharge, she still required assistance with activities of daily living, along with 24-hour supervision. Her daughter, Deirdre, had promised her that she would never end up in a nursing home, so Miriam went to live with Deirdre and her husband. I cannot imagine any greater or more loving caregiver than Deirdre. Miriam worked hard and graduated from the need of a walker to the aid of a cane. Deirdre began to worry that another disaster might occur if her mother insisted on living in her own house again. “What will I do when Mom demands to return to her house?” Deirdre asked me. “You need to let her go,” I replied. “She's going to be all right, and so will you.” Deirdre got busy and gave her mother's house a “makeover” in an effort to create as safe a living environment as possible. Miriam made it back home and has nicely recovered from her broken hip. This month she will be celebrating Mother's Day in her own house surrounded by children she loves and who love her. I don't think she could have asked for any better gift.

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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