Diary from a Week in Practice
Am Fam Physician. 2003 Jul 1;68(1):79-80.
“I can't believe it. I haven't felt this good since I was 20 years old. I feel like a new man.” Only a few days earlier, 74-year-old Wendell came to my office describing a 10-day history of muscle pain and stiffness especially in the mornings, low-grade fevers, mild unintentional weight loss, and a lack of energy that left him feeling “wiped out.” He denied having any headaches, visual changes, or jaw claudication. Wendell was slightly tender over both shoulders and, to a lesser extent, both hips. He had trouble raising his arms above his head. No tenderness was present over either temporal artery. His erythrocyte sedimentation rate (ESR) was 86 mm per hour. Wendell had started taking naproxen before coming to see me, but it had little effect on his symptoms. I prescribed prednisone, 10 mg per day, for his polymyalgia rheumatica. The results were astounding. We talked about the need to watch for signs of temporal arteritis. I told Wendell that he will require corti-costeroids for about a year, maybe longer, to reduce the likelihood of relapse. His prednisone dosage will be adjusted based on his clinical status and ESR. Because of long-term steroid therapy, calcium supplementation and alendronate (Fosamax) were recommended. Wendell has always looked younger than his age, and now he's feeling much younger than it, too.
Janet is a 56-year-old woman who I saw three months ago because she wanted to discontinue post-menopausal hormone therapy (HT). She was worried about the findings of the Women's Health Initiative study of continuous combination estrogen and medroxyprogesterone therapy. “Remember when you told me years ago that estrogen would not only help my hot flashes and night sweats but also protect my bones and heart and maybe even prevent Alzheimer's dementia and colon cancer? Well, what have you got to say for yourself now?” she asked. “Four out of six isn't bad,” was all I could offer in my defense.“I want to get off the hormones,” she continued.“After all, no one ever died from hot flashes.” Janet planned to continue her exercise program, add extra soy products to her diet, and keep taking calcium and vitamin D. Today, she wonders if she made the right decision.“Over the past three months I have made a major contribution to global warming,” Janet admitted as she fanned herself with a magazine.“What else can I do?” We decided to try a selective serotonin reuptake inhibitor. If that doesn't work, then the heat will be on me to come up with something better, or maybe she'll consider resuming HT at the lowest dosage that helps control her symptoms.
“I guess I overdid it,” Danny deduced. The 42-year-old man had a sheepish expression on his face and a noticeable limp as he made his way up onto the examination table. “I've been trying to get into shape, so I started jogging a mile a day beginning six weeks ago.” Pointing to his right lower leg, Danny proudly stated, “It started hurting two weeks ago, but I've been running through the pain.” He had localized tenderness over the proximal tibia. An x-ray confirmed a stress fracture. Although I encouraged Danny to continue exercising regularly, I prohibited him from running for at least two months. Instead, I steered him toward low-impact activities including bicycling and swimming. I emphasized the importance of having patience and giving his leg time to heal. “I'll do whatever you say. You're the boss,” Danny saluted me. I wasn't convinced. As he hopped off the examination table and sprinted out the door, I yelled after him, “Remember, if there's pain, there's surely no gain.” Danny poked his head back inside the room and said, “I think you've got that backwards.” Of course he was right … and wrong. I may have reversed the platitude, but it was his devotion to it that landed him in trouble in the beginning.
A good night's sleep can be hard to come by. Simon, a middle-aged salesman, came to see me requesting a prescription for a sleeping pill. He complained of difficulty staying asleep, feeling extremely tired during the day, headaches most mornings, and irritability. “Tell him about your snoring,” Simon's wife interrupted him. “It's awful, and it keeps me awake, too. There are times he actually stops breathing. I know I'm no doctor, but I think he's got sleep apnea.” Simon had tried using nasal strips. He thought they helped. Most over-the-counter sleep aids only made him feel “fuzzy” in the morning. He was an overweight man with a short, stocky neck, and I was treating him for mild hypertension and acid reflux disease. My examination of his nose and throat did not uncover any evidence of upper airway obstruction. I had to agree with his wife's presumptive diagnosis. Simon had a sleep study performed, and it documented moderately severe sleep apnea. Treatment with a nasal continuous positive airway pressure (CPAP) unit was recommended. The optimal level was titrated for him in the sleep laboratory. I'm happy to report that Simon and his wife are now sleeping better than ever.
Nineteen-year-old Flannery had been bothered by soreness and swelling of her left ankle for three weeks. She did not recall any injury. Ibuprofen seemed to “help a little.” She denied any other symptoms. There was no hint of a limp. Mild swelling was present over the left medial malleolus, but there was no tenderness, warmth, or erythema of the ankle. An x-ray of her ankle was normal. A rheumatoid factor was negative, but an antinuclear antibody test (ANA) was positive at a titer of 1:1,280 with a 4+ speckled pattern. The anti–double-stranded DNA test was negative, but these levels can be negative early in the presentation of systemic lupus erythematosus or during treatment. Flannery's white blood cell count was only 3,400 per mm3, but other laboratory tests, including a serum creatinine, were normal. In light of her mild symptoms, conservative therapy seemed appropriate. After just two weeks of celecoxib (Celebrex), Flannery was happy to report that her ankle felt fine. She understands the need to monitor the disease and to recognize all of its diverse signs and symptoms. “I'm gonna be okay,” she confidently announced for the benefit of herself and her doctor. As Flannery raced out of my office, I must admit she had me convinced.
When she was 16 years old, Gail had a terrible accident. While performing a cheerleading routine that she had done at least 100 times before, Gail fell and hurt her neck. She underwent surgery to stabilize a cervical fracture, but her legs remained paralyzed because of a spinal cord injury at the level of C5-C6. Gail is now 43 years old. In the intervening years, she has required treatment for osteomyelitis, severe decubitus ulcers, and recurrent urinary tract infections. She has had lithotripsy and multiple surgical procedures. She has even survived a cardiac arrest. Gail is an indomitable fighter. Nothing can stop her. She gets around in a motorized wheelchair and a specially configured van. I have never met a more courageous person, yet she seems unimpressed by all of her accomplishments. Gail just goes about living life the only way she knows how—one moment at a time. She is now employed as a childcare worker, and who could possibly be a greater role model for children than her? Each person's life impacts everyone else's. Thank you, Gail, for inspiring all those people who know you. Give me a “G.” Give me an “A.” Give me an “I.” Give me an “L.” What does it spell? HERO!
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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