Diary from a Week in Practice
Am Fam Physician. 2003 Oct 15;68(8):1523-1524.
“What have you done?” KS asked her patient in amazement. The 72-year-old woman held up a small jar, out of which she emptied three large toenails. KS took a fearful look at her patient's feet and saw that the right great toe was covered with a large bandage. The woman explained that her toenail had been loose and kept getting stuck on her socks, so the previous night, she had taken a pair of tweezers and pulled the whole nail off. “I was surprised that it bled so much,” she admitted. “The other nails that I pulled off did not bleed at all.” KS looked at the jar of toenails in dismay. This was a sensible woman, with good insight into the complications of diabetes and congestive heart failure. She knew about the problems associated with diabetic foot ulcers and, in fact, was under the care of a podiatrist. Her patient tried to explain further. Several years earlier, when the podiatrist removed one of her nails, she had watched the procedure carefully. She figured she could perform that procedure just as easily herself, with a lot less time and trouble. KS removed the dressing. To her relief, the nail bed was clean and dry with no evidence of infection. Pulling off toenails without anesthesia reminded her of medieval torture chambers. “Please do not do that ever again,” was her only comment.
Three of three blood cultures were positive for Staphylococcus aureus. The cultures confirmed the diagnosis of bacterial endocarditis, ensuring a four- to six-week hospital stay for the 27-year-old woman. KS remembered treating her first heart valve infection five years earlier. The daughter of one of her colleagues, this young woman had been born with a congenital ventricular septal defect, as well as mental retardation and autism. With the help of her family, she had overcome enormous obstacles. She was able to live in a group home and attend a workshop every day. The woman communicated with her family and caregivers using a combination of vocalization, grunts, hand signals, and finger tapping. The prospect of a long hospital stay was not a problem. She loved going to the doctor's office and insisted on having a complete physical at every visit. She never complained about having blood drawn or IVs started—although she frequently pulled the catheters out when nobody was looking. In truth, KS felt most concerned about the patient's devoted family, who made arrangements to spend every night with their daughter while she was hospitalized. Amid all their commitments to career, church, and community, family would always come first.
Sometimes ordering brand name drugs instead of generics does make a difference. Many of the patients in the Family Practice Center are self-pay or seniors without a prescription drug benefit. To keep costs down, KS prescribes generic drugs as often as possible. Most of the time, generic drugs seem to be just as beneficial and well tolerated by her patients. Today, KS saw a 30-year-old woman who had been taking oral contraceptive pills for several years. The formulation that she took had been helpful in the treatment of premenstrual dysphoric disorder. About six months earlier, the patient began to experience troublesome breakthrough bleeding. KS prescribed extra estrogen for several cycles, without any improvement at all. Finally, she referred the woman to a gynecologist, who determined that the problem began just about the time she had been switched to a generic pill. The patient resumed the original brand name, and her bleeding stopped. KS was not aware of the switch, because she had signed the prescription on the line allowing generic substitution by the pharmacist. In this case, the patient was happy to pay extra money for the brand name birth control pill. KS learned a lesson that day. It always pays to think a little harder and ask a few more questions.
“I am so glad to see you!” exclaimed the elderly woman with a big smile and a big hug. KS and second-year resident CC were visiting an 82-year-old woman who was homebound because of dementia and severe arthritis. The patient had fallen the day before and complained of pain in the right knee. She continued to walk without much more difficulty than usual, and the pain was improving. Physical examination revealed no point tenderness, swelling, warmth, or redness in the knee. KS diagnosed a mild sprain and explained to the family that there was no need for an x-ray. She recommended acetaminophen as needed for pain, and she decided to call the home health agency to arrange for a home physical therapist to evaluate her gait. The family was thankful that the doctors were able to make a home visit. Despite increasing memory impairment, the patient always recognized KS and greeted her with great enthusiasm. “Although she does not remember me as her doctor,” KS explained to the resident, “she recognizes me as a friend.” That makes home visits even more rewarding.
“This case is straight out of a textbook,” declared third-year resident BR to the attending physician in clinic. It was the first office visit for this 24-year-old woman who was complaining of shakiness and palpitations for the past several months. After glancing at her chief complaint, BR assumed that, like many of his patients, she suffered from stress, anxiety, and possibly depression. But, he realized that his first impression had been a mistake the minute he walked into the room. His patient had mild exophthalmos. When she extended her arm to shake hands, he detected an obvious tremor. BR reviewed her vital signs, and he noticed that her blood pressure was normal but her pulse was 110. The patient explained that she was not really nervous—she just could not quit shaking, and she felt her heart racing on and off. Physical examination revealed a moderately enlarged, smooth thyroid gland. BR explained to his patient that she had hyperthyroidism, probably secondary to Grave's disease. He asked the nurse to schedule thyroid function studies, and a thyroid scan. Then, he went back into the examination room to ask the patient for permission to have the medical students in clinic examine her. “This great case has just made my day,” he said enthusiastically. “The best part is that the condition is curable!”
Everybody knows that there is the easy way to do medical records—and the hard way. The easy way is to keep up by doing a little bit every day. Facing a mountain of charts, KS quickly realized that she had chosen the hard way. The top record was the death certificate of a patient who had been bedridden in the nursing home for a number of years. This unfortunate man had multiple diagnoses, many complications, and multiple possible causes of death. She chose one diagnosis and completed the form. Next was a lengthy disability form requiring detailed medical information; estimated dates of disability; dates, names, and addresses of referring physicians; and ICDM diagnostic codes. KS filled out most of it and forwarded the rest to medical records to complete. She turned her attention to a stack of home health orders, with type so small she could hardly read it. She signed, dated, and revised several orders, putting them aside for her nurse to mail. Home health orders were followed by Medicare forms for diabetic supplies and other medical devices. Next was an inch-thick stack of telephone orders from the nursing home to review. Finally, there were telephone prescription refills, followed by mail order refills. It was a great relief to get to the bottom of that stack of paperwork. What a way to spend Saturday afternoon.
Kathy Soch, M.D., is a clinical instructor with the Corpus Christi Family Residency Program, affiliated with the University of Texas Health Science Center in San Antonio. This community-based program, which employs nine full-time faculty and 36 residents, primarily serves low-income, uninsured patients.
Address correspondence to Kathy Soch, M.D., 2606 Hospital Blvd., Corpus Christi, TX 78405.
In order to preserve patient confidentiality, the patients' names and identifying characteristics have been changed in each scenario.
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