Diary from a Week in Practice
Am Fam Physician. 2003 Nov 1;68(9):1763-1764.
For the past several years, Mr. and Mrs. Benedict have spent the winter months vacationing in the southwestern United States. This year, the 80-year-old couple was driving their pick-up truck back to Illinois when they encountered some ferocious weather in New Mexico. Wind gusts exceeding 100 miles per hour flipped their vehicle over three times. Both of them incurred a pneumothorax, multiple rib fractures, and large scalp lacerations. Mrs. Benedict fractured her sternum, scapula, and cervical spine. Her husband developed congestive heart failure and experienced frequent hallucinations while in the hospital, including an especially haunting mirage of buzzards circling above him. “Get us home,” Mrs. Benedict begged her doctor. Two weeks after the accident, the couple was transported by airplane to a rehabilitation unit in southern Illinois. They were bruised and battered with a long convalescence still ahead of them, but they were grateful to be alive. Mrs. Benedict gripped my hand tightly and announced, “There's no place like home.” Even Dorothy in The Wizard of Oz couldn't have said it any better. “It's a miracle,” Mr. Benedict added. After clearing the large lump in my throat, I squeezed both their hands and said, “Welcome home.”
Four days of nonstop itching would drive most people crazy, and Otto was no exception. He had a rash that was really bugging him. “What do you think, Doc?” Otto asked. Scanning the large, raised bumps, I offered a diagnosis. “It looks like insect bites.” He scratched his skin, then nodded. “That's what I thought. I mowed my yard a few days ago and didn't wear a shirt. My wife's been putting cortisone cream on these welts, but it isn't helping.” I inched closer for a better view. Two of the lesions appeared infected and had small black centers. It might have been the motion of Otto's animated itching, but I imagined that one of the black dotsmoved. With the aid of a magnifying glass, I discovered that the black dots were in fact two tiny ticks. With some steady, gentle traction, the insects were completely removed. We discussed methods of minimizing his exposure to ticks. I wrote prescriptions for an antihistamine and doxycycline. Considering the prevalence of deer ticks in our area, I thought doxycycline was a good choice for double duty—treatment for his secondary skin infection and prophylaxis for Lyme disease. Otto had an interesting way of expressing his gratitude: “Thanks for exterminating me.”
“Every day there seems to be less of me,” Mavis concluded. The 89-year-old widow's self-assessment was spooky and accurate. During the past four months, she had lost 35 pounds. A careful review of systems yielded an important bit of information: “Food just doesn't sound good to me anymore.” Since her husband passed away nearly six months ago, Mavis lost not only her desire to cook but also her interest in eating. Despite the loving attention of her children, having meals delivered to her home, and consuming nutritional supplements, the lost weight has failed to return. The patient, her family, and I know she is still grieving for her husband of 70 years, but Mavis refuses to try antidepressant medication and will not consider counseling. An extensive evaluation failed to identify any cause of weight loss other than the diagnosis already established—a broken heart. Whoever said that time heals all wounds? As I complete the progress note in her chart, I list “loneliness” as the assessment. But, what shall I put down for the plan?
While performing a routine examination on Darrell a few years ago, I detected a Grade III/VI systolic ejection murmur that was best heard at the base of his heart and transmitted along the carotid arteries. An echocardiogram confirmed the presence of moderate aortic stenosis. Darrell denied experiencing dyspnea on exertion, angina, or syncope. We decided to monitor his valvular disease with clinical examinations and echocardiograms. Although the hemodynamics of his aortic stenosis have remained stable, I sensed Darrell remained worried that his calcified valve might one day make a “fossil” out of him as well. Not long ago, he complained of abdominal pain. While searching for a diagnosis, a computed tomographic scan of Darrell's abdomen revealed an unexpected finding—an abdominal aortic aneurysm measuring 5.8 cm in diameter. Surgery to repair the aneurysm was successful. At today's visit, Darrell confided, “I feel silly having worried about my heart valve the past couple of years when all the while I'm walking around with an aneurysm that might have ruptured at any time. He handed me a large bag of frozen bluegill that he caught recently. “My friends said the fish weren't biting,” he laughed, “but you just never know what you're going to catch.”
If you're going to solve a puzzle, it's important to have all the pieces. When Mrs. Christie was found on the floor of her bedroom, unable to get up, her daughter feared the elderly woman had suffered a stroke. Mrs. Christie was evaluated in the emergency department, and by the time all her test results had come back as normal, she felt considerably better. “I don't know what happened to me the other night,” Mrs. Christie told me at her office visit a few days later. “That makes two of us,” I candidly replied. “Other than the fact that I haven't had an entire night's sleep for the past 20 years, I'm fine,” she added. Her son-in-law was incredulous. “You're still not sleeping despite all those pills you take at bedtime?” he asked. She shook her head and answered, “Not a wink.” Her son-in-law estimated she had taken more than 100 over-the-counter sleeping pills containing diphenhydramine in the past month. She assumed the drug was safe because she could buy it without a prescription. Mrs. Christie promised not to take any more nonprescription medication without checking with me first. Although you can't choose your in-laws, Mrs. Christie fortuitously landed an insightful one.
Three years ago, a 61-year-old man came to my office describing “terrible” upper abdominal pain associated with weight loss. Within days, Gus acquired a diagnosis that matched his pain—pancreatic carcinoma. Throughout his difficult treatment—a Whipple's operation, radiation, and chemotherapy—Gus remained upbeat and never lost his sense of humor. At today's visit, his CA 19-9 tumor marker was up to 73 units per mL. “You need to have some additional tests,” I informed Gus. “Ah geez Doc,” he responded. “My insurance company has already spent a million dollars paying all my medical bills. Four months ago, they sent a letter offering me a $5,000 bonus if I just went ahead and died right now!” The astonished look on my face triggered an immediate confession from Gus. “Just kiddin',” he said. It was my turn to tease him. “If I were you, I'd hold out for at least $10,000,” I replied. We laughed so hard that my sides hurt and Gus had tears in his eyes. I'm sure anyone who heard us cackling believed we had lost our minds. For a single moment though, the two of us forgot about the past and didn't worry about the future. We already knew the true worth of a man like Gus—priceless.
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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