Diary from a Week in Practice



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Am Fam Physician. 2004 Jan 1;69(1):66-68.

Monday

During a high school basketball game, Jake took a turnaround jump shot, landed awkwardly, and twisted his left knee. Diagnosis: tear of the anterior cruciate ligament and medial meniscus. Jake had surgery and then worked hard at rehabilitating his knee during the next six months. Despite his recovery, he was reluctant to return to playing basketball. His parents suspected that Jake was afraid of reinjuring the surgically repaired knee. Help came from a familiar but unexpected source. Jake's younger brother, Jason, had an attitude problem. Plainly speaking, Jason believed he was the best at everything. “Even before you screwed up your knee, I was a better basketball player than you,” Jason boasted. Jake finally had enough of his younger brother's brag-gadocio. “Okay, wise guy. How about a little one on one?” Lately, as I drive past our city park, I'll frequently spot these two brothers running up and down the basketball court—yelling, sweating, bumping each other, and laughing. And, whenever I hear Jason taunting his brother, Jake will inevitably leap into the air, launch a jump shot, and land on the asphalt without fear of hurting his reconstructed knee. The result is always the same. Nothing but net!

Tuesday

In our neck of the woods, many of the natives like to think of themselves as “do-it-yourselfers.” For some, a trip to the doctor's office is viewed as the last resort, after all home remedies have failed. Estelle had been troubled by a recurrent rash on her legs for many months. Although she wasn't certain about the cause, she had plenty of theories on how to eliminate it. At various times, she applied diphenhydramine cream, aloe vera, hydrogen peroxide, triple antibiotic ointment, hydrocortisone cream, petroleum jelly, vitamin E cream, and even vinegar to the lesions. She came to see me either because she finally ran out of ideas for curing the rash, or she had completely depleted the contents of her medicine cabinet and kitchen pantry. “One day they'll itch, and the next day they'll burn,” the 77-year-old woman informed me. Estelle had a blistering eruption associated with a peripheral rim of inflammation. A biopsy was performed, and the results were suggestive of bullous pemphigoid. I recommended she apply clobetasol ointment twice a day to the lesions on her legs. If the rash is not controlled, we'll need to contemplate treatment with oral corticosteroids or a referral to a dermatologist for consideration of immunosuppressive therapy with methotrexate or azathioprine.

Wednesday

Whoops. High fashion can be dangerous. While dodging a snowball tossed at her by a friend, Andrea literally fell off her platform shoes with their three-inch heels. In the process of falling, the teenager twisted and then landed on her right foot. When I examined her in my office two days later, mild swelling and marked tenderness over the third and fourth metatarsal bones were present. A plain x-ray of the injured foot, however, was negative for a fracture. Conservative therapy was recommended—limited weight bearing on the right foot, application of ice, compressive dressing, elevation, and ibuprofen as needed for pain. Ten days later, Andrea's foot remained painful, but she was anxious to resume cheerleading and playing volleyball.“Is it safe to let her return to practice?” her mother asked me. A nuclear medicine bone scan of the right foot answered that question for the three of us. The scan demonstrated intense, increased activity in the head of the fourth metatarsal. It still required some imagination, a strong magnifying glass, and the radiologist's expertise to identify a subtle linear fracture on a repeat x-ray of the foot obtained in conjunction with the bone scan. When I broke the news of the fractured foot to Andrea, all she could say was “Cool.” Her mom's reaction was equally succinct,“Kids!”

Thursday

“Something's wrong with my heart,” Mr. Conrad proclaimed. “It's skipping beats all over the place.” Six weeks earlier, the middle-aged man had seen a physician assistant practicing in town who prescribed chlorthalidone for his elevated blood pressure. Since that visit, Mr. Conrad was pleased by his blood pressure readings at home, which averaged 110/70 mm Hg, but was bothered by frequent nocturia. His examination was noteworthy for a blood pressure of 116/72 mm Hg, frequent premature ventricular contractions (PVCs) including runs of trigeminy, and a mildly enlarged prostate gland. An electrocardiogram documented frequent PVCs but no other abnormalities. His potassium level was 3.0 mmol per L. We opted to discontinue the chlorthalidone, continue close surveillance of his blood pressure, and really push lifestyle modifications—a daily exercise program, weight loss to achieve a normal body mass index, and initiation of the Dietary Approaches to Stop Hypertension (DASH) eating plan. Two weeks later, Mr. Conrad's potassium was 4.1 mmol per L, and his blood pressure was 124/80 mm Hg. I could not detect any PVCs, and he was happy to report he no longer experienced any palpitations. Thiazide diuretics are an excellent choice in treating hypertension, but never underestimate the power of potassium (or lack of).

Friday

“Am I too young to have a stroke?” Bridget wanted to know. The 43-year-old woman sounded frantic over the telephone. She had woken this morning unable to move the left side of her face, and she was frightened by her appearance reflected in the bathroom mirror. “Get to the emergency room now,” I told her, “and I'll meet you there right away.” Sure enough, one side of her face was distorted by a drooping mouth and an eye that refused to blink. Bridget had Bell's palsy. She was relieved to learn it was not a stroke but horrified at the prospect that her face might remain disfigured for weeks to months, or even permanently. I recommended a tapering dose of prednisone and instructed Bridget on protecting her eye from damage caused by dryness. We reviewed some simple home exercises to strengthen her facial muscles. I assured her that most cases of Bell's palsy improve even without treatment. Bridget thanked me before she left and even attempted a smile. The result was a crooked smirk and the hope that things would straighten out in the very near future.

Saturday/Sunday

As a rule, snow doesn't come too often or last very long in southern Illinois. The children love to play in it, and they savor the memory long after the last snowball has been thrown. One winter, I watched a man in his early 30s die of a rare form of cancer. His life dissolved before my eyes. On the afternoon he died, I sat for hours next to his hospital bed, keeping vigil. He couldn't have even known I was there. I had so many troubling questions. Why him? Could I have done more? What would happen to his wife and children? When I left the hospital, the snow was already thawing, and water dripped from roofs and gutters everywhere. Icicles were transformed into tears. It was as if all the buildings in town were also weeping over the loss of this good man. On arriving home, I noticed my son playing in our backyard. “Hey Dad,” he greeted me. “Check this out.” He had constructed a snowman. Short and scrawny, with a tree twig about a foot long for a nose and one of my old stethoscopes around its neck, his creation was supposed to be me. Alongside it stood another snow creature about half the height. By the next day, both sculptures would be reduced to puddles of water. “Looks just like me,” I complimented my son. Loss is inevitable. Memories, however, refuse to melt away.

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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