Diary from a Week in Practice



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Am Fam Physician. 2004 May 1;69(9):2109-2110.

Monday

Smoke signals—the protruding front pocket on the left side of the shirt, nicotine-stained fingertips, and the scent of cologne mingled with traces of cigarette smoke. I must have told Emmett a hundred times to stop smoking. The 69-year-old man has averaged two packs of cigarettes a day since he was a teenager. “Have you ever thought about why you smoke?” I asked him. “I enjoy it,” he immediately responded. “How can I help you quit smoking?” I asked, listing once more the many options available to him. Emmett’s answer was always the same: “You’re wasting your time, Doc.” Recently, he had been bothered by a lingering, productive cough, so I ordered a chest x-ray. It demonstrated a small heart and changes of hyperinflation—low, flattened diaphragms and increased retrosternal translucency. “How does it look?” Emmett inquired. “There are some changes of emphysema, but no pneumonia or tumor,” I replied. “Emphysema!” he bellowed. Although Emmett had been told years earlier that he had chronic obstructive pulmonary disease and has been using an inhaler, he apparently never actually believed the diagnosis—until now. He studied his own chest film intently as I pointed out the changes. Flinging his package of cigarettes into the waste container, Emmett announced, “I quit.” Sometimes, a picture really is worth a thousand words.

Tuesday

My waiting room was packed. Along with everyone else in the office, I could hear one patient raising his voice: “I can’t wait.” That voice belonged to Kirk, a tall and lean 30ish man in excellent health. He had a reputation for being meticulous and combustible. It was, however, uncharacteristic for the self-employed mechanic to show up without an appointment and then demand to be seen immediately. “How about coming back around one this afternoon,” the receptionist tried to appease him. “Please get the doctor now,” Kirk politely ordered her. He described a sudden onset of shortness of breath. He appeared tachypneic, but his vital signs were stable. Breath sounds were markedly diminished over the right thorax, and the same side of his chest was hyperresonant to percussion. A chest x-ray revealed absent lung markings of much of his right lung—a moderate-sized spontaneous pneumothorax. Arrangements quickly were made for placement of a chest tube. “I’m afraid scuba diving and piloting an airplane are now out of the question.” I then shared with him some sobering statistics. “Unfortunately, there is about a 30 to 50 percent chance of recurrence.” Kirk just shook his head in disbelief. “Doctors,” he muttered. “When I fix something, I always give my customers a guarantee. If my lung collapses again, do I at least get a discount?”

Wednesday

Mrs. Wilbatch sat perfectly still on the examination table without uttering a word. As was usually the case, her daughter Naomi did all of the talking. “I’m worried about mother. She’s been awfully tired lately. The least amount of exertion makes her short of breath.” I asked Mrs. Wilbatch how she was feeling and was not surprised by her answer. “Fine,” she replied. “No chest pain, dizziness, weakness, or shortness of breath?” I interrogated her. The 88-year-old woman simply shook her head no. She was not one to waste words. On examination, Mrs. Wilbatch’s heart rate was very slow. She was not taking any medications that would be likely to cause bradycardia, and her thyroid function tests were normal. A 24-hour Holter monitor confirmed frequent episodes of severe bradycardia, with pauses as long as 2.5 seconds. The cardiologist recommended implantation of a permanent pacemaker. When I next saw Mrs. Wilbatch in the office, Naomi was ecstatic. “She has so much energy now, I can hardly keep up with her. Isn’t that right, mother?” Mrs. Wilbatch appeared as if she was dozing and had just been woken up from a nap. She nodded her head in agreement. “How are you doing with your pacemaker?” I inquired. Tapping the protuberance of her upper chest, she was unexpectedly garrulous. “Really fine,” she answered.

Thursday

As Margo adjusted the paper examining gown she was wearing, the 59-year-old woman pressed on the right side of her upper abdomen to show me the cause of her concern. “I noticed this swelling a few days ago. It doesn’t really bother me. Do you think it might be a hernia?” As I palpated Margo’s abdomen, it became clear that the woman’s “hernia” was actually hepatomegaly with at least one large nodule. An ultrasound study of the abdomen demonstrated multiple hepatic cysts. The largest one was located in the right lobe and measured 8.7 cm in diameter. She also had two small cysts on the right kidney and one on the left kidney. Margo’s blood work was fine: aspartate transaminase, 18 IU per L; alanine transaminase, 23 IU per L; and creatinine, 0.8 mg per dL. Frequently, I encounter simple cysts of the liver and kidneys as incidental findings on computed tomographic scans and ultrasound tests of the abdomen obtained for other indications. They are benign and require no treatment unless they become extremely large. Because Margo is asymptomatic, we’ll just keep an eye on her liver to make sure the cyst doesn’t get much bigger. Margo was happy to learn that she did not need surgery, but clearly needed more time to digest her diagnosis. “So essentially you’re telling me that I’m full of cysts. I’m not sure I appreciate the way that sounds,” she jested, “but I like the fact that I don’t need to worry.”

Friday

Nathaniel is a bright teenager who happens to be overweight. His body mass index is 32 kg per m2. He feels great and is physically active. He was here today for a preparticipation sports physical. It was a perfect opportunity to broach the subject of obesity. “Everything checks out fine except one thing,” I began. “I know,” the boy interjected, “I’m fat.” Nathaniel did not appear concerned about his weight. “Do you know all the problems that being overweight can lead to?” I asked him. “Things like diabetes, high blood pressure, elevated cholesterol levels, and heart disease.” Something clicked with Nathaniel. “Well, couldn’t I just take Lipitor?” he asked. His statement caught me off guard. It turned out that his knowledge of this medication (and many others) was gleaned from commercials he had seen on television. “For now, we’re going to concentrate on eating less, eating healthier, and continuing to exercise,” I insisted. When his plump mother took up his defense, I sensed she was not exactly my ally in the battle against obesity. “You know how teenage boys are,” she chipped in. “They really like to eat. It’s part of their growth spurt.” I scheduled Nathaniel and his mother to meet with a dietitian, and arranged to have his glucose level, lipid levels, and thyroid function measured. I’m afraid the boy may yet be too clever for his own good. As he exited the office, Nathaniel joked with his mother, “Don’t worry, there’s always liposuction.”

Saturday/Sunday

“Isn’t he cute?” Muriel asked. “His name is Lucky,” she added as she introduced her new pet to my office staff. “Cute” was not exactly the word I would choose to describe the tiny dog that looked more like a hairy rat than a pooch. Only a mother could find such a homely creature beautiful. Muriel’s adult children all lived far away from her, but she doted on the dog as if it were her last child still living at home. She pampered Lucky, and the canine in turn seemed a perfect solution for her loneliness. Every morning the two of them walked around the neighborhood. Not long ago, Lucky was hit by a car and suffered serious injuries. I could hardly imagine the fragile creature surviving a collision with a beach ball let alone an automobile. It was a miracle that Lucky had lived. With the assistance of an excellent veterinarian, Muriel nursed the dog back to health through sheer willpower—hers and the mutt’s. Many weeks later, Muriel brought Lucky to the office for a visit. The little dog was swaddled in a blanket. Muriel was radiant as she recounted the story of her pet’s recovery. Lucky couldn’t stop licking Muriel’s face. The near-death experience of the dog had transformed both pet and owner. What a magnificent animal this spunky dog really was! His moniker proved to be accurate—Lucky was indeed a fortunate canine. Calamity has a way of bringing out the best in all creatures.

Dr. Tony Miksanek has been a family physician for more than 20 years. Most of that time has been in solo private practice in Benton, a town of about 7,000 people in rural southern Illinois.

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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