From a Week in Practice
Am Fam Physician. 2004 Aug 15;70(4):683-684.
KS took one look at her patient and burst out laughing. “I can’t believe how different you look with that new hairdo!” she exclaimed. She had glanced at the patient as the nurse brought her into the examination room, but had not recognized her. She did not think much about it, concluding that she was new, or one of her partner’s patients. When KS took the chart out of the rack on the back of the door, however, she thought that the nurse must have pulled the wrong chart. She opened the door prepared to explain that an error had been made (and discretely ask the patient her real name), and she had the opportunity to take a closer look. Long dark hair had been transformed into light brown curls—but aside from that, it was definitely the person identified by the chart. After they both stopped laughing, the woman explained that she was wearing a wig. “It is unbelievable how different you look,” KS said. “Yes, but underneath my disguise, my blood pressure is still uncontrolled!” returned her patient.
“Never order a lab test unless you want to know the answer,” KS reminded the second-year resident. She had given this advice many times, particularly during nursing home rounds. The resident was examining an 83-year-old man who had been in the home for three years secondary to advanced Alzheimer’s dementia. Because the elderly man had lost about 10 lb in the past six months, the resident had ordered screening laboratory tests. He included a prostate-specific antigen (PSA) level, the result of which was elevated at 10 ng per mL (normal is 0 to 4 ng per mL). KS knew the patient well. Although the patient was nonverbal and unable to ambulate, he was in no pain or any kind of distress. He spent his day either in bed, or sitting in a wheelchair in the common room. KS showed the resident where to find the meal intake form, which revealed that the patient was eating at most 50 to 75 percent of his meals. KS explained that as Alzheimer’s disease progresses to the latest stage, patients gradually lose the ability to eat and swallow. Even if the patient had prostate cancer, there were no treatment options available for this asymptomatic man in the last few months of his life. The two physicians decided not to pursue the abnormal blood test, and to focus instead on making the patient’s last days as comfortable as possible.
Treating rashes can be tricky, and treating a rash acquired overseas is nearly impossible. This is especially true when the mother is describing the rash over the telephone. KS was thrilled to hear from her sister in Dallas, who had just arrived from China with her newly adopted three-year-old daughter. The new mother described an animated, smiling little girl who was healthy in every way—except that she was extremely itchy. Her trunk, arms, and legs were covered with a red, bumpy rash, which had been present since the day the child was picked up from the orphanage two weeks earlier. KS remembered reading about an outbreak of measles among young Chinese adoptees from a particular orphanage, but this itchy rash certainly was not measles. “I agree with you that it could be scabies,” KS advised her sister, “but frankly, I am not well versed in Chinese rashes.” The child had an appointment with her doctor in two days. In the interim, KS suggested hydrocortisone cream and an antihistamine for the itching. “I can’t wait to meet my new niece!” KS added as she congratulated her sister on the new arrival.
“I feel awful, Doctor. I just feel awful,” the 68-year-old man said with a big smile on his face. KS laughed at the longstanding joke between them. It always was a pleasure to visit this particular patient during nursing home rounds. Despite a tremendous amount of disability from a stroke that had left him wheelchair-bound for more than 10 years, he managed to retain a positive attitude and sense of humor. Even when he occasionally did feel “awful,” the patient would describe his problems in a matter-of-fact way, confident that things would get back to normal soon. Today he did not feel awful—he felt just fine. KS sat down for a minute to talk, but he reminded her that it was his bingo afternoon, and he was in a bit of a hurry to get to the recreation room. “Wish me some awful luck,” he called over his shoulder as he wheeled himself down the hallway.
“They tell me I nearly died,” the patient said, looking as if he still did not believe it. KS had to nod her head in agreement. This 58-year-old man presented with the sudden onset of severe headache, diaphoresis, nausea, and vomiting. An emergency computed tomographic scan revealed an acute intercerebral hemorrhage, and the patient ultimately underwent surgery for repair of a leaking aneurysm. Now on his fourth postoperative day, he had been transferred to the floor, and felt perfectly fine. “I never thought anything like this would ever happen to me,” the patient explained. “I have been healthy all my life, and it all happened so fast.” The most that he had to show for the experience was a small surgical wound on the top of his head. This patient indeed had been lucky, KS thought. She had seen several patients die from ruptured aneurysms, usually arriving at the hospital in critical condition. She wondered what it was like to have a near-death experience. Would it change your life? Probably not very much, she decided. Some people just naturally seem to live life to the fullest, regardless of ill health and misfortune. Others seem to let mild ailments and mishaps drag them down. In her experience, a life-threatening medical event does not seem to change a person’s basic temperament and attitude toward life.
“The patient also is an alcoholic, so I advised him to go to Alcoholics Anonymous,” the medical student reported. KS was quite surprised. She had known this 53-year-old man for many years, and although she realized he drank too much, she had never diagnosed him with alcohol dependence. When she questioned the student, he explained that the patient drank one mixed drink before dinner and two glasses of wine every evening. “An alcoholic drinks more than 14 drinks per week, and he exceeds that limit,” he concluded. KS took a few minutes to explain the difference between risky drinking and alcoholism. Men who drink more than 14 drinks per week certainly are at risk for alcohol dependence, as well as other health problems such as liver disease and hypertension. But, drinking more than a prescribed amount does not diagnose alcoholism. To distinguish between risky drinking and alcohol dependence, the physician should administer a screening instrument such as the CAGE questionnaire. True alcohol dependence means that the drinking significantly interferes with a patient’s social, job, or legal status. The student was good natured about heading back to the examination room to ask his patient more questions. “I should have known it wasn’t that easy,” was his only comment.
Copyright © 2004 by the American Academy of Family Physicians.
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