From a Week in Practice
Am Fam Physician. 2004 Sep 1;70(5):861-862.
“My elbow is giving me fits,” Wes proclaimed. “It’s gotten so bad in the last couple of weeks that it hurts just to lift a half gallon of milk out of the fridge.” The middle-aged man was a meat cutter who loved to golf. Wes’s right lateral epicondyle was very tender, and wrist extension provoked his elbow pain. A plain x-ray of the elbow appeared normal. No calcifications were present. “You’re suffering from lateral epicondylitis—tennis elbow,” I informed him. “You don’t have to play tennis to develop the problem.” His initial treatment would include the application of ice, use of nonsteroidal anti-inflammatory medication, modification of his activities, and the wearing of a counterforce strap. If he doesn’t get better, the next step is physical therapy and possibly a steroid injection. Some physicians are using shock wave therapy. Wes was reluctant to give up golfing, even temporarily. “It’s either your clubs or my needle,” I warned him. “You choose.” Despite his affinity for knives and cleavers, this meat cutter had a fear of injections. “Geez, I don’t know about you anymore,” he taunted me. “You forbid me to play golf and threaten to give me a shot, probably with a long needle.” I tried defending myself. “How about cutting me some slack?” Wes chuckled. “How about I cut you two thick steaks instead?” He held his right arm in the air and demonstrated the size of the imaginary steaks. The wince of pain on his face was unmistakable.
“You must love hearing about bowel movements all day long,” 67-year-old Blanche, an avid bridge player, snickered, “but last week mine were black as coal for five days.” She also described intense epigastric pain but no vomiting. Blanche had a history of osteoarthritis, hypertension, and coronary artery disease. She took metoprolol, hydrochlorothiazide, oxaprozin, and low-dose enteric-coated adult aspirin. She appeared pale, and her upper abdomen was tender. Her stool tested positive for occult blood. “My stomach has always been made of iron,” Blanche bragged. By the looks of her, iron was no longer a commodity. The laboratory work was fine except for a hemoglobin level of 10.5 g per dL and hematocrit of 31.1 percent. Less than one year ago, those values were 14.1 and 39.3, respectively. Blanche had experienced an upper gastrointestinal bleed. The oxaprozin was discontinued, and the aspirin was stopped. Lansoprazole was begun. Endoscopy demonstrated gastritis, and testing for Helicobacter pylori was negative. Within one week, her hemoglobin and hematocrit levels had risen to 11.3 and 33.4. Blanche is now taking extra-strength acetaminophen for arthritis. “You must love hearing about arthritis pain all day long,” she wailed, “but my joints were a lot happier with the old arthritis medication than they are with acetaminophen.” I saw this complaint coming. Somewhere down the line, we might try a COX-2 inhibitor in conjunction with lansoprazole, or perhaps a combination of diclofenac and misoprostol. At least for now, stomach trumps joints.
“How have you been?” I asked Derek. “Great,” he replied. “I’m starting a new job, and I need a physical.” It had been at least 10 years since I last saw him. He would have been about 13 years old at the time. Derek had lacerated his lower leg after running into the outfield fence while playing in a Little League baseball game. “Can you stitch this up?” his father had inquired. He pointed to a triangular flap laceration on his son’s leg. I carefully repaired the jagged defect. Although I was pleased with the end result, Derek’s dad was stunned. “My God, he looks like Frankenstein!” Derek wasn’t fazed in the least by his father’s comment, but it bothered me. I assured them that the wound would heal satisfactorily. Today, I deliberately searched for a prominent scar on Derek’s leg but the mark I discovered was small and slightly raised—more a blemish than a scar. I could not help but touch it and trace its outline with my finger. It was a link to the past and proof of the regenerative power of youth. “Do you remember sewing that up?” Derek questioned me. Now, he too was unable to resist caressing the diminutive imperfection. “You did a good job,” he told me. “My dad sure freaked out and gave you a hard time, though.” I decided to share only half the truth with Derek. “It was long ago. Your father was concerned. I don’t recall much else.” Reminiscing can be risky.
The Amazons were a mythological tribe of women warriors renowned for their ferocity and courage. Legend has it that Amazon girls allowed their right breast to be removed (by cutting or burning) so it would not interfere with the use of a bow and arrow. Yvonne was a large 54-year-old woman and a no-nonsense character who didn’t waste time or words. “Check this out,” she ordered me in a tone of voice typically associated with drill sergeants. Yvonne pointed to an inflamed, crusting rash that involved the nipple and areola of her right breast. She had applied an over-the-counter steroid cream, but it hadn’t helped. “I don’t like it,” she declared. “Let’s do something about it.” I had to agree with Yvonne. The rash might have been eczema or dermatitis, but its location made me worry about Paget’s disease of the breast. A biopsy of the nipple confirmed Paget’s disease. Yvonne underwent right breast-conserving surgery, including a resection of the nipple and areola. The pathologist also identified focal ductal carcinoma in situ, comedo type. No invasive carcinoma was present. When postoperative radiation therapy was recommended, Yvonne’s response was true to form. “Whatever it takes. Is that all I need?” She is scheduled to see an oncologist to help answer that question. Amazons were purported to be a strong and fearless group of women. I suspect it was no myth. Maybe their descendants still walk among us.
A few years ago, Gretchen was concerned about the fungus infection of her toenails. After I explained to her that onychomycosis was a cosmetic infection and not something that would adversely impact her general health, she quit worrying about it. Or at least I thought so. “I’ve been watching those commercials on TV for that medicine that cures nail fungus, and I’d like to try it,” she told me today. “My feet look hideous!” That word hideous absolutely melted me. Now I felt ashamed, too. I had never guessed how troubled she was by the appearance of her toenails. Sure, they were discolored and deformed, but I had seen plenty of cases that were much worse. Some of those patients had toenails so thick that they had outgrown the average nail clipper long ago. I wrote Gretchen a prescription for the oral antifungal medicine that she requested after discussing with her the potential adverse effects of the medicine. She was back a short time later. “My insurance doesn’t cover this medicine. It’s pretty expensive. I can’t afford to pay for it myself.” I had no office samples to give her. “Let me write a letter to your insurance company,” I offered. “I’ll enclose a photograph of your toenails as proof.” Once more, I was surprised by her response. “Don’t waste your time,” Gretchen said, “There’s always nail polish.” It bothers me when I misread people. Yet, it’s hard to know what some patients want when they haven’t quite decided either.
It didn’t dawn on me for the first few visits. Initially, he had trouble sleeping. The next time—headaches. Chest pain after that. Then an upset stomach most days of the week. Alvin was in his early 50s. His 15-minute office calls invariably extended into one-half hour visits. We liked to talk about sports, our children, and current events. Even so, there would be lapses in our conversation where neither of us said a word. Those stretches of silence were piercing. I always had the feeling that there was much more he wanted to say. Alvin was a Vietnam veteran, but he never mentioned that fact to me until recently. When I broached the subject, his eyes watered and he shook his head back and forth. “It was horrible, Doc.” Managing his PTSD has proven much more difficult than finally diagnosing it. Treatment with an SSRI and cognitive-behavioral therapy has helped a bit, but his past still haunts him. The scars he incurred in Vietnam not only defy revision but also seem to enlarge with the passage of time. Combat keloids. Lately, I think of Alvin every time I hear our national anthem: And the rockets’ red glare, the bombs bursting in air. . . . Even now, so many years later, Alvin is still a casualty of war.
Copyright © 2004 by the American Academy of Family Physicians.
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