Diary

From a Week in Practice

Am Fam Physician. 2004 Nov 1;70(9):1677-1678.

Monday

Donna never dreamed that one day she would be an organ donor. Of course, she never imagined that her mother, Isabell, would need a kidney transplant either. Despite heart problems most of her life, Isabell always gave a maximal effort. Her family bragged that she had the cleanest house in town. Such devotion to housework came with a price—extreme shortness of breath, fatigue, and even an episode of fainting one summer after hanging clothes to dry on the backyard clothesline. About seven years ago, Isabell suffered a heart attack. Not long afterwards, she developed chronic renal failure requiring dialysis. Donna was a compatible match for her mother, so at the age of 41, she donated her right kidney to Isabell. The entire family lined the hospital corridor to provide support for the mother and daughter. Even now, Donna remembers that operation as the “easiest” one she has ever had. Isabell was 62 years old when she accepted Donna’s kidney. On some days, she senses that the new kidney “feels heavy” in her abdomen. There has, however, been no organ rejection, and the kidney continues to function well. Donna attributes some of the credit to the fact that “Mom is now a finely tuned lab of medicines.” Two years ago, Donna became a grandmother for the first time. While Isabell has her share of good days and bad days, she still somehow manages to find the strength to babysit her sole great-grandchild one day a week. A million nephrons make a dazzling gift. The love between a daughter and mother is even more spectacular.

Tuesday

Rita was a model of consistency. Her blood pressure closely orbited 120/70 mm Hg. Her weight never fluctuated more than a pound or two. For the past several years, she had faithfully participated in the annual health screening program sponsored by her employer. Her laboratory work had never ventured beyond the normal range. Then, at the age of 47, Rita’s perfect record took a hit. Two values appeared in the abnormal column of her test results: hemoglobin 11 g per dL and hematocrit 33.9 percent. Granted, those figures weren’t too alarming, but just the year before they were 12.7 and 37.4, respectively. Two years earlier, Rita’s hemoglobin and hematocrit were 12.2 and 37.2. Red blood cell indices were normal. The white blood cell count was 7,200 cells per mm3 with a normal platelet count. When I asked how she felt, Rita’s reply came as no surprise: “Same as always—great.” Stool guaiac testing was negative. Her serum iron was 149 μg per dL, and the ferritin level also was normal. Her folic acid level was 12.4 ng per mL, but her vitamin B12 level was low at 129 pg per mL. Repeat testing confirmed the vitamin B12 deficiency. She was treated with intramuscular vitamin B12 (cyanocobalamin) and was able to administer her own injections. Six months later, her hemoglobin and hematocrit levels are 12.3 and 37.3. “I feel terrific today,” Rita announces, “just like usual.” Some people never change. So, when their blood work varies even a little bit, you can bet that something’s up. Or in some cases, maybe down.

Wednesday

“How low can it go?” Roger wanted to know. “My cholesterol level is already less than almost all my buddies’ cholesterol. Why would the cardiologist want me to double the dose of my cholesterol medication?” His total cholesterol level was 175 mg per dL, and low-density lipoprotein (LDL) cholesterol was 100 mg per dL. I understood his consternation. He was proud of his latest lipid levels, but suddenly his good numbers apparently weren’t good enough. The not-quite 50-year-old Roger had just had cardiac catheterization studies performed and learned he had mild coronary atherosclerosis. The findings were not a big surprise. In addition to hyperlipidemia and hypertension, there was a history of premature heart disease in Roger’s family. He was already taking aspirin, a beta blocker, an ACE inhibitor, and a statin. Roger had been exercising and watching his diet. “Now we’re aiming to reduce your LDL to less than 70,” I informed him. I explained how some current clinical studies suggest that persons with coronary heart disease benefit from intensive statin therapy—if they can tolerate it. Roger was only partially placated. “I don’t mind playing by the rules,” he commented, “but you guys keep changing them on me.”

Thursday

Stan is a sexagenarian with essential hypertension and symptoms of benign prostatic hyperplasia (BPH). Since he began taking terazosin (Hytrin) almost 10 years ago, his blood pressure and BPH have been well controlled. Today, the pharmacist telephoned me. “Are you aware that Levitra should not be taken along with alpha blockers like Hytrin?” he asked me. “Sure I am,” I answered. “Then what should I tell your patient, Stanley, who’s here with a prescription for Levitra?” the pharmacist inquired. “The script is not from you.” The conversation caught me off guard. I’m not sure why Stan felt the need to see another doctor. Perhaps a friend recommended the other physician. Maybe Stan couldn’t get an appointment to see me as quickly as he wished. Possibly, he felt embarrassed to discuss the problem with me. I suspect Stan didn’t mention he was taking Hytrin to the other doctor. If he did, maybe that physician advised him to stop it. Who knows? “Tell Stanley it is potentially dangerous to take both medications and that he needs to discuss the situation with the doctor who prescribed Levitra,” I paused, “or me. I don’t think you should fill the prescription until we’re sure everyone is on the same page.” Viagra (sildenafil). Levitra (vardenafil). Cialis (tadalafil). It’s nice to have options for treating erectile dysfunction. It’s even better to have conscientious pharmacists who truly care about their customers and our patients.

Friday

“I’m drained,” Mary Beth declared. “I ache all over. Even my butt hurts.” The 41-year-old woman had not felt well for the past few years—musculoskeletal pain, stiffness, trouble sleeping, and no energy. Different doctors had offered alternate diagnoses to explain her symptoms. “One said I was suffering from arthritis. Another was convinced I had chronic fatigue syndrome. The last doctor thought I might be depressed. I guess I was never able to make any of them understand what I was going through.” Her physical examination provided a helpful clue. She had 12 tender points on palpation, including her neck, shoulders, spine, and buttocks. No signs of inflammation were present. I recommended checking some basic blood tests, but the diagnosis that made the most sense was one I derived from the history and physical examination alone—fibromyalgia. I recommended she take a low-dose tricyclic antidepressant before bedtime. I encouraged Mary Beth to stay positive. “Exercise is essential,” I reminded her, “and swimming is a great choice.” I shared with her some other treatment options available—physical therapy including massage, different medications, psychotherapy, and biofeedback. We ended up having a long conversation. Actually, Mary Beth did most of the talking, and I listened. I was able to appreciate both the physical misery she had endured during the past few years and the mental anguish accompanying the lack of a definite diagnosis. A little empathy goes a long way.

Saturday/Sunday

Bruce knew something was terribly wrong. The athletic 43-year-old man felt exhausted and easily out of breath. Soon, he was diagnosed with idiopathic dilated cardiomyopathy and was in need of a heart transplant. Three years later, a donor heart became available—a gift from a 19-year-old man. His joy on hearing the good news was tempered by the realization that somewhere another telephone call had been made earlier—to a parent or a spouse—announcing the tragic loss of their loved one. Six weeks after receiving his heart transplant, Bruce ran one mile. Was it to see how far he had already come, or to determine how far he had yet to go? In 2002, he participated in the U.S. Transplant Games held in Florida. He didn’t medal. “Those darn kidneys always win,” Bruce told me. “The hearts and lungs don’t stand much of a chance against them.” He laughed with the satisfaction of a man who appreciated life and a second chance at it. I met Bruce only recently. We were strangers walking and jogging on a high school track in a city hundreds of miles from where we each live. As the two of us ran around the quarter-mile track, I slightly trailed Bruce. Maybe it was because the heart beating in his chest was 25 years younger than mine. Perhaps Bruce competes with the spirit of two men. Either way, it seems that outside the Transplant Games, the heart always wins.

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.


Copyright © 2004 by the American Academy of Family Physicians.
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