From a Week in Practice
Am Fam Physician. 2004 Dec 15;70(12):2296-2298.
“I’ve got high blood pressure, diabetes, a weak heart, blood clots, foot ulcers, and emphysema,” the elderly man explained. After waiting to catch his breath, he added, “If you can think of any problem I don’t have, give me a minute and I’ll get it!” Then he laughed heartily—and began to wheeze. After a few minutes he settled down in his wheelchair and took out a large bag of empty bottles. “I need refills on all of my medicines,” he announced. “Please give me a 30-day supply to get locally, and another set of prescriptions for a 90-day supply to mail off.” KS looked at the big bag in dismay. She could remember writing all those prescriptions at his last appointment, but on examining the bottles, they indeed needed refills. Deciding not to argue, she took out her pen and pad and got busy. She read each medication out loud as she wrote, reviewing the purpose and asking about side effects. After a quick physical examination, she sent him on his way. “I had better get him out of the office before he develops another complication,” she commented to her nurse as they watched him wheel out the door.
The elderly woman’s face glowed as she cuddled her “granddaughter” in her lap. She held her high in the air, cooing and laughing as she drew the baby back in her arms. “Have you ever seen such a beautiful child?” she exclaimed as she showed her off to everyone in the room. KS sat beside her on the bed to admire the baby, but her answering smile was a little sad. She was making a home visit to a patient who had advanced Alzheimer’s dementia. In truth, the “child” was a beautiful, life-sized baby doll, who the woman truly believed was her own granddaughter. “She spends most of the day caring for that doll,” the patient’s daughter explained. “She gets such joy out of it that I pretend she is a real baby as well.” KS thought back to a visit about a year before. At that time, the patient was up most nights pacing the floor, convinced that a strange man was trying to break into the house. Her fears abated somewhat with the use of an antipsychotic drug. “I stopped those medications several months ago, because those hallucinations went away,” her daughter explained. The human brain is truly remarkable, thought KS as she said goodbye. How can a disease that brings such fear and debilitation also conjure up the intense joy and love that flows between mothers and babies? KS hoped that this delusion would last a long time.
Sometimes the hardest thing to do is nothing. This is often true when treating frail elderly patients. KS was evaluating a patient who had been worked into the schedule after having a “spell” at home that morning. While eating breakfast, the 82-year-old woman suddenly became unresponsive for about a minute. After waking up, her speech was garbled and she was confused. Within 15 minutes or so, however, she was completely back to normal. KS knew the patient well, having been her doctor for more than 10 years. She was bedridden because of a stroke, bad heart disease, and dementia. Despite all of her disability, she enjoyed life at home with her daughter. KS ran through a quick differential diagnosis. The most obvious etiologies were a transient ischemic attack, a seizure, or a vasovagal episode. She reviewed the patient’s extensive list of medications (which cost more than $500 per month, the daughter reminded her), none of which seemed to contribute to the syncopal event. KS counseled the anxious family about the option of ordering studies like a CT scan and carotid dopplers. “There is no harm in doing nothing for now,” she reassured them. “She looks great, so let’s just wait and see how she does.”
KS left the young man’s room with a heavy heart. This 23-year-old patient, acutely ill with pneumonia, was also cachectic, depressed, and alone. He was miserable and dying from AIDS. He must have contracted the HIV virus about 10 years ago. KS thought about her own 13-year-old son—soccer player, a drummer in the marching band, smart and funny. He and two friends had just returned from a wonderful weekend at the beach swimming, surfing, fishing, and just generally being kids. She doubted that this young man could recall many experiences like that. His chart revealed a long history of drug abuse, lapsed appointments, and noncompliance. There were many referrals for counseling, substance abuse treatment, and financial aid. Prescriptions were written for a variety of antiretrovirals, antibiotics, antidepressants, and appetite enhancers. But, the fact remained that he was completely unable to cope with his drug habit, much less the complex regimens required for the treatment of HIV. Now, he was paying the price. It is so sad to see a young man die from a treatable illness. Unlike her son, this patient never really had a chance. How different the lives are of two young men growing up in the same city—only three miles apart.
KS knew it had been a long week when she was cheered by the prospect of seeing a five-year-old child with a chest cold. Despite a 101°F fever and a raspy cough, the little boy was playing happily with some blocks in the examination room. Holding his four-month-old sister in her arms, his mother was encouraging the child to add a seventh block to his wavering tower. As KS walked into the room, the puff of air from the corridor knocked the stack over, and they all laughed. KS spoke for a few minutes with the mother, examined the patient, and diagnosed a viral upper respiratory infection. She advised the mother on symptomatic therapy and sent them on their way. The whole visit took about five minutes. KS watched the family as they made their way to the front desk—cartoon stickers in hand. These children were obviously happy and well cared for. “It’s not that I’m glad that little guy is sick,” she explained to her nurse. “It’s just a pleasure to see someone with such a thin chart!”
“Coding on a faculty member has got to rate as the number one bad experience of my residency,” exclaimed KP, a second-year resident. Her smile and confident tone, however, contradicted that statement. A week earlier, the faculty member had been found unresponsive by the hospital cleaning staff. The residents ran to the Code Blue, never dreaming that they would resuscitate one of their own instructors. He was rushed to the cath lab, where a stent was placed in the occluded left anterior descending artery. Later that day, he developed cardiogenic shock, requiring numerous pressor agents and the aortic balloon pump to maintain his cardiac output. The entire residency program was in a state of shock. It was simply unfathomable that this vigorous 60-year-old racquetball player could be dying. KS had seen him a thousand times, rushing between his office and the hospital, always working, always going. Miraculously, over the next few days, he steadily improved. The drips were weaned, the balloon pump removed, and he finally was extubated. By some combination of his own sheer determination, the wonderful work of colleagues, and the support of his family, he seemed back to his old self again.
Kathy Soch, M.D., is a clinical instructor with the Corpus Christi Family Residency Program, affiliated with the University of Texas Health Science Center in San Antonio. This community-based program, which employs nine full-time faculty and 36 residents, primarily serves low-income, uninsured patients.
Address correspondence to Kathy Soch, M.D., 2606 Hospital Blvd., Corpus Christi, TX 78405.
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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