From a Week in Practice
Am Fam Physician. 2005 Jan 1;71(1):63-64.
“Stupid!” Mr. Solomon uttered as I entered the exam room. It turned out that the 72-year-old man’s interjection was directed toward himself and not me. He was clutching the right side of his rib cage with one hand. Two weeks earlier, Mr. Solomon had tripped over a tree limb that had fallen in his back yard, and he landed hard. It came as no surprise when an x-ray demonstrated a fracture of one posterior rib. What we didn’t expect was the presence of a round mass in his right lung. ACT scan of his chest confirmed a well-circumscribed oval mass in the anterior segment of the right upper lobe measuring 2.5 × 1.5 × 2.1 cm. Mr. Solomon had smoked cigarettes for 45 years prior to quitting 10 years ago. The lung mass was biopsied, and its histology revealed budding yeast and pseudohyphae. A culture of the lesion grew Sporothrix schenckii. I referred him to an infectious disease specialist at the university medical center. Because Mr. Solomon’s pulmonary sporotrichosis was considered “non–life-threatening,” the consultant advised treatment with itraconazole, 200 mg twice a day, for at least one and possibly two years. Eight months later, Mr. Solomon is getting along well. His most recent chest x-ray is reassuring. “Did you ever stop to think that if I hadn’t tumbled over that branch and broken my rib, you would’ve never found that fungus in my lung?” Mr. Solomon mused before concluding, “What a lucky break.” Some people see the good in everything.
“For the past 24 hours, I’ve been living in the bathroom,” Heather owned up. “So far today, I’ve already had diarrhea 10 times. At first the stools were watery, but now they’re green and full of mucus. Gross, huh?” The 28-year-old secretary also described abdominal cramping and nausea but no vomiting. Heather’s temperature was 99.8°F. Her abdomen was soft. She was keeping fluids down and didn’t appear dehydrated. She had not been traveling recently or taking antibiotics. As far as Heather knew, none of her friends, family, or co-workers had been similarly ill. “What about food?” I queried her. “Have you eaten anything unusual lately?” Heather shook her head. “No, nothing out of the ordinary.” She thought about the question a little longer. “I did have a chicken sandwich a few days ago, but it tasted okay.” It was a good bet that undercooked chicken was the culprit. Fecal leukocytes were detected in her stool specimen, and a stool culture identified Campylobacter jejuni. I prescribed erythromycin because it can decrease the duration of the illness. Ciprofloxacin would’ve been another option. Heather called a week later to report her complete recovery. “After all I’ve been through with this infection, I never want to see another chicken sandwich again!” I tried to reason with her. “You can’t live the rest of your life afraid of a sandwich.” Heather remained leery. “I’m chicken to eat poultry anymore,” she confessed. I suppose we truly are what we eat.
Cauliflower ears, nosebleeds, and the omnipresent smell of sweat. Wrestling may not be the most glamorous athletic activity out there, but it gets my vote as the toughest sport around. Zach is a 130-lb high school sophomore with a passion for wrestling. With one minute remaining in a closely contested match, the gritty 16-year-old grappler asked the referee for an “injury timeout.” I didn’t observe an actual injury, but the boy was obviously hurting. “Something’s wrong with my knee.” Sure enough, Zach had developed a sudden swelling in front of his right patella. He described a burning pain that was much worse with kneeling. My diagnosis was prepatellar bursitis. It would be wise to check an x-ray, though. Rest, application of ice to the knee, compression, and ibuprofen should suffice. Aspiration of the fluid is sometimes necessary if the problem worsens or persists. When Zach returns to practice and competition, he will need to wear a protective kneepad. Before then, I’ll have him follow up with his family doctor. Despite the pain, Zach desperately wanted to continue the match. “I can beat this guy even on one leg. Please let me finish.” It would’ve been wrong to allow him to continue. “You’re done,” I told him. “There will be plenty more chances, Zach.” I wanted to help my son off the mat, but he insisted on limping off by himself. High school wrestlers are exceptionally strong kids. Their fathers need to be equally tough.
Luck rarely seems to follow Scott, a happy-go-lucky young man. “I was taking a walk three days ago and passed a cute little dog tied to a leash. I stopped to smile and say hello. Next thing I know, the critter has his teeth sunk into my leg.” Scott didn’t believe the dog bite was any big deal. The animal’s owner assured him that the dog had been healthy and was properly vaccinated. The incident was reported to the local animal control authority. The dog would be observed for 10 days. Scott had cleaned the bite thoroughly with soap and water right after it occurred. He had been applying a topical antibiotic ointment to the wound three times a day. He didn’t feel there was any need to have it checked out. Scott changed his mind, however, when he awoke today and noticed that the area surrounding the bite was reddened, mildly swollen, and slightly tender. I cleaned and dressed the infected wound. There was no exudate to culture. I prescribed a 10-day course of amoxicillin/clavulanate. He had received a tetanus booster less than five years ago. I’ll recheck the infected bite in a couple of days. On the way out of the office, Scott accidentally bumped into my nurse and almost knocked her to the floor. “Beware of dogs,” I hollered after him. “What do you mean dogs?” my nurse asked, still clearing the cobwebs out of her head. “Better beware of Scott!”
Katrina didn’t have time to be tired. Caring for her two youngsters at home and attending community college classes in the evening, she certainly had good cause to feel run down. “I can doze off at the drop of a hat,” Katrina confided to me. “I’ve fallen asleep while playing with my children, talking, and even eating. No matter how much sleep I get at night, I just feel exhausted during the day.” Her profound sense of daytime sleepiness and fatigue occasionally was accompanied by vivid dreams during her “sleep attacks.” These episodes lasted anywhere from five to 30 minutes. Katrina’s physical examination and screening lab tests failed to pinpoint any medical condition that might explain her daytime drowsiness. She didn’t appear depressed. I thought narcolepsy seemed the most likely diagnosis. I advised her to visit a sleep disorder clinic in a nearby city or at least schedule a polysomnogram. “No time,” Katrina replied. She elected to try modafinil, 200 mg every morning. Two months later, Katrina was unconvinced the medicine had helped and stopped taking it. She still wanted to wait before scheduling any recommended sleep studies. Four weeks after that, she telephoned me. “I was wrong,” she admitted. “That medicine helped more than I realized.” In addition to resuming modafinil, I encouraged her to sneak a siesta into her daily schedule. Some people might pay a fortune for a good night’s sleep. Katrina, on the other hand, is still searching for a solid day of wakefulness.
For 23 consecutive years, my wife, Arlene, has made the same New Year’s resolution: LOSE WEIGHT. Lots of folks share the same resolution. But not everyone. Angela never could kick her smoking habit. So it was not exactly a shock when she was diagnosed with small cell lung cancer. It had already metastasized. We were both cognizant of her poor prognosis. Even so, she had made up her mind to do everything possible to combat her extensive stage malignant disease. “One more day” became her mantra. Although Angela was always a thin woman, she was now flirting with that undesirable label of being a 98-lb weakling. Her resolution was to put some weight back on. I encouraged her to eat whatever she wanted—and lots of it. Angela loved cookies, so she began eating an entire package every week. Her oncologist had her taking megestrol (Megace). I had her consuming so much Ensure that she could barely stand to hear the product’s name any longer. Neither the nutritional supplements nor the medication seemed to do much good. The simple act of weighing on my office scale became a ritual. In her mind, she correlated any further loss of weight with decreased survival. When Angela last stepped on the scale, she had gained one pound. I doubt that any human being who has ever lived worked harder or was prouder to have gained 16 oz. She died less than six weeks later. I have never been inclined to make resolutions, but here are two that I won’t soon forget: Cookies every week. Live another day. For Angela.
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.
In order to preserve patient confidentiality, the patients’ names and identifying characteristics have been changed in each scenario.
Copyright © 2005 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact email@example.com for copyright questions and/or permission requests.
Want to use this article elsewhere? Get Permissions