From a Week in Practice
Am Fam Physician. 2005 Feb 15;71(4):692-694.
“Let’s send the poor man back to the nursing home before anything else can go wrong,” KS advised the second-year resident. Needless to say, she was only half kidding. This frail 85-year-old man had been transferred to the hospital two days earlier because of an exacerbation of congestive heart failure. As to be expected in any patient with dementia, he became increasingly confused in his new environment, complete with painful blood draws, intravenous catheters, and an oxygen mask. He kept trying to pull out his various lines and had finally succeeded in yanking out his urinary catheter. The resident ordered a CT scan of the pelvis because the patient continued to pass bloody urine for several hours. After the case was discussed with faculty, the test was canceled, but the unfortunate patient inadvertently was kept NPO. “I’m starving!” he shouted to KS as she made rounds early that afternoon. “Please send me home so I can eat.” KS concluded that anybody who could shout that loudly was indeed ready to go home. By this time, the hematuria had resolved spontaneously and he was voiding without difficulty. “Next time, leave the catheter out,” was KS’s final bit of advice to the resident.
When KS skimmed the letter from a state agency regarding drug therapy for several of her patients, her first reaction was to be annoyed. “This is just another case of a bureaucratic institution reviewing pharmacy records without having any idea at all about the patient’s real problems,” she thought to herself as she tossed the paperwork into the recycling bin. But the letter bothered her a little bit. Later that afternoon, she pulled it from the bin and read it more closely. It is common knowledge that patients who take more than five medications have a significant risk of drug interactions. This letter asked her to review the drug regimens of six elderly patients, each of whom took 10 or more drugs a month. That seemed reasonable. KS reviewed the first patient—an 82-year-old woman with diabetes mellitus (three drugs), severe obsessive-compulsive disorder (two drugs), asthma (two inhalers), incontinence, dementia, and hypothyroidism (one drug each), and also taking an antiplatelet agent. KS had taken care of this woman for more than 10 years. In all that time, she had never been hospitalized and actually managed fairly well. In truth, KS was a little surprised that she was taking 11 medications. It seemed unlikely that her patient took such a complex regimen as directed. A politely worded letter reminding physicians to monitor complicated medication lists in elderly patients turned out to be more sensible than onerous.
The following day, KS kept a count of each patient’s prescription drugs. Frankly, it is a tribute to polypharmacy that her next patient’s diabetes, hypertension, and hyperlipidemia were finally brought under control with the use of six drugs and insulin shots. If one counted aspirin and calcium, this 52-year-old woman took nine drugs every day for the treatment of asymptomatic medical conditions. She remembered the letter she had received the day before cautioning physicians about the high risk of drug-drug interactions in patients who took more than five medications. In this case, she did have concern about combining a CoA reductase inhibitor drug (to lower cholesterol levels) with a fibrate (to lower triglycerides), because of the increased risk of rhabdomyolysis. She discussed the issue with her patient, and together they decided that the benefits of the lipid lowering drugs outweighed the risks. This patient also suffered from depression, osteoarthritis, and allergies, for which she took three additional drugs and a nasal spray. At least four of her 13 drugs were for the treatment of conditions with actual symptoms, KS thought to herself.
“I haven’t had a minute to myself since I retired,” the patient complained with a laugh. KS was not surprised. This dynamic, 72-year-old woman was in perfect health. In the office for an annual check-up, she was not taking a single prescription medication, and was completely up-to-date on all the usual preventive screenings. The patient described her involvement in a dozen different activities, ranging from a trip abroad, to volunteering in four organizations, gardening, and a book club. Since retiring she was more active than ever and worked out at a local gym four times a week. KS wondered aloud how the woman ever found the time to work all those years. “You are certainly in perfect health,” she said. “In another 20 or so years, I hope that I am just like you.” As KS went on to the next patient, she thought for a minute about this patient as a role model. She was exactly how KS hoped to be at that age. She had no ambition of winning the Nobel Prize for medicine, or even “Physician of the Year.” All she wanted was a good retirement plan and good health to go along with it. It is funny how our goals change as we get older!
The telephone message read “Needs refill of blood pressure pills and written referral for gastric bypass surgery.” KS knew the patient well and in fact had discussed the option of bariatric surgery at the last office visit. Nevertheless, one usually does not refer a patient for surgery over the telephone. This 42-year-old woman had struggled with her weight for most of her life. Last month, they had been so happy that her weight was 285 pounds, which was four pounds less than three months earlier. Even so, both patient and physician knew that the chances for significant, permanent weight loss were small. KS went to the computer to review an article she read several weeks earlier that seemed to describe this patient perfectly (Pratt J, et al. Case 25-004—A 49-year-old woman with severe obesity, diabetes, and hypertension. N Engl J Med 2004;351:696–705). According to this paper, there is consensus that weight loss surgery is a safe and effective option for people with a body mass index over 40, or over 35 with complications, such as hypertension and diabetes (this patient had both). Healthy patients without severe psychologic problems seem to do best. Surgical options include gastric bypass, which may lead to more successful weight loss, and gastric banding, which may have fewer complications. “We need to go over her options,” KS told the nurse. “Please refill the prescription, but ask her to make an appointment to discuss the referral.”
“I spent most of the night worrying about you,” KS told the third-year resident with a smile. She could tell immediately that he was feeling a lot better. KS had seen him in the office the day before complaining of severe upper abdominal pain. He denied associated symptoms such as fever, nausea, and vomiting, but was unable to eat. “This pain is terrible,” he explained, “I am never sick and I have never had anything like this before.” On physical examination, bowel sounds were audible. There was tenderness localized to the midepigastric area, but no rebound or guarding. Liver enzymes, amylase, and lipase were normal, as was an upper abdominal ultrasound examination. What concerned them both was that his white count was 15,800 per mm3, with a left shift. Despite the high blood count, KS thought he had either a viral syndrome or an acute gastritis. The other possibility was early appendicitis. She advised the resident to go home and come back the next day for reevaluation. “When I examined you yesterday, I was confident that you did not have a surgical abdomen,” KS explained, “but being a lifelong worrier, about 10 p.m. last night I started wondering if I had missed something obscure.” The resident assured her that all the worrying was for naught. His abdominal pain was almost gone and the white count had normalized. “How many times have I preached to residents to treat the patient, not the lab result,” KS thought to herself. “If I had listened to my own advice, I would have slept better last night.”
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.
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