From a Week in Practice
Am Fam Physician. 2005 Apr 15;71(8):1525-1526.
“I did not want to make an appointment,” the patient said, “because I was afraid to find out that I have diabetes.” This was the explanation offered by a smart, successful, 50-year-old businesswoman who had not seen a doctor in more than 10 years. She went on to tell me that she had borrowed her sister's glucometer periodically during the past year to check her own blood sugar—and the results were always higher than 200 mg per dL. “Then I would cut sugar out of my diet for a while and hope that the problem would go away,” she admitted with a rueful smile. “I know it doesn't make sense, but I am frightened that I will end up on dialysis like my sister.” I silently agreed that her thought processes did not make much sense. She knew perfectly well that ignoring the symptoms of diabetes makes complications from the disease more likely and more dangerous. For some reason, she had been unable or unwilling to face the diagnosis until now. “I am glad that you came in today because you are still in good health,” I advised her. We had a long discussion about the goals of diabetes care and I reassured her that, with good medical care, many of the complications from diabetes can be delayed or even avoided. Before my eyes, she seemed to transform from frightened patient to confident businesswoman. “Knowledge is power,” she declared. “I want to enroll in diabetes classes this week.”
“For 20 years, I have been nagging this man to quit smoking and look what he has done!” I exclaimed. At first, I had been pleasantly surprised to see the picture of one of my favorite patients on the front page of the morning newspaper. Looking a little closer, I saw that he had a cigarette in one hand and was looking at his watch on the other. The city recently had passed an ordinance that banned smoking in all restaurants, and he was counting down the seconds until he had to extinguish that last cigarette. He had a big smile on his face, as he usually did, and I had to laugh in spite of myself. I asked the clinic nurse to pull his chart and send him an appointment for another session on smoking cessation. “I guess I should be glad that he didn't mention his doctor's name in the article!” I concluded.
“The Department of Health just called to report that your new patient has a positive VDRL test,” the aide at the nursing home explained. I had just finished examining the 73-year-old man admitted with advanced dementia. Our conversation had consisted of his mumbling a few incoherent words in response to my questions. He was confused, bedridden, and contractured. The fact is, I always get a little confused myself when trying to interpret the serologic tests for syphilis. The main thing I did remember was that the diagnosis of neurosyphilis requires a spinal tap. It was certainly possible that this man's severe dementia could result from neurosyphilis. After examining him, it seemed questionable that the diagnosis and treatment of the illness would improve his mental status. Luckily, the hospital chart had some answers. He had been treated for syphilis in 1988, and subsequent VDRLs were 1:2 (1990) and 1:1 (1992). The current titer was 1:8. I went to the Internet and typed in the address for the Centers for Disease Control and Prevention (http://www.cdc.gov). According to their guidelines, a sustained fourfold increase in VDRL titer suggests treatment failure or reinfection. I decided to repeat the titer and order a human immunodeficiency virus test. If the titer remained greater than 1:4, I would discuss the option of a spinal tap with his family.
“I am so glad you called back,” Mary explained. “When I called, I needed a prescription for my husband, but now I need to talk to you about my neighbor Sue.” I had been at a PTA meeting the previous evening when Mary had left a message about the refill, and had waited until the next morning to return her telephone call, which turned out to be fortuitous. I was the physician for a number of residents who live in a small town about 45 miles away, including this family and several of their neighbors. Sue awoke at 4 a.m. with a severe nosebleed that she could not control. Having left her address book at the office, Sue called next door to get my telephone number. Mary and her husband rushed over and managed to get the bleeding to stop. I promised to call in the prescription and then called Sue, who was surprised and glad to hear from me. Sue assured me that the blood loss had been relatively minor and had not recurred. I reviewed with her how to stop a nosebleed and advised her to notify me if the problem recurred. “Thank you so much for calling,” she graciously replied. “And here comes your other patient with a batch of blueberry muffins!” I hung up the telephone thinking that good friends, like good patients, make life worthwhile. Good neighbors certainly saved me from getting a telephone call at 4 a.m.
“Now I know why she keeps coming back,” I thought to myself. The patient was a 28-year-old woman who suffered from classic migraine headaches. The symptoms always began with an aura, followed in 30 minutes by a severe, unilateral throbbing, frontal headache that occurred three to four times a year, and were relieved by a commonly prescribed 5-HT1 receptor agonist. I had seen her several times in the past three months. At each visit, I questioned her about the headaches, which were unchanged, and discussed the treatment plan that seemed satisfactory. I suggested prophylactic treatment with beta blockers, which she declined. After the third visit with the same routine, I finally thought to ask the simple question, “Why are you concerned?” The answer came as a surprise. “I am afraid that I have an aneurysm,” she admitted. “You know that my father died of an aneurysm when he was 41 years old.” To my chagrin, I did not know this, or at least did not remember. I explained to her that these headaches were in no way related to an aneurysm and that patients with migraines are not at increased risk of an aneurysm. Her relief was almost palpable. I wished I had reviewed the chart more closely two or three visits ago, and was reminded that a patient's concerns often are far removed from a doctor's.
“Mother did so much for me; now it is my turn to help her.” I have heard that statement many times over the years, and I heard it today at the home visits I made, accompanied by a second-year resident (RH). Until I started making home visits about three years ago, I had no idea how many patients in the residency practice were bed bound, entirely dependent upon a devoted caregiver. Today's patients were both stricken with multi-infarct dementia and completely dependent in the activities of daily living. Their conditions included immobility, incontinence, and the need to be fed. Neither patient had much to say and merely smiled and nodded at the two physician visitors. The caregivers, however, each had a remarkable story to tell. One was a daughter, the other a daughter-in-law, and both were retired and in their 60s. At times overwhelmed by their responsibilities, they were determined to give the best care possible to their frail mother and mother-in-law. “When making home visits, it is remarkable that I never hear a caregiver complain or feel sorry for herself,” I remarked to RH between visits. “It takes great resilience and love to devote your entire life to caring for a sick relative. I doubt that I could do as well.”
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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