From a Week in Practice
Am Fam Physician. 2005 Jun 15;71(12):2283-2284.
I love to walk and have made hundreds of laps around the park in my neighborhood over the past 10 years. I use the time to relax, plan my day, and enjoy the fresh air. A doctor is always on call, and today was no exception. Across the grass, I noticed a group of children huddled around a small body lying on the ground. Having invested a lot of time in worrying and lecturing my own children about the risk of head injuries, my immediate fear was that this child had fallen off the playground equipment and hit her head. Rushing over, my fears were somewhat allayed when I heard her sobbing. Relief turned quickly to sympathy and concern. The little girl, about nine years old, was clutching an obviously broken leg. A group of six or seven children huddled around, all talking at once, trying to explain what had happened. “We were chasing each other around the playground, and she fell off those high bars,” explained a very distraught boy, about the same age. “I swear I didn’t push her,” he added. The children were getting more and more upset, which made the injured child cry all the louder, obviously in terrible pain. “I would like all of you children to go sit over on the swings while I take a look,” I ordered in my most doctorly voice. Luckily, another mom ran over, cell phone in hand, and the ambulance arrived a few minutes later.
Today, another patient presented with a fracture. This man was a 50-year-old avid bicycle rider. “I drove right through an oil slick and lost control of the bike,” the patient admitted ruefully. “The area looked just like a puddle of water. I didn’t think twice about it until I was flying through the air.” The accident had occurred two weeks earlier. Falling on an outstretched hand, he had sustained a small avulsion fracture to the hamate bone. On physical examination, the wrist was not swollen, but there was marked tenderness directly over the injured site. I explained to him that it was more of a severe sprain than an actual fracture and prescribed a wrist splint to be worn for the next three weeks. Then I remembered how he had sprained his ankle several months earlier playing tennis. When questioned, he admitted even more ruefully, “I have cut down to playing twice a week, but my wrist sure hurts when I serve.” After strongly recommending that he lay off playing tennis for a few weeks, I went on to the next exam room. This patient also happened to be a cheerful, 50-year-old man, but unlike the bike rider, he was overweight and had diabetes and hypertension. I knew that he had not voluntarily exercised in years. As I prepared to give him another encouraging lecture about the value of a short daily walk, I could not help compare the two men. One is a constant overachiever, while the other happily spends his evenings watching television. One I lecture to take it easy, and the other I urge to get off the couch. I hope I can influence each of them a little!
“I guess you just can’t fool the lab,” the 70-year-old man lamented. “I’ve been starving myself for two weeks, and my blood sugars are still too high.” We looked at each other and simultaneously began to laugh. The patient was referring to the A1C test, which reflects the average blood sugar for the past several months. It certainly is true that no amount of diet and exercise for a week or two is going to improve the results. “In spite of your recent efforts, you have gained three pounds since your last visit,” I observed. Luckily, there was some good news in that his lipids and blood pressure were better than before. We spent a few minutes reviewing a diet and exercise plan. “Let’s increase your diabetes medication,” I suggested. “But the bottom line is, you will have to stretch those two weeks of ‘starvation’ into two or three months of sensible eating before we make real progress.” The patient left the office muttering something about how much he loved enchiladas, rice, and refried beans. Insisting on having the last word, I replied, “One enchilada, once a month.”
Whenever I see a teenager, I always try to discuss sex, drugs, smoking, alcohol, and acne. Teens may not want to talk about the first four topics, but every one of them wants help with problem skin. My first patient today was a 14-year-old boy, brought in by his mother with a complaint of sore throat, sinus congestion, and cough for three or four days. In short, he had a cold, and we discussed over-the-counter decongestants. He was one of those teens who barely say a word without direct interrogation, so the encounter took about four minutes. As the patient jumped up to leave, I asked which medication he used on his face. He abruptly turned back around, sat down, and began to talk. Obviously upset by acne, he welcomed the opportunity to get advice, if someone happened to bring up the embarrassing subject. A quick exam revealed moderately severe inflammatory acne on his face and chest, so I prescribed oral and topical antibiotics. “The medication is going to take a month or so to really help,” I encouraged him, “so keep after it and don’t give up.” Despite no treatment for today’s chief complaint, he and his mother left feeling satisfied.
At least one in five Americans older than 12 years tests seropositive for herpes simplex virus type 2 (HSV-2) (N Engl J Med 2000;342:844–50). The majority of these patients are asymptomatic, but a fair number of upset patients present to our office with the typical symptoms of painful genital ulcers. Today, an attractive, usually self-assured businesswoman and mother of two was near tears as she described her symptoms. “I used to have an outbreak every few months,” she explained, “but after a year went by without any problems, I thought I was cured.” Then just a few days ago, she developed several painful lesions again, which on physical exam were typical of HSV-2. I explained to her that although the virus cannot be cured, the frequency of outbreaks usually decreases over time, just as they had in her case. Medication helps shorten the duration of the ulcers and in severe cases can prevent frequent outbreaks. Having researched the virus on the Internet, the patient already knew most of that information. “I had no idea that herpes was so common,” she said. “More than 45 million Americans are infected,” was my response. “Explain the risks to your kids today.”
It often is said in medical practice that diagnoses occur in threes, so I should not have been surprised to see a third patient this week with an acute fracture. Nevertheless, I was sorry to read the x-ray report, confirming two compression fractures of the lumbar spine. The patient was a 78-year-old nursing home resident with dementia, bilateral amputations, heart disease, diabetes, and more. Despite a tremendous amount of disability, he spent most of the day in his wheelchair in the nursing home common room smiling, talking, and generally seeming to enjoy life. Because of his dementia, he often “forgot” that he could not walk and had taken several falls over the years. Today, he took a hard fall out of his chair. “I was right there when it happened,” the nurse explained, “but I just couldn’t get there in time.” By the time I arrived, he was back in bed, which sensibly was a mattress on the floor, with a thick mat right beside it. At a glance, I could tell that he was in a lot of pain. “I am sorry this happened,” I told him, “I will do everything I can to get you some pain relief.” While writing the orders for narcotics, laxatives, and physical therapy, I thought about what a setback this will be for this man. I have thought so many times that, while it takes just a second to fall, it takes months to recuperate.
To preserve patient confidentiality, the patients’ names and identifying characteristics have been changed in each scenario. Any resemblance to actual persons is concidental.
Copyright © 2005 by the American Academy of Family Physicians.
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