From a Week in Practice
Am Fam Physician. 2005 Aug 15;72(4):616-618.
My first patient today wanted to talk about his wife’s health rather than his own. “My wife has seen three doctors this year for her arthritis, and not one of them has counseled her about how important it is to her health for her to lose weight,” the patient complained. I immediately felt guilty because his wife is also my patient. I pictured her in my mind: a lovely, gracious woman, beautifully dressed and confident. Generally healthy, she came in once or twice a year with the main complaint of osteoarthritis, particularly severe in the ankles and knees. Her pain recently had worsened, so she had been to physical therapy and then to an orthopedist. I had never pictured her as overweight, so when I pulled her chart later that day, I was chagrined to notice that she was close to 45 lb over her ideal weight. We had discussed diet and exercise at a visit two years ago, but clearly that discussion had not had much impact. I often feel a little embarrassed talking about weight with my patients. I assume they know what to do and do not welcome any more advice on diet and exercise. On the other hand, it didn’t seem appropriate to discuss treatment for his wife’s arthritis in her absence. I made a mental note to counsel her again about diet and exercise at her follow-up visit, but ultimately the decision to lose weight would be hers.
Today, I stopped by the funeral home to view the body of one of my nursing home patients and to visit with the family. This wonderful 86-year-old woman had died in her sleep. I met her brother who told me that he had visited her just hours before she died. “She looked fine that day,” he said. “She was wearing the same brightly beaded necklaces she has on now.” I had admired those same necklaces repeatedly over the years and was happy to admire them one last time. The patient had spent more than 10 years in the nursing home, and I pictured her sitting with a group of other residents playing bingo, laughing, and talking. I was sad and even surprised by the news of her sudden death. I had seen her frequently over the past few months for a small ulcer on her second toe. The circulation in that foot was terrible, and it was unlikely that the ulcer would heal. I remember telling the geriatrics resident a few weeks ago that diabetic foot ulcers in nursing home residents are different from those in younger patients. “Let’s not be very aggressive,” I recommended. “The ulcer will heal or the patient will die of unrelated causes.” In this case, the latter proved to be true.
Whenever I see Mrs. T, we talk more about her husband’s medical problems than about her own. She is in remarkably good health for being 77 years old. Her husband, on the other hand, has a chart six inches thick. When Mrs. T comes in four or five times a year, often with some minor complaint, we know that she mainly wants to talk about her husband’s worsening dementia. Today, we discussed her arthritis for a few minutes and then reviewed some recent blood work. When I asked about her husband, a wave of sadness washed over her face. “He can’t understand a thing I say anymore!” she exclaimed. “Yesterday, I found him eating raw bacon out of the refrigerator.” She describes her feelings of frustration when he constantly follows her around the house, asking the same questions over and over. I sit quietly for a time, listening and sympathizing. We have had this conversation several times. I encourage her to get more help, and I promise to contact the home health agency to see if the caregiver can stay a few hours longer each day. As I see her to the door, I think about how terrible it must be to stand by while your loved one’s dementia worsens.
“Anybody who comes to see the doctor with a sunburn like that is just begging for a lecture,” I said in my sternest voice. “I did not come for the sunburn,” the patient retorted, “I came because I think I broke my ankle.” She explained how she had taken her grandchildren to the beach for a couple of hours on Saturday morning. It was cloudy, and she did not realize she had gotten such a burn. On top of that, she fell in the rocks on one of the jetties and twisted her ankle. After examining the purplish, swollen ankle, I began to sympathize. This woman lived in Minnesota and was here visiting her daughter. She did not realize how brutal the South Texas sun can be. Even on a cloudy day, the experienced beachgoer applies sunscreen every two hours, never leaves the house without a hat, and avoids the beach between 10 a.m. and 2:00 or 3:00 in the afternoon. This unfortunate woman was red from head to toe and looked miserable. I could not do much about the sunburn, but I did order a radiograph of her ankle, which showed no fracture. After we discussed ice packs, ace wraps, and crutches, she left the office promising to spend her next vacation in Alaska.
“I made an appointment to see you the day I got my Medicare card,” the 61-year-old man explained. “Now I can get back on my medications.” My heart sank when I saw that his blood pressure was 180/110 mm Hg, but at least I understood why it was so high. I thought back to the day he arrived at the emergency department after having suffered an acute stroke, with paralysis on the right side. He did not seem to comprehend what had happened, and his first words after receiving the diagnosis were, “When will I go back to work?” After intense inpatient rehabilitation, and a lot of hard work, this determined man made a remarkable recovery. Now he walks with a cane and has fairly good strength and coordination in his right arm. It was clear from the start that he would never operate heavy equipment again. Being disabled, he was eligible for Social Security benefits, but could no longer afford his medical insurance premium. A proud man, he refused to come to the office if he could not pay. Now two years after his stroke, he finally qualified for Medicare. As I wrote prescriptions for two generic blood pressure pills and a cholesterol lowering agent, I extracted a promise that he would return the next week for a blood pressure check. “I would do anything for you, doctor!” he exclaimed in a booming voice. “You saved my life.” That really is not true at all, but I decided not to argue the point.
“Her sodium level has increased two or three points each day, and her weight has decreased 12 lb since admission,” the resident reported. He was presenting a complicated patient who had been admitted three days earlier for antibiotic therapy of cellulitis of the left leg. She also had cirrhosis of the liver, massive ascites, and pitting edema to mid thigh. The initial laboratory examinations revealed that her serum sodium level was 118 mg. The patient’s sensorium was clear, and she was asymptomatic from the low sodium. At first, the resident’s plan had been to administer normal saline until the serum sodium level reached a “safe” value, which he thought was around 125 mg. The team discussed the patient in detail. “The first step in evaluating asymptomatic hyponatremia is to assess the patient’s volume status,” I suggested. These patients fit into one of three categories: some patients are dehydrated and need salt and water replacement; the second category of patients are fluid overloaded, which dilutes the sodium; and third, an occasional patient will have normal volume status, at which time the differential diagnosis includes Addison’s disease, syndrome of inappropriate antidiuretic hormone, or other unusual causes. This woman clearly was fluid overloaded. The resident discontinued the intravenous fluids and substituted fluid restriction and diuretics. Three days later, the patient’s sodium level was 128 mg and the edema was improving. The resident concluded that a safe sodium level depends more on the patient’s clinical picture than on a particular number.
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.
To preserve patient confidentiality, the patients’ names and identifying characteristics have been changed in each scenario. Any resemblance to actual persons is coincidental.
Copyright © 2005 by the American Academy of Family Physicians.
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