From a Week in Practice
Am Fam Physician. 2005 Oct 1;72(7):1219-1220.
Fatigue is a nonspecific symptom but a common complaint of many patients. Deidre knew something was not right, yet she wasn’t one to seek medical attention lightly. Ten months postpartum, she had lost 70 lb of her pregnancy weight and was hoping to lose more, having gained more than 100 lb. Her weight loss had plateaued, she was sleeping nine to 10 hours daily, and she still felt tired. Taking care of a 10-month-old and a toddler is demanding work, but she didn’t think this was the cause of her lack of energy. Physically, she appeared well, and I could not elicit a reason for her fatigue on my examination. Anemia was high on the differential because she had stopped taking her prenatal vitamins. She also was in the usual time frame for the hypothyroid phase of postpartum thyroiditis. The hyperthyroid state can begin from one to four months postpartum, followed by hypothyroidism with an elevated thyroid-stimulating hormone (TSH) level, decreased serum thyroxine level, and high titers of antithyroid antibodies. The complete blood count showed no anemia, but Deidre’s antithyroid antibodies were markedly elevated. She did have postpartum thyroiditis, and treatment would be based on her symptoms. Explaining the prognosis of the disease and the appropriate treatment with levothyroxine (Levoxyl) would go a long way toward helping her regain her energy.
Chief complaints can be helpful or frustrating. Tonight on the mobile clinic, Howard presented the latter. “My anatomy is unbalanced” was his response to my question of how he was feeling. Somewhat taken aback, I asked him what he meant by that. “You’re the doctor, you should know!” It had been a long day, and fatigue was starting to set in. My impulse to argue was rising steadily, but I held back and tried to obtain a proper history. We were making little progress, and the most I could manage for his main complaint was a feeling of tiredness when he did any activity. His lungs were clear and his cardiac and physical examinations were unremarkable. He had gone to the local emergency department a few days earlier and, from what Howard told me, I sensed that the attending physician had had the same issues. He had done an electrocardiogram, but no blood work, and had told Howard that he could do nothing for him. I could offer him the basic fatigue workup, a complete blood count, a basic metabolic profile, liver function tests, and TSH level. I offered Howard some multivitamins, but told him we would have to wait on the blood test results to determine the cause of his “unbalanced anatomy.” We parted on a friendly note, something I hadn’t anticipated when the encounter began.
Physicians can sometimes see things that aren’t there. J.S., a family medicine resident, had seen Sally for ear pain and “muffled hearing” in her left ear. The examination revealed what J.S. described as “bubbles” behind the tympanic membrane. Her assessment was serous otitis media, and her plan was to treat the problem with a nasal corticosteroid and decongestant. After discussing the case with J.S., I suggested self-politzerization (holding her nose and gently popping her ears) several times a day as adjunctive therapy. I certainly did not doubt her evaluation, but I was intrigued enough to go and look at the “bubbles” for myself. What I found was a normal looking tympanic membrane and no hearing loss. There was a rapid resolution of the fluid or perhaps a missed diagnosis. On pneumatic otoscopy, the preferred test for the diagnosis of middle ear effusion, Sally’s tympanic membrane flapped like a sail in the wind. Otalgia does not always come from the ear and can be referred from other areas. Instinctively I asked Sally to open her mouth. Palpating the temporomandibular joint (TMJ) produced severe pain on the left side. The diagnosis was now clear—TMJ syndrome. Sally acknowledged a history of bruxism, and I suggested a referral to her dentist for fitting of a bite plate plus an anti-inflammatory medication. I didn’t get to see the “bubbles,” but hopefully J.S. saw the light.
I love bacon: is there anything wrong with that? Apparently there was, judging from the pained expression on the face of the mother of one of my patients when she inquired about my food preferences. I found out later that she was sizing me up as a potential physician for herself. Now, Sylvia was returning as a patient for the first time. A physician in Florida had recommended a computed tomography (CT) scan of her pelvis because of what Sylvia called a “fibroid.” “I don’t want any surgery; I want it starved.” I told her to take one step at a time and allow me to examine her abdomen before jumping to conclusions. When she lay down, her abdomen was exposed and ascites was obvious. Palpating the suprapubic area revealed a rock-hard mass that was suspicious for a malignancy. “I will go ahead and order the CT scan,” I stated without hesitation. I still hedged when she asked what I thought it was. Telling her the bad news before some more definitive studies would not be appropriate. The CT scan confirmed my first impression—an ovarian cancer with ascites. Her aversion to surgery would have to be overcome. For this gallant lady, the future would not be altered with simply a healthy diet.
“I tried to kill myself many times by overdosing on heroin, but I always woke up.” Off the drug for a year after a mandatory withdrawal in jail, Albert, who was university educated, had lost everything—his wife and three children, and a job as an engineer. He was now drug-free and working for a temporary staffing agency, but the realization of what he had done to his life was catching up with him. Albert was struggling with depression. His failed attempts at suicide had impressed on him that his life might have a purpose, but this was not enough to lift his feelings of despair. “I saw a counselor at the local mental health emergency center, but I can’t see a psychiatrist about medication for a couple of months.” I could help him with one of the selective serotonin reuptake inhibitors that we have on the mobile clinic. It has been reported that family physicians routinely miss bipolar disorder diagnoses in patients. Albert may have an underlying manic-depressive illness; he will return to report on the effectiveness of his medication in two weeks. There is certainly a need for more psychiatrists for the patient population I see. Until the day comes when there is an adequate number of mental health care providers, family physicians will continue to fill the breach and provide the help so many patients need.
Exercise is one of the best ways to attain or maintain health: this is something I stress to all my patients, and I try to practice what I preach. For me, swimming has been the ideal means of maintaining my fitness. So, when I found myself running the last leg of my first-ever 5K race, I had to ask myself, “What the heck am I doing here?” The incentive was certainly not to win, but only to beat the time of D.W., who had promised to give one year’s free dues in his flying club to anyone older than 60 years who could beat his time. Such a challenge was hard to turn down. The race was in the early morning before our clinic started, and I nonchalantly figured I would have sufficient time to shower before heading for work. The gods were not kind and the race, which was on an airport runway, was postponed for 15 minutes because of skydivers. Then the really bad news came: D.W. had pulled a muscle earlier and decided just before race time that he was going to drop out. He informed me that when his healing process was complete in X amount of weeks, he would try to beat whatever my time was on a measured 5K course. This was not the kind of news I was expecting. Now I had my own pride to spur me on, rather than trying to match D.W. stride for stride. I did finish the race (avoiding falling on my face, as my wife warned me not to do), and I have gained a greater respect for runners. But from now on, I think I’ll stick to swimming.
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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