Practice Diary

Sanford J. Brown, MD

Horses vs. zebras II

It was not an uncommon symptom ­ dyspnea ­ but something about Sarah's complaint had me worried. Although she was used to vigorous exercise, she had become short of breath and fatigued after a bike ride. Her exam was unremarkable except for a slight forced expiratory wheeze, and she was afebrile. Still, something wasn't right. I sent her for a chest X-ray.

The report was abnormal but not diagnostic: "Mild pulmonary hyperinflation with mild pleural thickening. A small right pleural effusion is believed to be present." What to do? I opted for a course of antibiotics, prednisone and a three-day follow-up, figuring to treat a not yet visible pneumonia with some reactive airway component. But when she returned, she was subjectively no better; in fact, she was experiencing orthopnea and I now heard crackles in her bases. A pulmonologist colleague diplomatically suggested an axial CT to rule out a pulmonary embolus. "Great," I thought to myself, "I missed a PE." Fortunately, the CT showed no pulmonary pathology, but it did note an enlarged left ventricle and atrium. It was time for a referral, and I made Sarah an appointment. Unfortunately, she went into frank heart failure before she could keep it.

Her echocardiogram showed a hypertrophied, dilated, poorly contracting left ventricle and an ejection fraction of less than 20 percent, but no valvular disease. She was transferred to a tertiary care facility with a diagnosis of "congestive heart failure secondary to severe left ventricular dysfunction, etiology unclear." Emergency cardiac catheterization failed to show any coronary artery disease. Her diagnosis, by exclusion, became virus-induced idiopathic dilated cardiomyopathy.

On a regimen of carvedilol, Diovan and Aldactone, Sarah improved enough to be discharged from the hospital. A follow-up chest X-ray two months later was normal, but her echocardiogram still showed a severely depressed ejection fraction. She remains stable but short of breath with any exertion and has applied for disability. Her prognosis? Gregg, her cardiologist, says some patients recover completely while others go onto transplant waiting lists. I'm hopeful Sarah will be one of the lucky ones.

I had heard the hoofbeats and expected a horse but found a zebra instead. Fooled again!

Moving on

I suppose if I hadn't encouraged Isabel, my office manager, to take courses at our local community college and given her time off from work to do it and paid for her textbooks, it might never have happened. But five years and an AA degree later, Isabel decided she wanted to go to a four-year school and get her BA, which meant her resignation from my practice. No one else in her family had ever attended college and Isabel had never lived far from home, so I always thought I was relatively safe in keeping my best employee ever, but Isabel had outgrown our small town.

Being the loyal, conscientious employee that she was, she gave three months' notice and even found a replacement: her cousin Dalia, who had filled in for Isabel briefly when she was attending classes. Dalia spent a month training with Isabel, making the transition seamless, but I found myself worrying. "What if Dalia
pulls an Isabel?" I asked my former office manager.

"Don't worry, boss," Isabel said. "Dalia still lives at home, she has a boyfriend in town and she hates school. She's not leaving."

"All the same," I said, "I won't be paying for her textbooks any time soon."

Excuses

When it comes to reasons not to exercise, I've heard them all:

"It's too [cold/hot/wet] outside."

"My [legs/knees/feet/ankles] hurt too much."

"I just don't have the time."

"I just don't like to exercise."

And then there's the ubiquitous "I don't have a good excuse, but to tell you the truth, [pick one of the above]."

Getting my patients to start exercising is harder than getting them to stop smoking or drinking or to go for counseling. They'll perform monthly breast or testicular exams and wear their seat belts, but I can't get them to walk three times a week, even though I prescribe it. It boggles my mind.

So, I've developed my pat replies. To the fair-weather walkers, I say, "Invest in the best exercise outfit you can afford. You'll be comfortable walking in the rain and feel guilty about leaving it in your closet unworn." To those who complain of soreness, I explain that exercise can help alleviate pain by promoting circulation and weight loss. To the schedule-challenged, I ask when they're going to find the time to exercise ­ after their first MI? And to those who just don't like to exercise, I say, "Try it for a month. I guarantee you'll love it. Trust me. I'm a doctor."

Dr. Brown, a solo family physician living in Mendocino, Calif., is a contributing editor to Family Practice Management. These excerpts from his journal illustrate the many characters, stories and lessons family practice has to offer. No real patient names have been used. Conflicts of interest: none reported.

Send comments to fpmedit@aafp.org.