PRACTICE DIARY

Chapter 42

 

Fam Pract Manag. 2003 Feb;10(2):55.

All in the family

Maria, a new patient, was seeing me because of dizziness, weakness and numbness in her hands – the sort of vague complaints that often engender negative workups and abate on their own. Maria’s symptoms had been going on for many months but had markedly worsened during the past two. She was overweight and looked a bit puffy, but there was nothing in her physical exam to give me a diagnosis.

Her past medical history was completely benign – no hospitalizations, no surgeries, no accidents, no serious illnesses – but her family history was notable for a brother with a thyroid disorder. “Maria,” I said, “I hate to run you up a bill, but I think we should do a thyroid test.”

“You’re the doctor,” she said.

We ran the test and found that Maria’s thyroid stimulating hormone (TSH) was an astounding 308. “Dalia,” I said to my office manager, “I want Maria in here now!”

An hour later she was in my office. “Maria,” I said, “you are profoundly hypothyroid. Without treatment you could progress to a comatose state and possibly die.” I had, truthfully, never seen myxedema coma but could imagine that with her TSH it might not be very far away. The only TSH I’d ever seen as high was the year before – a then record-setting TSH of 175. “Dalia,” I asked, “Who was that man we saw last year for severe hypothyroidism? I think his first name was Carlos.”

“Carlos Martinez?” Maria piped in. “He’s my brother.”

A quick look at Maria’s family tree showed that she had two other brothers besides. “Here’s a prescription for you, and tell your brothers to hightail it in here for testing,” I said. Maria promised to send them in, and I awaited with curiosity the TSH of the two remaining siblings.

A great diagnosis

Dalia called with an emergency just as I arrived home on a stormy day. “Dr. Brown, there’s a leak in the kitchen. The drywall in the middle of the ceiling has bubbled, and water is dripping onto the floor. I’ve put a bucket under it.”

“Great work,” I said. “I’ll be right in.”

All I could imagine was a plumbing catastrophe, perhaps an overflowing toilet, in the apartment that sits above my office. Why else would water be dripping from the ceiling?

The “bubble” was the size of a basketball, but the upstairs apartment was dry as a bone. I punctured the bubble with a broom handle, and a couple of quarts of water ran out. There were two possible diagnoses for my building’s ailment: Most likely, there was a pinhole leak in a pipe; less likely was a roof leak. But when I shut off the water to the building, the leak didn’t stop; therefore, however improbable, my roof had to be leaking somewhere. Later that evening after the rain had stopped, so had the leak.

The next day I took a ladder and climbed into the crawl space over the upstairs apartment. I immediately heard the drip. Following the sound, I found water leaking in from where the plywood roofing came together to form a valley. It had run down to a joist, over to the wall, down a stud to my ceiling joist and finally to the center of the room. Amazing! I climbed up onto the roof and found the culprit; the flashing covering the valley had corroded and was letting in a steady stream of water that had puddled around it. While waiting for a roofer to install new flashing, I made a quick fix with some roof patch.

Why can’t medicine be more like repairing leaks? The mysteries are always solvable, the solutions are always logical and the worst that happens if you’re wrong is that you get wet.

Disability insurance

I should have known better. You have to protect the quarterback. Instead, I invited Adam, our newly chosen hospitalist, to join me and seven other guys on dirt bikes and ATVs for a group ride. The wild bunch converged on a beautiful Saturday morning, managed to ride to the off-road area without attracting highway patrol and had just taken off in the dirt when Adam, going much too fast, flipped his four-wheeler and wound up underneath it. It wasn’t pretty. He fractured his left clavicle and five ribs.

“There’s no pneumothorax, though at the time I sure thought there was!” Adam e-mailed later. “The four-wheeler’s fine. It landed on something soft.” Adam’s sense of humor (likely abetted by some Vioxx and Percocet) brought up the issue of just how much fun doctors should have without putting their health and, consequently, their patients’ welfare in jeopardy. Adam can’t do much in the way of procedures until his bones start sticking together; luckily he’s a cognitive specialist, not a surgeon.

I know doctors who parachute out of planes, rock climb, free dive for abalone, bungee jump and race down hills on mountain bikes. Most of them have disability policies, but real disability insurance comes not from paying premiums but from making intelligent choices and being careful. An avid dirt bike rider, I always wear a helmet, boots, gloves, goggles, knee and elbow guards, and a chest protector when I ride. Despite all that, I broke my fibula several years ago. I went to work on crutches the next day, but at least I didn’t have to feel stupid or guilty about not being properly accoutered.

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.

 

Copyright © 2003 by the American Academy of Family Physicians.
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