PRACTICE DIARY

Chapter 52

 


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Fam Pract Manag. 2004 Feb;11(2):64.

A pain in the neck

Barbara was one of my patients with chronic pain, and although she went to a pain clinic in a nearby city, I occasionally treated her when a trip out of town was inconvenient. This last occurred after she was rear-ended in an automobile accident. Her emergency department work-up (including X-rays) was normal, and the ED doc had discharged her after a 50-mg shot of Demerol with a prescription for some Vioxx and Vicodin. She was at my office the next morning. “I’m hurting,” she exclaimed, “and I need a pain shot the size of Texas. Fifty of Demerol didn’t touch it. I didn’t even feel that.” After examining her and determining she had assorted strains, contusions and spasms, I sent her to outpatient surgery for 150 mg of Demerol and some IV Toradol as well. That worked until the next morning.

The rest of the week became a negotiation for pain meds and muscle relaxants. What really helped her was Soma, and she took four to six per day. I thought she was actually improving, until I got yet another frantic call from her husband; this time she had a painful swelling in her neck. Because Barbara had a past history of severe temporomandibular joint dysfunction, I told him to take her to the ED, where they gave her her usual cocktail and told her to follow up with her physician. So, the next morning, she again appeared on my doorstep. The routine was getting tiresome, and I paid scant attention to the slight puffiness under her mandible that was tender to the touch but didn’t feel quite like a lymph node.

“My dentist wants to take panoramic views,” she said.

“Good idea,” I said, thinking of her prior history. “If he doesn’t know what’s happening, perhaps we should refer you to an ENT.”

A week later, Barbara called to say she was doing much better and the ENT had told her she had some disease she couldn’t pronounce but was taking antibiotics for it and using hot compresses. The consult note came the same day: “Dx: sialadenitis. Rx: clindamycin 400mg qid.”

She had salivary gland inflammation! I knew that! Although not a common condition, I’d seen and treated it before, but I’d let my frustration and impatience cloud my clinical judgment. I felt stupid. Several years before I had given a similar patient short shrift when she came in for a 15-minute appointment with a long laundry list of complaints; the last was a skin lesion that I cursorily dismissed as a nevus. It was, in fact, an early melanoma. “Pay attention and be vigilant,” I chided myself, vowing to be more patient with Barbara and others like her in the future.

Scoped!

After years of doing wellness medicine, I decided to practice what I preach and get a colonoscopy. “Why not?” I thought. I’ve sent my patients for enough of them. Yet, I had some reservations. The first was the usual fear doctors have of being the one in a thousand who gets a colon perforation from the procedure; the second was that they might actually find something! And then, there was the issue of doing it at our local hospital, where I knew everyone. “Don’t worry,” Dan, our visiting gastroenterologist said, “you’re not the first doctor I’ve scoped here.”

“I’m not? OK, I’ll do it,” I said, relieved to learn that some of my colleagues had bared their bottoms before me.

Dan’s nurse, Cathy, faxed me the bowel prep procedure. “I have two openings,” she said, “Tomorrow or the day after. If you do it tomorrow, you’ll have to drink a gallon of GoLytely today. Otherwise, you can start clear liquids tomorrow and do a Fleet Phospho-Soda purge tomorrow afternoon.”

“How much of that do I have to drink?” I asked.

“One-and-a-half ounces in four ounces of water tomorrow and another one-and-a-half ounces three hours before the procedure.”

“OK, I’ll do the three-ounce prep,” I said, figuring it would be easier to get that down than a gallon of stuff that would have me doing anything but going lightly.

The prep was worse than the procedure. Eating Popsicles and Jell-O and drinking eight ounces of water every hour was no fun, and the lemon-flavored cathartic was god-awful. Worse was the night before, knowing that if I had gotten scoped that day, as my wife had suggested, I would already be eating real food and not be irritable and famished. I was actually glad when it was my time to go. My friend Adam, the hospitalist, who had once had a colonoscopy without any sedation, graciously agreed to cover for me and offered these words of advice: “Take the joy juice.”

The colonoscopy was a breeze, and I was relieved that they actually did it with me on the gurney rather than on some sort of torture table in the prone jackknife position. “Can I get a tape?” I asked Dan before he started.

“We don’t do tapes,” Dan said, “but you can watch it on the screen.”

Afterward, I had some vague recollection of seeing bowels, but the Versed/fentanyl cocktail Dan administered erased nearly all memory of the event.

“Negative screening,” Dan strode in and told me. “You won’t need another one for 10 years.”

“I don’t know about that,” I kidded him. “It took me 55 years to get this one. But next time I want to remember seeing my splenic flexure and ileocecal valve.”

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.


 

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