From a Week in Practice
Am Fam Physician. 2004 Jul 1;70(1):77-78.
“My foot really hurts,” Mona winced as she gently massaged her right heel. The middle-aged woman was devoted to walking. Rain or shine, wind or snow—it didn’t matter. She was up early every morning and walked five miles before eating breakfast. As I palpated the medial calcaneal tubercle, the diagnosis came to me in the form of a protest. “Ouch!” Mona erupted. “Not so hard.” She quickly pulled her foot away from my hand before I could utter “plantar fasciitis.” I suggested that she take a nonsteroidal anti-inflammatory drug, wear a heel cushion, and apply ice after activity. I taught her the proper method of stretching and strengthening exercises. “Rest works best,” I preached. Mona was back in the office two weeks later. “It’s not any better,” she reported. We discussed other treatment options—night splints, plantar strapping, orthotics, and a cortisone injection. At my request, she had brought her walking shoes with her. “I’ve had them a year and it still feels like I’m walking on air,” she bragged. It turned out those “magnificent” shoes were totally treadless. After ambling 1,800 miles, the soles were completely worn down. It could be months before Mona’s plantar fasciitis improves, but I have convinced her to change shoes every 300 to 500 miles. “Think of it as a tune-up for your feet,” I suggested. There are times when it is helpful to walk a mile in someone else’s shoes. This was not one of them.
Mr. Bryan swore he wasn’t lying. “I was shot,” the 71-year-old man matter-of-factly told me. His wife shrugged her shoulders and raised her hands. “He was in the woods all by himself two weeks ago. He returned to the house that evening and told me the same story. He had a hole in his T-shirt and a small opening on the skin of his chest. I didn’t know what to think,” she admitted. Mr. Bryan was cognitively intact. “I feel fine except a little sore where I was shot.” He had a small wound over the right pectoral area that was scabbed but not infected. I could not palpate any foreign body. No metallic object in the soft tissue was visualized on an x-ray. “It’s weird,” the patient concluded. I had to agree with him. “At first, I thought something stung me or bit me,” he said. “But that wouldn’t explain the hole in your shirt,” I countered. “Exactly,” he nodded. “Maybe it was a stray bullet from a hunter’s rifle or some kid firing his pellet gun,” I hypothesized. That didn’t make sense either. Where was the evidence? I assured Mr. Bryan he would be fine, but admitted I was just as clueless as he was as to what had caused his injury. Not a day goes by without a reminder that I don’t have all of the answers. Today, all I had was a shot in the dark.
“Turnips,” Mrs. Quemby uttered in disgust. The 77-year-old woman was staring at her outstretched hands. “When my hands get cold, my fingers turn colors—turnip, almond, purple. Sometimes they remind me of the colors of the American flag. My fingers sting and tingle, but feel better after they warm up.” Mrs. Quemby smoked four cigarettes a day and had hypertension. She took a baby aspirin every day. She liked to talk and loved to laugh. “Even at the frozen foods section in the grocery store, my hands go Technicolor. I wouldn’t mind walking around like a rainbow, but I never did care for turnips.” Mrs. Quemby’s description convinced me she suffered from Raynaud’s disease. Her physical examination showed no evidence of any connective tissue disease. Her erythrocyte sedimentation rate was 18 mm per hr. A rheumatoid factor and antinuclear antibodies test were negative. I emphasized the need to stop smoking. I discontinued her thiazide diuretic and substituted nifedipine. I coached her on caring for Raynaud’s disease. “Always dress warmly,” I instructed her. “This problem is going to ruin my career as a hand model,” she kidded me, “but at least I know what to ask everyone to get me for my birthday—gloves.” Mrs. Quemby is a colorful character—and that’s just her anatomy!
Farming may have been in Kyle’s blood, but dirt seemed ingrained everywhere else—embedded in his calloused hands, inside his nose, and blanketing his face. “I’m sorry I’m such a mess,” the 36-year-old man apologized, “but I’m busy as all git-out in the field. I didn’t have time to clean up.” As he removed his green baseball cap and lowered his bib overalls, Kyle unleashed a cloud of dust that eventually disappeared into the examination room carpet. “My allergies and asthma have been acting up,” he said. Although there was slight expiratory wheezing over both lungs, he was not coughing or visibly short of breath. His oxygen saturation was 98 percent as measured by pulse oximetry, and his peak flows were only mildly reduced from his baseline. Kyle had considerable nasal congestion and frequent episodes of sneezing. I increased his dose of Advair Discus and added Singulair. I recommended that he continue to take Zyrtec-D but also begin using Flonase nasal spray. I reminded Kyle that he could still use his albuterol inhaler if necessary. As he stood up to leave, he once more released a drizzle of dust. “Perfect day to be outdoors,” he declared. Kyle loves the land, but it doesn’t much care for him. Grain and other particulate matter, chemicals, dust, and exhaust from farm machinery cause havoc with his asthma and allergies. As I waved goodbye, Kyle naturally returned the gesture with one of his own—an allergic salute.
All Russell wanted was some prescription cream for his psoriasis. The 62-year-old man was a new patient, but the diagnosis was obvious. The few psoriatic patches that were present over his elbows and knees generously shed a few flaky scales when I lightly touched them. Russell’s blood pressure in the left arm was 162/94 mm Hg. When I rechecked it later, it was still 160/90 mm Hg. The reading was identical in his right arm. “Let me listen to your heart and lungs,” I requested. “I’m only here for my psoriasis,” Russell protested but finally submitted. His breath sounds and heart tones were normal. When I placed the stethoscope over his neck, however, a nearly silent noise kept repeating itself— whew, whew, whew. “Really doctor, I’m just here for some cream,” Russell objected. “Quiet please. Wait just one moment,” I pleaded. Now there was no mistaking the soft bruit emanating from his right carotid artery. I had him begin taking an enteric-coated aspirin once a day. Laboratory testing revealed significant hyperlipidemia. I scheduled a carotid ultrasound examination for him. The study demonstrated a 90 percent stenosis of the right carotid. A cardiac stress treadmill test was negative. I then referred him to a vascular surgeon. An arteriogram confirmed the severe occlusion, and Russell had a right carotid endarterectomy without any complications. When we carefully listen to our patients, it is sometimes astonishing how much they tell us—even when their mouths are closed.
West Nile disease. SARS. Avian influenza. My patients have lots of questions and concerns about these “imported” infectious diseases. I am convinced, however, that fear is much more contagious than any of these illnesses. “I haven’t seen you walking lately,” I mentioned to Mr. and Mrs. Xavier during a recent office visit. “Is everything all right?” I asked. The elderly couple walked regularly, and I often had seen them holding hands on their daily morning stroll. “We haven’t been out of the house much since last fall,” Mrs. Xavier admitted. “Instead, we walk on our treadmill machine and use the exercise bicycle, but it’s not nearly as enjoyable as being outside.” She sounded depressed. It was her husband who spilled the beans. “We can’t afford to come down with anything. If we get sick at our age, it might kill us. Why take a chance?” They were adequately immunized—pneumococcal, annual influenza, and recent diphtheria-tetanus booster vaccines were all up-to-date. “The world’s crazy,” Mrs. Xavier lamented. “How sad,” I thought aloud. She assumed I also was referring to the sorry state of world affairs, but it grieved me to consider this nice couple’s self-imposed confinement to home. Isolation was clearly not the answer. “I think it’s perfectly safe for you to spend some time outdoors. Take advantage of the nice weather,” I recommended. Exercise definitely boosts the immune system, and doing it outdoors does wonders for our mood as well.
Dr. Tony Miksanek has been a family physician for more than 20 years. Most of that time has been in solo private practice in Benton, a town of about 7,000 people in rural southern Illinois.
Address correspondence to Tony Miksanek, M.D., 712 Old Orchard Dr., Benton, IL 62812.
In order to preserve patient confidentiality, the patients’ names and identifying characteristics have been changed in each scenario.
Copyright © 2004 by the American Academy of Family Physicians.
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