From a Week in Practice
Am Fam Physician. 2005 May 1;71(9):1695-1696.
“Doesn’t his face look unusually red?” Otis’s wife asked. Her 54-year-old husband had hypertension treated with sustained-release verapamil. He didn’t smoke cigarettes or consume alcohol. His wife was right; Otis had a ruddy face. Otis reported feeling tired and experiencing occasional headaches. His blood pressure was 120/72 mm Hg and oxygen saturation on room air was 97 percent. He had splenomegaly, but no lymphadenopathy on examination. Laboratory testing revealed a white blood cell count of 12,400 cells per mm3, hemoglobin 18.6 g per dL, hematocrit 56.1 percent, and platelet count 460,000 per mm3. His vitamin B12 level was at the upper range of normal, but his erythropoietin level was low. “Your blood is too thick,” I informed Otis. “We call it polycythemia vera.” I planned on arranging a hematology consultation for him. In the meantime, I encouraged Otis to discontinue any iron supplements and to begin a one-unit phlebotomy every week until his hematocrit fell below 45 percent. “I’m not real keen about having my blood drained once a week,” he grumbled. “Is that the best you can do?” I could understand his skepticism. I knew Otis was a NASCAR fan so I relied on his knowledge of car racing and motor engines to make my point. “We need to reduce your viscosity,” I explained. He slowly nodded his head. “Bloodletting!” his wife butted in, “How long has it been since you graduated from medical school?” I could suddenly feel my face turning almost as red as Otis’s.
Although Vanessa is not an actress, the 33-year-old is dramatic. She likes to lay flat on the examination table with her head tilted towards the ceiling and arms outstretched with palms up. Vanessa had panic disorder and exhibited most of the classic symptoms—unprovoked episodes of anxiety, palpitations, sweating, and dizziness. She had revealed the diagnosis to me a few months earlier. “There are times,” she said, “when I feel like something bad is going to happen to me and I think I could die.” Vanessa was exquisitely sensitive to drugs. Now, she was taking 10 mg of paroxetine (Paxil) daily and, on rare occasions, 0.25 mg of alprazolam (Xanax). She also was seeing a therapist. Recently, I detected a midsystolic click and late systolic murmur. An echocardiogram confirmed the presence of mitral valve pro-lapse without mitral regurgitation. I started her on atenolol 25 mg, one half tablet a day. “It’s amazing what just a half a pill can do,” she boasted today. “My heart is no longer a problem. That new medicine has completely stopped it from racing and skipping. I feel so much better.” For a change, she was sitting straight up on the examination table. As I listened to Vanessa and her valve, I had to agree that her heart was clearly in a better place.
After two unsuccessful attempts to secure a prescription for an antibiotic called into the pharmacy, Neil grudgingly showed up at my office. “I’m wasting your time,” the 38-year-old car salesman said, “and mine. All I need is a prescription for penicillin.” Neil had been having recurrent sore throat. The pain was worse in the morning and improved throughout the day. At times, he felt the need to clear his throat. He didn’t smoke or chew tobacco, and he took no prescription medicines. He had no fever, sinus congestion, facial tenderness, or enlarged cervical lymph nodes. There were no lesions in his mouth. The back of his throat was red, but no exudate was present. His breath was slightly sour. “Do you ever experience heartburn?” I asked him. After pausing for a few seconds, Neil answered, “I guess so. Doesn’t everyone?” Further interrogation revealed that he had heartburn more than twice a week, occasionally had a sore tongue, and was sometimes hoarse. I was convinced he had laryngopharyngeal reflux and recommended omeprazole (Prilosec). Neil was dubious. We reviewed lifestyle changes that address acid reflux disease. I asked him to return in four weeks and advised him that further evaluation might be necessary. Neil was peeved when I refused his request for a prescription for penicillin. I realize that our encounter left a bad taste in his mouth, but I’m optimistic that the unpleasant sensation will clear up after the omeprazole therapy.
“My daughter has worms,” Megan’s mother whispered. Megan placed her hand over her face, lowered her head, and quivered. “Her bottom’s been itching all this week, especially at night. The other day she saw little bitty white threads outside her bowel movement. When I checked it out, I knew right away they were pinworms.” All this time, the 11-year-old girl was silently enduring her embarrassment with her face still guarded by her right hand. The history provided by the mother, plus her findings on examination of her child’s stool, were sufficient to make a diagnosis of Enterobius vermicularis. No “tape test” was necessary. I instructed them to wash everything in hot water, asked Megan to keep her fingernails trimmed and clean, and prescribed mebendazole (Vermox), one 100-mg tablet today and a repeat dose in two weeks. I also recommended mebendazole for Megan’s immediate family members. Megan refused to make eye contact with her mother or me throughout the office visit and examination. Her only interjection was a softly spoken, “This is really gross.” Adults and children don’t always see eye-to-eye, but today the three of us were in complete agreement.
After a voluntary recall of rofecoxib (Vioxx) was issued, a flurry of telephone calls from worried patients followed. Ford worked at an assembly plant where he stood on his feet almost all day long. The 51-year-old man had a history of peptic ulcer disease and suffered from osteoarthritis of the knees and low back pain. He was moderately overweight and didn’t exercise. “That rofecoxib worked wonders for my knees,” Ford declared. “What am I going to do now?” I listed some options. He could try another cyclooxygenase inhibitor like celecoxib (Celebrex) or valdecoxib (Bextra), though I cautioned him that the verdict is still out on the entire class of these drugs and that I am reluctant to prescribe them. He could try an older nonsteroidal anti-inflammatory drug with a proton pump inhibitor. Ford mulled over the alternatives then said, “If it’s all the same to you, Doc, I think I’ll hold off on any new prescriptions. I’m going to get a big bottle of Tylenol and maybe borrow some of my brother-in-law’s glucosamine chondroitin. You’ve been after me for years to lose weight and exercise. It just might help my knees and back. Wish me luck.” I was going to share a few other suggestions with Ford, but decided instead to let him keep talking. He was excited about formulating his own solution to the problem, and it dawned on me that Ford really had a better idea.
Despite being “retired” and in his 70s, Lester still keeps a busy schedule. His philosophy of life could be expressed in two words: “Stay useful.” Who could argue with wisdom like that? Lester loves the outdoors. He owns some acreage outside of town where he raises livestock, including a small herd of cattle. A little more than one month ago, Lester was injured. A rowdy steer rammed him and knocked him to the ground. Lester is a tough guy, but not so sturdy that he could avoid nondisplaced fractures of two ribs from the accident. At that visit, he stated, “I figured there’s not much you can do about broken ribs.” He laughed and then added, “If you think these bruises look bad, you should see the steer.” Six weeks after that incident, Lester paid me an unexpected visit. He was carrying a package wrapped in white butcher’s paper. “For you,” he said. Lester watched with intense interest as I unwrapped the parcel and found four steaks inside. “Best I’ve ever eaten,” he asserted without any hint of malevolence. Lester didn’t have to tell me where the beef had come from. “Revenge is sweet,” proclaims one famous cliché. Lester is of the opinion that there are times when it is downright delicious.
To preserve patient confidentiality, the patients’ names and identifying characteristics have been changed in each scenario.
Copyright © 2005 by the American Academy of Family Physicians.
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