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Am Fam Physician. 2003;67(10):2114-2116


As I walk down the street from our family health center, a familiar elderly woman catches my eye. She beams and veers toward me. Her halting English and crooked right arm bring it all back. Mrs. Puelo is an affable woman with a history of unexplained dizziness. Months ago, when she fell and fractured her right elbow, our inpatient team took care of her. After she had appropriate surgery, we were reluctant to send her home (she lived alone, with no family nearby), afraid of what her casted, club-like arm would do to her precarious balance. But she absolutely refused our arrangements for short-term nursing home rehabilitation. “I’m concerned about you,” I said, sitting at the edge of her bed. “How will you use the bathroom at night? What if you fall again?” My argument, though logically sound, bounced off her. “I be okay. My friend, she visit me.” With some irritation, I accepted her decision. Today, recalling our disagreement, I am surprised at her joy as she pulls me close to kiss my cheek. She waves her misshapen wing. “Can’t straighten it. Hurts bad,” she says. Even so, she hasn’t suffered a single dire consequence that I predicted. Why the kiss, then? Maybe it’s her way of saying, “You were obtuse, but thanks for caring.”


The medical student with me today returns after 45 minutes with a six-year-old patient. “Fascinating!” he says of this large child who doesn’t talk. “He weighs 94 pounds, but he used to weigh 140! His mom was told he might have Prader-Willi syndrome.” Prader-Willi. I dimly recall medical school photos of disturbingly obese boys with small testes. A textbook now reminds me that a chromosome 15 disruption also produces mental retardation, behavior problems, almond-shaped eyes, and small hands and feet. I walk into the room expecting the worst and am pleasantly surprised. Edward is a curious boy who communicates with cheerful points and word-like grunts. “He gets along with everyone,” says his mom, an articulate, patient, single working mother. She wants me to figure out what “Punkin” has. My examination picks up the almond eyes and smallish gonads, but I confess to her that I’ve never encountered Prader-Willi in my practice. Luckily, the student knows the developmental disorders maven who lectured his class on Prader-Willi. Grateful for the name, I write a consultation letter. After blood work and shots, there’s an orange plastic ruler for Punkin to wave around. Given a few answers, I hope to give Punkin the care he needs and his mom a little peace of mind.


My first patient is Mr. Fuentes—shy, shrugging, and positive for human immunodeficiency virus (HIV), who is here with his robust, uninfected wife. I diagnosed Mr. Fuentes with HIV and hepatitis C 10 years ago. He’s done well on antiretroviral therapy, but today he looks sallow and cachectic. “Tengo náuseas y vómito.” Throwing up for three weeks. Twelve-pound weight loss since his last visit. I look him over. Sclera nonicteric. Tender epigastrium. No stool in the vault. Lactic acidosis? Hepatic carcinoma? An ulcer? I order blood work and an abdominal computed tomographic scan, arrange for a gastroenterology referral, and prescribe omeprazole. His laboratory results show aspartate transaminase and alanine amino-transferase levels in the mid 200s, and his bilirubin level is 4.4 mg per dL. I call Mr. Perez. “Deje de tomar sus pastillas.” Stop the didanosine, stavudine, and nevirapine, all of which can cause hepatic toxicity. Managing antiretroviral therapy is tricky business. If medications are the culprits here, could I reuse his current agents later? Is there any regimen that would be kind to Mr. Fuentes’s liver but not exacerbate his lipodystrophy? For guidance, I’ll contact the National HIV Telephone Consultation Service (800-933-3413).


Often, the most precious medicine we offer is neither pill nor liquid, but merely our caring presence. Mrs. Garcia comes in today, as she has every month since her husband Alfredo, also my patient, died. It had been something of a privilege for me to observe Mrs. Garcia’s loving attentiveness as Parkinson’s disease overtook her husband. Today, she reflects on their 60 years together. “We married young,” she says. She tells me she’d like to move out of their apartment, where she’s flooded with reminders of him. “Ay, doctor.” When I mention the hospital’s geriatric day program, the one Alfredo attended, she expresses an interest in participating herself. “Is it all right if I call in a referral?” I ask. She nods. “Sí.” I’m glad. Although Mrs. Garcia still looks sad today, her expression is less distraught than it was a month ago, and at this visit her eyes require only a single dab from a tissue she holds crumpled in her hand. She hugs me goodbye. “I feel better after seeing you.” Even though—or maybe because—I couldn’t fix or save her husband, this visit makes me feel better, too.


“I’m glad I won’t have to ride the school bus for a few days,” says our older daughter, now a commuting middle schooler, when she arrives home today. She’s responding to two episodes of bullying, cursing, and hitting that she witnessed on the bus this week, each involving the same aggressor and victim. In each instance the driver made no attempt to intervene. Several calls by my wife to a school vice-principal revealed that the perpetrator had finally been identified, the parents contacted, and appropriate disciplinary actions taken. Still, our daughter found the experience harrowing—and it wasn’t just the bullying. “The other kids acted like it was a sporting event,” she says in disbelief. “They were standing on seats, pointing and shouting, ‘Did you see that?’ Like they were enjoying it.” In discussing our daughter’s tale with other parents, I’ve learned that many children hate these overcrowded, poorly supervised bus rides. And now I know why: they feel vulnerable and afraid. Who wouldn’t? This episode has highlighted for me another common situation where kids can run into trouble, and I may start asking about the school bus ride at well-child visits. As independent as our children sometimes seem, there are many times when they still need adult protection and guidance—and a willingness to march down to school and advocate for them.


I’m often struck by how real-life medicine rarely resembles the straightforward diagnoses and clear-cut choices found in textbooks. Picking up family practice service for the weekend, I learn about Mr. Manetta, a diabetic patient who’s in the hospital yet again for his infected foot. He lost one toe in the past, has had osteomyelitis of his metatarsals several times, and this time around presented with redness and swelling in his heel. Our infectious disease consultant knows him well. “He’s got another osteo. The foot’s a mess—did you see the films? We need a bone biopsy to guide therapy. ” But the next day, our orthopedic consultant begs to differ. “He’s got a disfigured Charcot’s foot, but there’s no osteomyelitis at the site of the current infection. I’m convinced of it. That’s just a cellulitis caused by his footwear.” He recommends sending the patient home today on oral antibiotics. I ask the disagreeing consultants to have a conversation with each other. Meanwhile, I visit our radiology department in the hopes of resolving this conundrum myself. Mr. Manetta’s folder is nowhere to be found. Based on my physical examination, I’m tempted to believe the orthopedist, but then again the patient’s erythrocyte sedimentation rate on admission was 104 mm per hour. Ouch. Signing out to my colleague after the weekend, I review Mr. Manetta’s situation, then offer a rueful shrug. “Good luck.”

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