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Am Fam Physician. 2003;68(5):843-844


Warning: What goes up must sometimes come down. I never miss an opportunity to encourage my patients to exercise. So, you can hardly blame me if I was feeling pretty good about myself and my patient when 67-year-old Annette credited me with her newfound interest in cycling. She had started biking six days a week and loved it. Recently, Annette was riding her bicycle outside of town when it slipped on loose gravel. She was catapulted off the bike and landed hard on the road. Talk about Technicolor! The entire right side of her body was tattooed with road burn and hues of purple, yellow, and blue. Unfortunately for her, she was not wearing a bicycle helmet that day. There was no loss of consciousness, yet she still resembled a boxer who had just completed 15 rounds of a prizefight—extensive facial swelling, along with a laceration above the right eye and a severe subconjunctival hemorrhage. A computed tomographic scan of the head and facial bones was negative except for soft tissue swelling. Her ophthalmologist found no permanent damage to her eye. Before long, Annette's bruising resolved. She was back on her bicycle pedaling all around town. This time she was wearing a helmet. There's only one way to keep a good woman like Annette down. Gravity.


Ashley is a college student who also works part-time and performs volunteer services. She usually has energy to spare—at least up until the past five days. Now she described extreme fatigue, fever, chills, nausea, vomiting, and a sore throat. Ashley yawned and then said, “I must've slept 16 hours yesterday, and I still feel tired.” Her temperature was 101°F, and she appeared mildly jaundiced. Right upper quadrant abdominal tenderness, cervical lymphadenopathy, and petechiae of the soft palate were present. Her white blood cell count was 4,900 mm3, with a platelet count of 91,000 per mm3. Her total bilirubin level was 3.8 mg per dL, aspartate transaminase level was 263 IU per L, and alanine transaminase level: 349 IU per L. A monospot test was positive. Mononucleosis hepatitis occurs in approximately 10 percent of cases of infectious mononucleosis. Rest and antiemetic medication were prescribed. Reassurance was provided. I gave her a useful American Family Physician patient information handout, appropriately titled “Getting Through Mononucleosis.” Three weeks later, Ashley was back to her usual self. Her liver enzymes returned to normal levels, and her platelet count was 211,000 per mm3. Life for this young woman is once again full speed ahead.


“What do you think it is?” asked Albert, an elderly man with type 2 diabetes, as he caressed the rash on his right temple. I wasn't sure if he was trying to soothe it or make it disappear. Albert reported that his rash had been present for one week, was gradually increasing in size, and was “sore to the touch.” It seemed to originate in his hairline but involved most of the temple and part of the right forehead. The rash had an outline that resembled the state of Nebraska. It was raised and erythematous with a number of scabbed lesions in the area closest to Albert's hairline. It looked like a bacterial skin infection, but I was stumped as to what had caused it. The answer appeared in the form of a question. “Do you think it might have anything to do with the hairs my wife plucked?” Ouch! Albert had a thick head of hair that could easily have passed for steel wool. “She cleaned the tweezers real thoroughly before she started,” he added. I wrote him a prescription for amoxicillin/clavulanate (Augmentin). “Next time your wife approaches you with a pair of tweezers,” I suggested, “RUN.” Never miss an opportunity to practice a little preventive medicine.


Heath is an exceptional high school student-athlete who has never been sick a day in his life. As he sat on the examining table, he looked more worried than ill. “My chest hurts.” To illustrate the point, he tapped the left pectoral region of his chest with four fingers. He had no other symptoms, and the examination didn't yield a clue—no rubs, rales, wheezes, or murmur. My clinical impression was musculoskeletal pain. That opinion was bolstered by Heath's admission that the pain was accentuated with certain movements of his upper body, including stretching and turning. “You don't think it's my heart, do you?” Heath asked. He was well aware that even professional athletes occasionally die suddenly of undiagnosed hypertrophic cardiomyopathy or coronary artery disease. “No, I don't. Your heart sounds fine.” I sensed he needed more proof. I did an electrocardiogram (ECG) in the office and made him a copy. “Looks okay?” Heath asked. “Perfect,” I replied. He folded the ECG and stuffed it into his shirt pocket. That was all the reassurance he needed. “Try taking some ibuprofen and call me in two days with a progress report.” If Heath continues to experience chest pain, he's going to have a chest x-ray and an echocardiogram. But, at least for now, we both feel satisfied and relieved that his record of invulnerability remains pretty much intact.


“My neck and back are killing me,” Mr. Hugo proclaimed. “I need something for pain.” He had extensive degenerative disk disease of the spine. Back surgery performed years ago had unfortunately failed to eliminate his suffering. “That last stuff you gave me was worthless,” he continued. “The only thing that ever helps is Vicodin.” The “stuff” he was referring to had been tramadol (Ultram), or maybe any one of a half dozen other medications he had tried for his bad back. Amitriptyline (Elavil) was ineffective in reducing his chronic pain, but in my opinion, he didn't allow nearly enough time for it to work.

Today, Mr. Hugo refuses a referral to a chronic pain management program—again. He rates his pain as “11” on a scale of 1 to 10. His level of anger and frustration appear to exceed that ranking. When I lightly touch the skin over his low back, he yells as if I had prodded him with a hot cattle iron. He is irritated by the need for a physical examination and my endless questions. “If you won't prescribe Vicodin,” Mr. Hugo informs me, “I'll get it somewhere else.” Before I can utter another word, he growls, “I'm wasting my time here” and exits the office. Suddenly, my neck and back begin aching. As I rub my tense muscles, I realize that failure is a two-way street.


“Benton is boring. Nothing ever happens around here.” These are just two of the lamentations I frequently hear from my teenaged patients. Many of these young people long to escape the doldrums of small town living. If only they could walk a mile in my shoes, they might experience a not-so-average day in the life of one citizen. Before I even see my first scheduled patient of the day, a young woman asks my nurse for samples of an expensive prescription medication. Suddenly, her toddler starts choking. I quickly perform an abdeominal thrust on the child and out plops the offender—a piece of hard candy. Later that morning, I meet with a nice elderly woman to discuss test results. She has been experiencing atraumatic shoulder pain for six weeks. A plain x-ray demonstrates what looks like a large metastatic lesion of the humerus. Her bone scan “lights up” in multiple areas of the skeleton. How do I begin to break the bad news to her? That afternoon, a middle-aged man with every major risk factor for coronary artery disease except diabetes walks into the office complaining of chest pain. An electrocardiogram, aspirin, and sublingual nitroglycerin are followed by a trip to the emergency room. Dull life in a small town? Hardly. It all depends on your perspective.

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