Teaching Fourth Graders

Today was a very rewarding day. I received 24 hand-written thank you notes from all the students in the fourth grade class which I attended last week. They had been studying the human body, and so my daughter, who is a member of Mrs. Sommers' class, asked me if I would make a presentation to the class. Since they had studied muscles and bones last week, and were currently studying the heart, I borrowed a skeleton from the hospital's community education department, and a heart from the pathology department. Both activities were great hits with the students.

The black lymph nodes around the heart, caused by cigarette smoking, especially made an impression with them. Many of students commented in their thank you notes that they intended never to smoke. We also listened to each other's hearts, checked blood pressure, and learned about reflexes. They asked many good questions, such as why does a baby have a soft spot and why the pathology specimen heart was not red. Fourth graders are a perfect age for learning and curiosity, and if I were a teacher I think I'd teach that age. The experience was quite rewarding and the thank you notes were just icing on the cake.

Husband-wife hypothyroidism

Remember the Bushes? Before they left the Whitehouse they were both diagnosed with Grave's Disease (hyperthyroidism or overactive thyroid). Well, I recently diagnosed both a husband and wife with hypothyroidism (underactive or low thyroid). Both are being treated with thyroid replacement medicine and are doing well, but we all continue to wonder what causes cluster diseases like this. Probably the most likely explanation is a virus. Or maybe it's the liberals. (Just kidding. I don't have a political agenda.)

Diabetic Complications

Today I saw two different patients that both exemplify the severe and undesirable complications of diabetes. I would not wish them upon any person or patient. The first patient was a lady whom I will call Judy Lath*. She has been hospitalized for the past week and I discharged her today. She has been a long term brittle diabetic on an insulin pump. Because of the brittle diabetes she has contracted complications with her eyes, her stomach, and her nervous system. She was hospitalized because of vomiting and dehydration. During the hospitalization I discovered that she had what is called autonomic dysfunction where the nervous system doesn't function to raise BP when a person stands up as it normally does without us even thinking about it. With intravenous fluids and a medication called Clonidine to control her gastric symptoms as well as her essential hypertension, and a medicine called Florinef we were able to control her BP when she was lying down and keep the BP from decreasing dramatically when she stood up. I discharged Judy home today and she was feeling a lot better, although not perfect. She will obviously have a lifetime of complications. The next patient I saw in my office is an example of a person who could have controlled his diabetes but desired not to and by the time he had that desire his feet were completely numb, he had undergone bypass surgery, and he is on disability because of congestive heart failure and recurrent infections of his feet. All this before age 50. He is not an insulin diabetic and when he wants to he can control his glucose with diet and oral medication. The one large ulcer on his left foot has been debrided by the orthopedist and seems to be finally healing in even though it extends along the whole side of his left foot. The surgeon is able to cut on his foot without the need for local anesthesia because his foot is so numb. Unfortunately today the other foot ulcer was becoming more infected and I added a strong medicine called Levoquin to the Bactrim and Flagyl that he was already on. I will see him back next week for a follow up. I often use the example of this last patient to my other diabetics when they seem not to have the desire to control the diabetes.

Curing Neck Pain on a road in India

Sometimes cures for medical ailments come in most unlikely ways. Hearing my patients' stories about how these cures happen is one of the enjoyable parts of medical practice. I'm always willing to learn something new, plus I like a good story.

Today's story is about Mary Beachman, who has been having neck pain and stiffness for the last 6 to 9 months. Now Mary is a spry 80-year-old, but her neck x-ray did show the expected osteoarthritis. I treated her the standard way with different anti-inflammatory medication. She also received physical therapy and manipulation. She really didn't improve that much, although the pain did not incapacitate her.

I offered her further options for treatment, but she declined, because she was getting ready to go with her husband on a return trip to India, where they had spent much of their life as missionaries.

Well, I am happy to report that not only did she and her husband have a great time traveling, and visiting old friends, she was cured of a major part of her neck pain. You see, the roads in India are full of potholes. And even though the speedy taxi drivers are quite adept at avoiding many of these potholes, they cannot avoid all of them. Mary Beachman describes their taxi driver hitting one of these potholes at a good rate of speed, feeling her neck go "Crunch", followed by immediate relief of her pain. Definitely an added benefit to an already great trip.

 

 

Light Bulb Moment

I celebrated with 35 year old Mike Lodge today because of what I call a "light bulb moment". He had discovered that by eating at least 2 meals a day instead of one huge meal at supper, he could actually lose weight.

For many years, he has weighed 300 to 325 pounds, but today he weighed 285 pounds, and stated he felt great. For Mike this is especially important because he has hypertension and heart disease. In fact, his blood pressure improved enough that I was able to decrease the dosage of one of his anti-hypertensive medications.

Way to go Mike.

 

 

Ritalin Story

Ritalin can be a wonderful drug for helping some people with ADD (Attention deficit disorder) . Infrequently, it is an abused drug, and therefore, doctors have to constantly be on the lookout for drug-seeking behavior.

Some of ;the stories doctors get about lost Ritalin prescriptions are downright obvious and boring; for example, "someone stole my prescription". Some are quite creative and worthy of commendation, like today's effort by Justin.

Justin had tried the routine stories before. Today he called the receptionist first thing in the morning, telling her that he had left his latest prescription for Ritalin in the pants pocket of a pair of pants he had donated to Goodwill. My receptionist, being the astute person she is, found it hard to believe this latest story, but played along. First, she complimented him on his charitable donation and then suggested that he go to Goodwill and search for the lost prescription. We both thought we wouldn't hear anymore from Justin, so we were both humored when he called back later in the day and told us he had indeed climbed into the Goodwill box and retrieved his Ritalin prescription. Do you think Justin was just keeping his options open for future Ritalin stories? I hope they're good ones.

 

 

Ear Wax Causes Cough

I am always amazed that even after l8 years of family practice I have the opportunity to learn or discover new things that are not in the medical textbooks. That is one of the reasons that I like family practice so well.

I saw Mr. Jones* today whom I have treated for a number of different problems, but the thing that I learned from him today was that the cough which he had had for a number of months was simply relieved by cleaning out his ears of impacted cerumen. I had tried various antihistamines with the thought that his cough was related to sinus drainage. This makes since because there is a cough reflex nerve that does go to the ear canal and certainly if the ear wax was impacted enough it could cause a chronic cough, although you will never see that in the medical textbooks. (Most of us know that if you put something into your ear you may get a cough as a result. Try it sometime if you have never seen this happen).

So everyone, keep on learning.           (TOP)

   

"365 Days a Year"

When I see a patient we sometimes get into discussions about anything and everything, especially at the time of scheduled physical examination because I leave a lot of time for finding out about patient’s lives and how that is affecting their health, but also because I am truly interested in my patients.

At today’s visit, Jim*, was struggling with possible retirement so we talked about it. He and his wife had started a company in their garage and grew it to the point where they now have 30 employees, and now that he has a buyer for the company he is trying to decide whether to accept the offer or not. Fortunately, Jim has outside interests other than work so I think he will do fine. As far as his health I told him to limit his alcohol to no more than 2 drinks per day. My nurse drew blood work to check his cholesterol and glucose and I added too the request for PSA because of a family history of prostate cancer. We scheduled a flexible sigmoidoscopy because of a family history of colon cancer.           (TOP)

   

"Miracle of Birth"

At 3:00 a.m. today I was at the hospital delivering a healthy baby girl for a young family. I did not mind that I was awake at that hour, or that it was my own birthday. In fact, I still get excited to have the opportunity of helping out with God’s "miracle of birth", even after 1,000 deliveries. It’s one of the many reasons that I enjoy being a Family Physician.

After the delivery of the 6 lb. l2 oz. baby girl, and as I was finishing the paperwork, the nurses were admitting a lady who had had no prenatal care, and was ready to deliver. So, guess what, I delivered a second "miracle of birth" healthy baby girl in the early morning of my birthday. Coincidentally she also weighed 6 lb. l2 oz.          (TOP)

   

Ovarian Cancer

June* saw me today for a rash which I diagnosed and treated as a contact dermatitis. Her husband was with her today in support, just as he always has been for her office visits over the last 4 years that she has been my patient. She has been a real trooper and model patient, certainly gaining my admiration as she has gone through the trials and tribulations of Ovarian Cancer, its treatments and its complications. She has always had a positive attitude throughout the multiple surgeries, the colostomy, the ureterostomy, and the pain. Certainly it is a miracle that she is doing so well.

I cannot give a "why" explanation as to why she is still living, and sometimes I cannot give "why" explanations when other patients die. I will say though that God measures us not whether we live or die, but how we respond in life and death.          (TOP)

   

College Freshmen Gain Weight

I think it is routine for a college student to put on l0-l5 lbs the first year in school. Christy* was no exception. She had put off coming in for an office visit all summer. She had been a tennis player in high school but stopped that physical activity and so today when I saw her she not only had problems of weight gain but also lack of energy - something I see frequently in other patients. We talked quite a while trying to discover any basis for her problems. I found out she continued to be inactive and now had a decreased  self esteem because of the weight gain. As expected my physical examination was normal and I ordered some basic lab work including a thyroid test, all of which I expect to be normal. She promised to exercise regularly and see me back in 3 weeks. I think that will help but my suspicion is she has a mild depression.            (TOP)

   

Viagra

Mrs. Wiley* stood in my nursing station beaming from ear to ear. Not being able to figure out what she was there for, I asked her what I could do to help her. She exclaimed, "I am so happy!". Sorry, I still did not have a clue. "What about?" I questioned further. "About the Viagra"(link or ad), she  replied. Now I was really confused because I couldn’t remember prescribing Viagra for her.

Mrs. Wiley finally went on to explain that I had given her husband some samples of Viagra recently and they as husband and wife were finally able to   have intercourse, something they had not been able to enjoy for many years, even after trying many other options. That’s why she was so happy. I chuckled to myself at my initial puzzlement, but in the end I too was beaming at being able to help my patients. Mrs. Wiley thanked me many times and I sent her away with a prescription and a few more samples of Viagra.        (TOP)

   

Vacation Day

Today was a vacation day - a day with the family. We ventured to Cedar Point(Link) along with a neighbor family. We all had a great time, even though only my 8 year old daughter and I could test some of the roller coasters because of the 48 inch height restriction.

While waiting in line my analytical mind often strayed to issues of safety and health. I observed the operations of the rides and the way the staff treated people - all seemed excellent. I observed how parents, including myself, parented their children - what a tough job but with great rewards. I checked for healthy lifestyles - not a very good place to demonstrate healthy food choices but the number of people smoking does seem to be down. Thank goodness.           (TOP)

   

A blind man and his gastritis

Not only is family practice about taking care of patients and their illnesses, it is also learning to know the patients as people.

Elroy Yoder* is a semi-retired businessman who came to the office today for a follow up visit for hypertension. You would never know this unassuming 70 year old struck blind by glaucoma is a multimillionaire.

His visit today is fairly routine and as he guides himself out of the exam room with his red-tipped white cane in hand, I thought back to a year ago when he nearly died of blood loss because he could not see the blood he was passing in bowels. It was not until he passed out on the floor of the bathroom and his wife found him in a pool of blood that he was brought to the hospital. His hemoglobin  (blood count) was significantly decreased at 6 grams. Fortunately his situation stabilized quickly with a couple of units of transfused blood and treatment for his bleeding gastritis caused by bacteria, Helicobacter Pylori ( H. Pylori).

As a footnote about H. Pylori. I am truly amazed as I enter my l9th year in private practice that there continues to be milestone advances in medicine. H.Pylori, only this decade was discovered to be a major cause of gastritis and stomach ulcers and in most cases it can be cured by taking a combination of antibiotics just as it was in Mr. Yoder’s case. (Link to Abbott Labs)

Anyway, I am glad that Mr. Yoder was cured and now continues to enjoy ahealthy life. His wife has been alerted to watching for any future episodes ofbleeding, and I think I have finally convinced a fairly stubborn gentlemanabout the benefits of taking his blood pressure medicines.            (TOP)

   

Death of a patient

I was awakened this morning by a 6:30 a.m. phone call from one of my officenurses who asked if I had seen the morning paper. Obviously I hadn’t. She said that Mr. Evans* had died in an auto accident on the way home from my office yesterday. I was shocked!

It is never easy having one of my patients die. I still couldn’t stop going over and over in my mind what I might have done differently yesterday when I saw him in the office even though eye witnesses to the accident told the police that Mr. Evans had pulled out in front of traffic. Only 2 months ago he had successfully undergone cardiac bypass surgery replacement of his aortic heart valve and a carotid endarterectomy. He also had diabetes although he didn’t take his diabetic medicines faithfully. I had checked him over quite thoroughly yesterday and even recommended that he be hospitalized because his glucose level was quite elevated. He convinced me to let him go home after an extra shot of insulin and a promise from him that he would take his medicines faithfully. I thought he would be okay since his examination was normal and he had no signs of infection or ketoacidosis. I also made him promise to check his glucose level frequently and call me in the morning to report his condition. Maybe I should have called him wife to drive him home. We all second guess ourselves. I don’t think I would have handled his medical situation any differently, but I just with there was something I could have done.

I called Mrs. Evans this afternoon to extend my sympathy. I think of these conversations as my most difficult job, but something I have to do. It doesn’t seem to get any easier over the years, but it’s good for me and the family. Mrs. Evans explained to me that her husband unfortunately often pulled out inappropriately at stop signs or stop lights. I still wish it hadn’t happened.           (TOP)

   

Whiplash

I think one of the more frustrating problems to deal with, both for me and the patient, is a whiplash injury resulting from an auto accident. Usually the auto accident is not serious, fortunately, nor are the injuries usually serious, but the pain and suffering can persist for quite some time.  Witness Beth Heston* whom I saw today in follow up for the auto accident she sustained 2 months ago.

Ironically, Beth who is a teacher, was hit by one of her students as they were both going to and coming from graduation parties. There was no alcohol involved and all were wearing seat belts. Beth was banged up pretty good but was too tough to go to the emergency room. (Like many persons, when they are in a minor accident they might not be seen by a physician that day, but will come to my office a few days after the accident when they discover how stiff they are). Beth even had a fracture of her sternum ( breast bone) as I discovered when I performed X-rays. 

At this point, 2 months from the accident, Beth is recovering from the bumps and bruises and even the fractured sternum feels better, but she still is frustrated by neck pain and stiffness and headaches. I have tried the usual regimens of heat, exercise, medication and physical therapy. They all provide some relief but not complete relief. I express my sympathy for her situation as best as I can, however have also recommended patience, a positive attitude and a realistic outlook because probably the best cure for problem is time in my experience.  It is hard to take away the frustration and some of these patients will develop a situational depression as a result. Beth though, is not depressed and I hope that she does not become so.           (TOP)

   

Plugged nose

David* has the worst continually plugged nose in my practice. Now that is quite a distinction. While I am totally frustrated at improving my treatment of his condition, he also has got me laughing with his good natured humor.  Today he is wearing a Superman t-shirt.

So, here is this scrawny l7 year old boy with his Superman t-shirt hanging loosely on him, his voice sounding as if he were pinching his nose shut with his fingers, his mother who is on the other side of the room bantering back and forth with the kid, and I’m cracking up with laughter. My curiosity has got the best of me now so I ask him why has had a Superman t-shirt. His mother answers that everyone calls him "Super Dave", so he decided to wear the Superman t-shirt to go with the name. I asked him if he feels that his nose is congested and he answers, "No."

I think maybe I shouldn’t worry about how bad he sounds, but then I think if we improve his congestion he won’t have as many sinus infections.  David has tried just about every allergy, sinus, and asthma medicine. He has been to the dentist, the ENT doctor and even had nose and sinus surgery. He took allergy shots for a while but refused to take them anymore because he didn’t like the needles. When he gets a sinus infection I prescribe antibiotics. I think he has been through all of them too, everything from good old Amoxil to a new one called Trovan (Links). He thinks the Z pack works the best.   Still joking around I see him out of the office today reminding him to take his Vancenase (Link) nose spray regularly, increased his dose of Zyrtec (Link) and added Entex .. I will see him back in 2 weeks. I wonder if he’ll wear his Superman t-shirt.           (TOP)

   

Bug spray inhalation

Yes what they say on the labels of the insect sprays is true. "Don’t use in closed space" or " may be hazardous if inhaled".  

I saw Eleanor*, a 50 year old otherwise intelligent lady, who was brought in by her husband today because he found her passed out. She was awake and walking okay but she kept babbling "I’m sorry", "I’m sorry", and "what time is it?". As the story unfolded, piecing together the husband’s sketchy information and the patient’s limited history, I determined that she had been using at least three different types of chemicals and sprays in the crawl space of their house in order to get rid of spiders. 

I checked Eleanor over thoroughly and found nothing abnormal physically except a large bruise on her leg from where, I learned later, she had fallen down the stairs in her confusion. Initially I was worried that she was having a psychotic break or that she was manifesting the start of a diabetic coma. Her glucose level was normal however. 

Fifteen minutes had passed now and she did not appear to be in serious danger. Her mental status was improving and she was able to give me more details about what happened. I allowed her to go home under the supervision of her husband as long as he called me in one hour to report her condition. She was a fortunate lady. Her husband reported complete resolution of her symptoms.   We all know the danger of chemicals, but we all don’t follow the precautions very well because we don’t believe anything serious will happen to us.            (TOP)

   

Sleep Apnea

John Maple* is one of my successfully treated sleep apnea patients. He now wears the pressurized mask system to sleep at night and he is amazed at how good he feels. He is no longer fatigued all the time. I’m certainly glad he is better because he is a long haul truck driver.

Today after he and I reminded ourselves how had he used to feel and how good (Link to Patel) he was doing now, we checked his blood pressure and talked again on losing weight . He is 5’ 6" and weights 300 lbs.

( I just wonder is societies without so much obesity have a sleep apnea epidemic.)

John has only been able to lose 5 lbs since I started seeing him. I praised his meager efforts of l0 minutes walking per day, and encouraged continued improvement. He states that truck stop food just wasn’t meant to lose weight on. I guess I’d have to agree with that so we decided to emphasize the exercise part of the equation. He left the office smiling.           (TOP)

 

 

Cute little baby

I’ve never had a baby who would smile and smile through all the adversity of visiting a doctor’s office. Little Monica*, who is by now l0 months old, just makes my day when she comes in. No matter if she has an ear infection, bronchitis, or is in for a well baby check and shots, Monica is always happy and smiling.

Monica’s mother is a positive personality which certainly transfers to her baby. But you know what - Monica is adopted, which makes her all the more special and probably explains why this first time mother wants to have her special baby checked frequently for her illnesses. I don’t mind. 

Today Monica was getting over a viral illness. She had a fever ( Link to our fever page) up to l0l deg. yesterday, had vomited some, and was pulling at her right ear. She also was teething according to her mother. My nurse and I picked on Monica today in trying to remove a large chunk of wax from her right ear. Finally we were successful and I could see the ear drum. No ear infection today. Her mother was relieved and Monica smiled through it all.           (TOP)

   

Heart Murmur

Mervin* is now 8 months old, but 2 months ago I didn’t know if he would live this long.Thanks to modern medicine and the pediatric cardiologist, Mervin looks pretty good at his well baby check up today. You see he has the same diagnosis as his brother who died before him - Cardiomyopathy.

After I delivered little Mervin for this Amish couple there was tremendous anxiety when I informed them that this son too had a heart murmur. ( They have one 3 year old son with no apparent heart murmur) His chest X-ray showed no enlargement of the heart and he did well for the first 5 months of life. It was then that he started having feeding problems and slowing his weight gain.One day when I saw him he was extra fussy and breathing fast, so I knew it was time for him to see the cardiologist. Fortunately, Mervin didn’t even need to be hospitalized, but improved quickly on Digitalis and two different diuretics.

At the office today everyone seemed quite pleased, and Mervin is smiling again and is catching up on growth and development like any 8 month old baby. Obviously the parent are still worried about the outcome, but I encouraged them that it seemed Mervin was doing better than his deceased brother did and there was still hope.            (TOP)

 

 

Reese’s Pieces and Sammy Sosa

When I entered the exam room, Diane* was so excited. "I saw it!" she exclaimed. "Saw what?" I answered in puzzlement. "I saw Sammy hit number 62." she said, still excited. Diane and her family were lucky enough to have purchased Cubs tickets before the season started for yesterday’s game when Sammy Sosa hit his 62nd home run. I was caught up in the excitement of her story too, even though I’m not necessarily a die hard Cubs fan.

We finally got around to the discussing her medical problem. That is, while watching the game she had what sounds like an allergic reaction to eating a Reese’s Pieces candy. The whole side of her face , mouth and tongue swelled up. Fortunately, she had some Benadryl  in her purse, because she was concerned about dust at the ballpark setting off her allergies. She was able to take the Benadryl and get immediate relief from this potentially life threatening reaction.

Diane’s exam today was normal so we discussed this possible allergic food reaction, most likely either the peanut or the chocolate.  My office nurse drew blood to test allergies to the most common allergic foods. I then gave Diane strict orders to avoid eating chocolate or peanuts. I also gave her a prescription for Claritan to take regularly for her hay fever and told her to keep Benadryl close.           (TOP)

 

 

HEPATITIS C

Mr. and Mrs. Bocc were in the room for a follow-up consultation; on Mr. Bocc's lab tests, which had showed elevated liver enzymes and a positive Hepatitis C antibody. Both were nervous. Except for being a heavy beer drinker, Mr. Bocc thought he was a fairly healthy 41-year-old when he came in for a routine physical 2 months ago at the urging of his wife. At that first visit, I had discovered hypertension (high blood pressure). Because of the hypertension, I ordered lab work, which showed elevated liver enzymes. I was able to persuade him to stop his beer drinking so that we could see if the liver abnormalities would improve. When the liver tests remained abnormal, I ordered a hepatitis panel. Even though Mr. Bocc was not at high risk for hepatitis, the results showed a positive Hepatitis C antibody. Today, I discussed information about Hepatitis C and possible treatments. There were many intelligent questions from Mr. and Mrs. Bocc. You see knowledge and treatment of Hepatitis C are only 10 years old, and the treatment options are only now starting to improve. One interesting discovery that we made today was that Mr. Bocc's mother had died at the young age of 46 of what the family thought was ovarian cancer. (But there was no autopsy done.) I'll bet you $100 his mother actually died of liver failure secondary to Hepatitis C.

More information on Hepatits C 
(TOP)

 

 

Poems of a Patient

When you've taken care of people long enough to develop a bond, they share things with you. With permission, I am sharing two poems by Lisa Buckmaster (her real name).


Who are you?
Do you hurt and knock people down to fulfill your needs
Do you use people to do your dirty deeds
Are you the only one you see Is your ego bigger than me
Do you always take instead of give
Would you take a life or help it live
Thinking of only yourself you'll surely not succeed
Years of sorrow, loneliness and pain you would lead
If you give instead of take
A happy heart and life you'll make
If you help someone up instead of knocking them down
You will always have someone to love around


What's Inside
Open you Heart and Mind, Feel and See
What God gives to you and me

Most people walk through life only seeing through their eyes
They can't feel others sorrow, pain heartaches and sighs.

God made us all the same
No matter what color, size, wealth, age or name
No matter who you are, you are no better than any other
You need to Love, Support and Respect Each other
Everyone can be Good or Bad
It's what you can say and do that makes God and you Happy or Sad

(TOP)

 

 

Two Lacerations for the Price of One

The weirdest thing happened this morning. Being a Saturday morning, we schedule some routine checks and leave time for the acute visits and "call ins". Fortunately then, we had plenty of time to take care of what happened to one of my patient families.

Mrs. Miller cut her finger with a kitchen knife while preparing a meal. While I was suturing the laceration, Mr. Miller, who was sitting next to his wife, giving her moral support, receives a call on his cellular phone. He announces to us all that their 8-year-old son had just cut his finger on a cat food can lid. The timing was perfect, because as I was finishing the suture repair on his wife, Mr. Miller was able to drive home and bring his son back to the office.

Yes indeed, the 8-year old boy also needed stitches. I sutured his finger laceration without any problem to complete family affair of lacerations. Mother and son healed well, and 10 days later I was able to remove the sutures for both of them.

(TOP)

 

 

Acromegaly

With snow on the ground, my thoughts often turn toward skiing-one of my extra-curricular passions. This week, a wonderful medical story, one that comes from my ski travels, popped into my head.
It was 8 or 9 years ago when our pastor and his wife asked my wife and I if we wanted to go skiing with them to Squaw Valley where the pastor's brother from San Francisco had a condo. Always willing to consider a quick skiing jaunt, my wife and I left our 1 year old daughter in the capable hands of the grandparents and set off for Reno the weekend before Christmas. I had never been to Lake Tahoe skiing and was looking forward to it. Unfortunately, the skiing was terrible since California was in the middle of a drought; but the medical diagnosis I made for my pastor's brother still to this day makes me quite proud.
To be a family physician, one has to have a huge breadth of knowledge that often times is impossible to achieve. Sometimes though, the family physician is the first doctor to see the patient for a particular problem, and the first to make the diagnosis of a disease.
The pastor's brother met us at the Reno Airport and it was during our introduction and hand shakes that I immediately recognized features of a rare condition called acromegaly, which I remembered from medical school studies. Even though he was a short man, he had a large beefy hand and coarse facial features, including prominent forehead ridges over his eyes. I didn't know anything about this man, but he appeared healthy and had no problem skiing. Over the next few days, I kept replaying the signs of acromegaly over and over again, trying to decide what to do or say. I reminded myself not to say anything to our gracious host, fearing that I must be mistaken in my diagnosis.
Finally on the plane ride home, as I sat next to our pastor, and relived the wonderful time we had, I gently raised the issue of his brother's physical characteristics. He agreed that there had been some changes in his brother and so I further explained my reasoning. To make a long story short, the ending is happy. Upon arriving home, our pastor immediately telephoned his brother, who ended up having microsurgery on his pituitary gland to remove the tumor causing his acromegaly. In gratitude he sent my daughter a beautiful framed poster of a Santa Cruz boardwalk carousel horse which still hangs in her room as a continual reminder of our encounter.

(TOP)

 

 

New Screen for Heart Disease

I always try to emphasize to my patients that test results are only one part of making a diagnosis. Still though, I do marvel at the technological advances that medical science is able to continue to achieve. We must always be careful how we use these inventions because often the technology far precedes the science of how best to use it, and not use it. With that caution, one piece of recent technology that we are still defining how best to use is the ultrafast electron beam CT scan of the heart, whose purpose is to find calcium in the coronary arteries. Today, I discussed the results of an ultrafast CT scan with my patient, and my own dentist, Dr. Crown. Even though he runs regularly and is very conscientious about his low cholesterol diet, his cholesterol level has gradually increased, he has a family history of heart attacks on his mother's side, and to top it all off, he just had his 50th birthday. So I ordered an electron beam CT scan at LIFETEST. I was happy to report to Dr. Crown that his calcium score was 0. What a relief for him. This completely negative result tells him and me that the chance of him having coronary artery disease is very low. Of course I told him that he should continue his running and low cholesterol diet. As an aside, I have a medical colleague who is a miraculous testimony to the ultrafast electron beam CT heart scan. He is a healthy 50-year-old physician who had this test done as a screening test and found it to be decidedly abnormal. To make a long story short, he had coronary artery bypass surgery, which undoubtedly saved his life. Not all ultrafast heart scans result in immediate lifesaving testimonials. Most surely will help patients over the long term. Hopefully they lead to patients improving their lifestyles, stopping smoking, lowering their cholesterol, and therefore avoiding the necessity of coronary bypass surgery. To find out more about this new technology or to find the center nearest you, go to www.imatron-web.com.

(TOP)

 

 

A Bat and a Broken Hand

Donna was quite embarrassed today when she told me how she injured her hand. Last night she discovered a bat flying around her house. (Bats are relatively harmless, except for rare cases of rabies, and do a lot of good by eating insects.) Panicking like most people do when they see a bat, she began swinging various objects at the bat, including a folding gate and broom. Sometime during the course of this struggle she injured her right hand. She had trouble sleeping that night because of the pain, and so she came to my office. On examination she had a slightly swollen hand and a worrisome clicking with movement of the bone. The xray, which I ordered, sure enough showed a fracture of the 4th metacarpal (one of the bones in the middle of the hand). I was certainly surprised at the mechanism of injury, but it makes for a good story. Through it all Donna maintained a sense of humor about her bad luck. I formed a fiberglass splint, which provided immediate comfort, and will see her back in one week.

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Hives from the Tragedy

The tragic events of September 11, 2001 have definitely brought great sadness. The whole world is affected, everyone in different ways. Witness my patient Mrs. Vail, who, even though she had no direct connection to the tragedy, was so distraught that she presented to my office with hives all over her body. She is scheduled to fly to a vacation destination in a few days and certainly wanted to be in better shape physically and mentally. She and I spent time exchanging feelings and talking about the tragic events. Hopefully the cortisone shot and a prescription for anxiety medication will provide enough improvement that she will be able to enjoy her vacation.

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An Admirable Stoke Patient

I admire my patient "Ace" Akers very much for his determination and perseverance since he has had his stoke. "Ace", as his friends call him, was and is an avid golfer. Unfortunately, 2 years ago he had a stroke, which paralyzed his left side. Since then he has undergone carotid endarterectomies, to clean out the cholesterol plaque obstructions in the major arteries of his neck; he has survived a subdural hematoma, related to the blood thinners he was on to prevent another stroke; and he has had to retire from work. All at the young age of 60. Regardless of all these obstacles, he has drastically changed his lifestyle and his eating habits, and has worked very hard to maintain and even improve his health. He is taking his medicine faithfully, so that, along with his diet, he has been able to normalize his cholesterol and lipids. Yet, the most amazing thing he has done has been to purchase and then faithfully work out on his Bowflex fitness machine. (hot link bowflex to www.bowflex.com) By doing this he has been able to strengthen the stroke-affected left side of his body so that he can continue to play golf. He's not down to his previous handicap, but what counts is the effort he is making to improve himself and his health.

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Hyponatremia in an Elderly Lady

I visited Susie Powers in the hospital today before going to church. At least today she was able to talk, and was alert and oriented to where she was. Yesterday, she was comatose after having had seizures secondary to hyponatremia. Her sodium level was extremely low (110 mEq). The normal level in the body is 140 mEq. Susie has a few other medical problems at age 78, including severe hypertension, and generalized atherosclerosis, which has resulted in a previous heart attack and an angioplasty procedure to open up her clogged renal arteries. Despite these problems, she had been living alone. Susie's case has also been difficult to manage because she is fearful of medicines, and seems to find herself quite sensitive to most anything that the cardiologist or I prescribe for her. Her previous attempts at using diuretics have resulted in mild hyponatremia. Sometimes being the patient's Family Physician involves being a detective in order to track down the problem. In Susie's case, the interesting chain of events that lead to this current hospitalization played out as follows. Three days ago, after an overnight stay in the hospital for chest pain the cardiologist sent the patient home on 2 new medicines, one was Isordil (a type of nitroglycerin) and Hydrodiuril (a diuretic). The first day home Susie was feeling a little lightheaded. She attributed this to the Isordil, so she started drinking great quantities of water in order to "flush the Isordil out of her system". In most persons, a problem would not result, but unfortunately, in Susie's case, the combination of the 2 doses of diuretic and the extremely excessive amount of water lead to her severe hyponatremia and seizures. I'm glad Susie is doing well. Hopefully her sodium level will be normal enough so that she can be discharged from the hospital. For most patients, I have to strongly encouraged enough water drinking, but in Susie's case, I will limit her to no more than 1 gallon of water a day.

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Family Charts

Being a family physician means taking care of the whole family. I truly do love this, and that is why I believe in maintaining all the family charts in one folder. It still is sort of funny though, when patients like Betty* come in with their own list of problems as well as separate lists of problems in the rest of their family. During Betty's visit I was able to take care of her newly diagnosed hypothyroidism, her hypertension, and her sinusitis. In addition I was able to hear a follow up report on her 2 year old son Riley's* bronchitis and schedule a 24 hour holter monitor for her husband who was still having palpitations. Amazing isn't it, and all for only one office fee. Praise the Lord for the efficiency of family physicians.

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Klinefelter's Syndrome

Today I performed a DOT ( Department of Transportation) physical exam on a 6'2", 237 lb truck driver who except for the fact that he can't shave and his voice is high, looks like a man. If I obtained a chromosome test on him though, he would technically be a she. You see, he has Klinefelter's Syndrome which means he has two female chromosomes and one male chromosome. Therefore he has testes which do not function and do not make the male hormone testosterone. That is why he does not shave and that is why his voice is high pitched. Needless to say he and his wife have no children. His exam today other than these features is completely normal and I am able to certify his DOT physical for another two years. Fortunately, I have finally been able to talk him into taking testosterone which he reports to me is helping him feel quite a bit better. The testosterone now comes in body patch form ( Alza). I have also been trying to talk this man and his wife into using donor insemination as a means to have their own child. Needless to say, Klinefelter's Syndrome is very rare and presents me as the family physician with a " text book medical case". I want to emphasize that my primary purpose in treating this patient is to take care of him as a person and not his rare case.

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Depression

I spent extra time today with Rita*. She told me she "just can't handle it any more". She is 45 years old, divorced, and worrying terribly about her 22 year old daughter who just moved out on her own and refuses to take care of her own diabetes. Rita works very hard 7 days a week running her own cleaning business in addition to waitressing on the side. She feels as if she should be able to "control" her daughter's diabetes and the inability to do this seems to be the basis of her depression. She had to go home from work today because she was crying. In addition she has no energy, she can't sleep very well, and she has lost 5 lbs. Fortunately she denies wanting to harm herself or anyone else. Being quite upset, anxious, and agitated, I could not provide much insight today, only a lot of listening and support. I am hopeful that by starting Prozac and a short course of Xanax, she will feel improved enough in 2 weeks, when I see her back, that we will be able to delve into some of her issues a little more. I did suggest seeing a counselor in addition to me but she declined for the time being. She did promise to call me if she felt worse or became suicidal.

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Osteoporosis

Mr. Eggert Caloss was complaining about severe pain in his upper back. He walked along the office hallway very slowly, hunched over his cane. Except for mild hypertension, he is in good health. In fact, one would never guess he is 90 years old. His mind is sharp, and he still drives a car. He didn't remember falling or injuring his back. I suspected, because of the nature of his symptom, his age, his slender stature, and the hunched-over appearance of his spine, that he unfortunately had a spontaneous compression fracture of his upper spine as a result of underlying osteoporosis (thin bones). The xray of his spine agreed with my clinical diagnosis of compression fracture. The rest of the visit he and I spent discussing the pros and cons of treating osteoporosis, as well as the medications used in the treatment. Since he is still active and of sound mind, we elected to try the new once a week Fosamax. *This true patient encounter is not an endorsement for the drug Fosamax by Merck. If you want to learn more about osteoporosis click on:
www.nof.org
www.fosamax.com

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