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A Family Physician’s Day in Review
February 4, 2005
Once again, I was late at the office, yet another busy Monday after I had done rounds at the hospital. I recall Mrs. H., a 77-year-old white female, whom I saw a week ago because of severe lumbar pain. She had fallen in her tub and a lumbar x-ray was negative. She complained of severe lumbosacral pain now radiating to the right sacroiliac joint and down the leg. We had to admit her to control her pain. I ordered an MRI, but had to cancel it. She had a piece of metal in her body and certainly was a contraindication for the test.
Obviously, a CT scan would be the next best, so I ordered that too. And an Ortho (for lack of a neurosurgeon in our hospital system) and Pain Management consult to help with the case to top it off. Then you have to cover symptoms and in her case a round-the-clock coverage with Percocet and perhaps NSAID or Cox-2. Don’t forget physical therapy as well.
What was racing on my mind was how long will this patient be in the hospital, will her pain subside, does she need transfer, what about subsequent care - perhaps some short term rehab or home therapy. She’s one of my good ones though and she was comfortable and thankful for her care.
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Next to room 405. I had this readmitted, unassigned patient, a 28-year-old white male, complaining of abdominal pain with some intractable nausea and vomiting. We treated him vigorously with some PPI (proton-pump inhibitors) and some Reglan and scheduled him for EGD as an outpatient. He was well for a week and not really sure if he was on the meds he was discharged with. He has Medicare but no Medicaid, which means he has medical coverage but no prescription coverage. So compliance to meds would be an issue.
I spoke to Gastroenterology, time now 9:45AM and I was supposed to be in the office by 9AM. I pleaded (to the GI specialist) that this guy needs a scope ASAP, this is his readmission and though no anemia or overt signs of bleeding, I needed some answers. I had also done a CT scan of his abdomen and pelvis. Physicals did not show any guarding nor masses, at most there was anticipation and delayed response to palpation.
As expected, the tests were negative. Does this guy have gastroparesis? Or some kind of mass in his abdomen? Gut instinct says he’s putting me on for whatever gains he has in mind. Objectively, we need to rule out a few things. You run through the differentials – acute abdomen? Nope? Gastritis, ulcer, pancreatitis, polyps, gastroparesis, reflux disease, gallstone, mass? Maybe? Normally this won’t even be an admission, but this was a recurrence. Defensive medicine? I guess. Time to go to the office. I actually saw four patients in-hospital before I came to the office by 10 AM.
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Mrs. L came in today with a smiley face. That’s unusual she is often miserable and nothing is working right for her all the time. But today was different. She had bonded with one of my new medical assistants and made her life much easier knowing a friend was out there to support her. She tells me she stopped Celebrex because of all the news she heard on TV. She had also decided to stop her Aleve (Naproxen) which she says helps her arthritis tremendously (not sure why she is on both anyway). She was afraid this was going to cause her a heart attack. Or so, the news would say. I looked at her and say, “and you still smoke?” She pondered for a while somehow embarrassed with a small smirk in her face. She’s 67. Now I know how to make millions of people stop smoking cigarettes. Put vioxx or celebrex in them. Sick! Huh?
Sometimes, I’ve had it with all the liability issues that is hitting the drug industry. FDA- approved drugs are dropping like flies and to think most times these drugs are used inappropriately or are they? TV news is now the best source of medical info, throw away New England Journal or JAMA. What about those consumer ads with the likes of Viagra and Cialis, and oh, don’t forget the purple pill. Mrs. L left with one piece of advise – quit smoking.
The rest of the morning was spent with seeing patients having colds, cough, allergies. The bread and butter of family practice. Lunch was free! We had a drug-rep lunch.
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Ms. Q came in with her mom, she thinks she might be diabetic. Her blood sugars were at the 400 range. She managed to drop it down to 216 by today. She appeared obese and the mother is diabetic.
Seeing your blood sugar go up can be a life changing experience. I know I did. Last March 2004 I had the classic, polyuria, polydipsia, and water craving spell. My goodness, glucose in the urine too. Spot check sugar of 256. I could only counsel from the heart. Drop anything sweet or refined. Start getting fit. Life will never be the same again. We become insulin resistant way before we develop the symptoms. Underneath, the insulin rises, we store more fat. To a certain point, we can only do so much. Insulin is rendered ineffective and then we start breaking down fat. Acidosis ensues, we piss a lot. We get thirsty and try to replenish the on-going dehyration. At this time, the blood sugar rises to uncontrollable levels.
It took 3 months of daily activity. First walking, then running. Then building the muscles. We don’t totally get to where we used to be, however. Early on, the use of thiazolidones (TZDs – Actos and Avandia) are probably standard of care. Add Metformin to the bat. It is not unusual to start on Insulin sometimes to get the levels down quicker. Diet still works and so does activity and there is no reason why we could not. Having time for activity and changing our lifestyle is the key ingredient to healing diabetes.
The visit ended with a positive note. I started her on Avandamet (combination pill). Get a hemoglobin A1C, lipid profile, do fasting and post-prandial (2 hours post meal) blood sugar for confirmation and documentation. I also advised on getting more physically active and go for diabetic education. Ms Q is only 23.
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I had 9 more patients that day. One perhaps with Benign prostatic hypertrophy. The other with anxiety symptoms.
By the time the day was over, it was time for me to work out at the gym. I was a bit worn out. I did only cardio today. I jog for 20 minutes and did abdominals. I still have time to rent some movies for the night. Tomorrow’s another day. Have I made a difference in one’s life today? Perhaps I have. We all have been set up to do what we do best. If you feel it that way, it will come to you. It is not easy to be a doctor in the States. Still, it pays off and you feel good at the end of day.
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All views expressed on this column and any other by-lined articles on this site are the authors' own and do not necessarily reflect the views of the organization or its members.
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