Friday, December 28, 2007

Mr. J

Mr. J has been a patient of mine since I've been in practice. He's in his 80s, and he's one of my favorites (yes, doctors have favorite patients). For the last 4 years I've seen him monthly, not really because he needs it medically (let's hope the medicare fraud folks aren't reading my blog) but because he lives all by himself in a very physically remote area and no one checks up on him. Some months I think I'm the only person he sees.

He's had the dwindles for about 12 months, which I was hoping weren't going to get real exciting. Unfortunately, the dwindles turned into weakness and weight loss, and not unexpectedly, he was recently found to have metastatic cancer.

Due to my own family crisis, I've not been the point person on much of this, for which I've felt sorry. In fact, I've not physically seen him since he was diagnosed, tho I did speak with him on the phone a couple of times.

I saw him in the office today. We talked about his cancer, and his decision to not pursue any treatment, which I support. I talked to him about hospice care, and though he was reluctant, he agreed to getting established with them. We talked about his fears of pain and loss of independence, and I told him what I planned to do to help avoid those things.

When the visit was over, I asked for a hug. I helped him stand up, and as I hugged him I said, "I'm sorry that this is happening to you." I think I said it as much to Henry, and myself, as I did to him.

"It'll be alright," he answered.

Sunday, December 23, 2007

A last minute Christmas gift

Henry and I came home from the hospital today, his second fever/neutropenia admission. He's still feeling great; it was remarkable how much easier chemo round #2 was compared to the agony of chemo round #1.

His counts are good, which means that we'll be able to play with all of his germ-infested cousins on Christmas day.

Blessings and a healthy new year to all of my readers and blogging buddies.

Thursday, December 20, 2007

11 years of higher education...

...was put to great use yesterday.

30 year old female. Chief complaint: blurry vision.

Dr. Smak: (ever the astute clinician) Tell me about your blurry vision.

Ms. Sharpasatack: I squirted water in my eye in the bath tub last night. I couldn't see anything for like 5 seconds.

Dr. Smak: Uuhhhh....any other time?

Ms. Sharpasatack: It's really been blurry for like the past 2 months, pretty much when I lost my glasses.

Dr. Smak: Uuhhhh....have you seen your eye doctor?

Ms. Sharpasatack: No, I guess I need to.

Dr. Smak: Uuhhhh.....

I think we're done here.

Thursday, December 13, 2007

No one is to blame

You can look at the menu but you just can't eat
You can feel the cushions but you can't have a seat
You can dip your foot in the pool but you can't have a swim
You can feel the punishment but you can't commit the sin

--Howard Jones

This is where life lies right now. In a sick way, it's harder to be at home with Henry feeling so well. We can almost taste normalcy, but we know we can't get it back.

He's still got cancer. He's still got months of chemotherapy in front of him. He's got possible radiation treatment. He's got loads of doctor's appointments, invasive procedures, sedations, MRIs. In the best case scenario, he's looking at developmental delay and some degree of chronic illness.

In the hospital, the goal to work toward is getting home with him feeling well.

Once we're home with him feeling well, I realize this is as good as it gets.

But it's not good enough.

No one, no one, no one ever is to blame.

Sunday, December 9, 2007

Hearts and Minds

Hearts and minds. Thoughts and emotions. Conscious and subconscious.

People use different terms to describe the same thing. I think we all sense that there is a more cognitive, cerebral part of us that directs our actions, as well as an emotional, fuzzy part that directs as well.

For the most part, I'm one of those lucky people who's parts tend to walk in tandem. There's not often a sense of discord, and when there is I can usually resolve things.

Lately, it's been different.

There have been weeks when my mind is operating well. I'm working, juggling my family, my son's illness, and the laundry without breaking a sweat. But there's a deep, underlying sorrow, sadness that I feel with each step, the way the floor feels sticky for days after your daughter spills her apple juice, no matter how many times you wash it.

And then it will flip. I will watch my bald son struggle with his balance as he walks five feet between the couch and a chair, and am overcome with exactly how horrible this is. But my heart is singing at his grins, and his pride at walking without needing to hold someone's hand.

I have always thought that discordance between the heart and mind would be uncomfortable, maybe even the origins of clinical depression. But I find that I don't mind it at all. Perhaps it's a way of protecting myself from getting too low or too high during this stressful time.

Thursday, December 6, 2007

A thorough neurologic exam...

A thorough neurologic exam only delays the MRI.
--my neurosurgical resident when I was a 3rd year medical student

Primary care doctors do a lot of neurologic exams. We should. They are important for the assessment of many complaints. Unfortunately, I find them to be extremely low yield from a diagnostic perspective.

In general, I get all of the information that I need from the patient's history. If someone presents with a history of stroke symptoms, a normal exam does not preclude them from a trip to the ER. True neurologic disease is also generally quite obvious from the history. The diagnosis isn't always obvious, but the decision for additional labs and imaging (as well as a neurologic consult) has been made before my hands touch the patient. Lots of patients present with kooky neuro symptoms, heralded by a "good luck" from my nurse when she hands me the chart. I always know in advance that their exams are going to be normal.

It's true that for most medical complaints, the history yields more than the physical exam. But I've been surprised by virtually every organ system, happening upon something that I really wasn't expecting. Rashes, murmurs, masses, lymph nodes, foreign bodies...but the neuro exam has never surprised me.

So I was so excited this week to find something on a neuro exam! Hypertonicity, clonus, muscle weakness...but then I realized that even with a normal exam this unfortunate young lady would still have warranted an MRI, and her multiple sclerosis would have been discovered that way.

So I will continue to do my neurologic exams, when indicated.

But I'm beginning to think that arrogant resident was right.

Wednesday, December 5, 2007

Eat your Wheaties

It was nice to be back at work for a while. We'll be in the hospital for chemo round #2 for several days now. Looking back on the week spent in my "old life", it was an interesting one. Two patients stick out in my memory.

The first, a mid-60s female who doesn't complain, presented with 5 days of "feeling sick", lying in bed, and having fevers without localizing symptoms.

The second, a late 50s female who can't open her mouth without whining whining whining, had 5 days of "feeling sick", lying in bed, and having low-grade fevers without localizing symptoms.

The first had a pulse of 120, a temp of 100.4, and a BP of 170/100.

The second had a pulse of 76, a temp of 98, and a BP of 140/90.

I sent them both for bloodwork and a chest Xray after a negative physical exam.

The first was admitted to the hospital for 5 days for urosepsis and renal failure (and is doing great back at home now).

The second had stone cold normal labs and called begging for an antibiotic to help with her fatigue.

Ask me if I was surprised.

Tuesday, December 4, 2007

Pass the salt...

A tale of two Sodiums:

Mr. Pabst was back for his 6 month checkup. He now smacks twice as fast as before, feels great, and is drinking "about the same" though he couldn't (or wouldn't) quantify that for me. His last recorded sodium level was 123. I'm guessing we're in the mid-teens now? I wonder if I could get a publication out of this one...Correlation of Repetitive Mouth Movements with Sodium Level in Chronic Hyponatremic Patients Who Refuse All Care Except their Inhalers.

My son, after 1000 cc of GoLytely via NG tube for his constipation, was ferociously thirsty. I have never seen someone so thirsty in my entire life. It was torturous to listen to him beg for water, which I couldn't give him since he vomited immediately when I let him put anything in his mouth. We finally settled on ice chips which limited the speed at which he could drink, so he didn't vomit. I found out in the morning when his labs were back (that were drawn during the thirst) that his sodium was 156. I've never seen one that high except on someone who was alert before. I hope I never see it again.