Sometimes in family medicine there are days when I feel like I just can’t do anything right for a patient; sometimes a patient’s psychosocial problems seem so overwhelming that I question what the hell I am doing; sometimes a patient haunts my dreams; and sometimes, my instincts are bang-on and I pat myself on the back for a job well done.
I have three stories to tell today .
First. An elderly man came in to my office last week feeling pretty crappy. His words, not mine. He is a diabetic with several complications. Four years ago, while I was on my first maternity leave, he was admitted to hospital in urosepsis (uro·sep·sis/ (u″ro-sep´sis) a term used imprecisely to denote infection ranging from urinary tract infection to generalized sepsis which may result from such infection.urosep´tic). The gentleman said he was feeling sick and urinating a lot more than usual and feared he was heading down the same path he did 4 years ago. He really didn’t want to go to the hospital again and pleaded with me not to send him. Upon reviewing the notes from 4 years ago, he had been sick for at least 5 days when he presented. This time, however, he had only been feeling unwell for about 12 hours. Clinically, he looked pale. He was afebrile, mildly tachypneic (fast breathing rate) and tachycardic (fast heart rate) with a stable blood pressure. His urinalysis in the office showed red blood cells, nitrates and white blood cells. These were the tell-tale signs that he indeed had another bladder infection. The question though, in my mind, was whether or not he needed to be assessed in the ER. Normally I wouldn’t think twice about it, but as I mentioned at the start, this man was elderly (mid 70s), had an underlying condition (diabetes), and had a previous history of urosepsis, so it was a reasonable thing to ponder. On the other hand, he was hemodynamically stable and had a doting wife to look after him. It was totally appropriate to allow him to go home with a prescription for antibiotics that he would start immediately. He and his wife promised that if he continued to decline, they would not hesitate to call 911 or get a friend to take them to the hospital. The following morning, I called the patient myself to see how he was. The patient answered the phone in his usual chipper voice and announced that he felt much better since starting the antibiotics and is grateful not to have gone to the hospital.
Second. A young woman, early 30s, who is 30 weeks pregnant. She comes in because she has been getting progressively short of breath all week. The doctors in the audience are probably already thinking what I initially thought – this pregnant patient has a VTE/PE (venous thromboembolism/pulmonary embolism), until proven otherwise. Rather than panic, I get a history from this lady which is pretty benign. She’s been gradually feeling more tired and short of breath over the past week. She’s had no cold or flu symptoms, denies any chest pain or cough. Baby is active and the pregnancy has been smooth sailing. Her examination is totally normal. No swelling in her feet or ankles. Normal heart and breathing rate, normal blood pressure. Normal fetal heart tones. If someone had a PE you’d expect they’d be tachypneic and tachycardic. I’ve seen people with PEs – they look uncomfortable. This young woman looked fine. Hmm. I probe a little further and she admits that she is under a lot of stress. I suggested that she take a few days off, get some rest, put her feet up and start slowing down. I advised her that if she felt her symptoms worsening or suddenly felt like she couldn’t breath she had to go straight to the hospital. Then, this morning, I read a problem-based self learning module about VTE/PE in pregnancy. My heart started racing…. OMG, did I totally miss this in my patient? Why didn’t I check her calves for tenderness (often the first sign of a blood clot)?? I asked my secretary to call her to see how she was. She old me that the patient was feeling much better after taking my advice and appreciated the phone call checking up on her. Phew!
And finally, I have a patient who is in his early 60s with very badly controlled type 2 diabetes. He is new to my practice, and we are just starting to get his diabetes under control. He has been under a tremendous amount of stress recently, and also has a history of heartburn. He came to see me complaining of chest pain but only when he lay down at nighttime. As soon as he gets up and walks around, it’s better. He never gets pain with exercise or other physical exertion. Pretty straightforward, right? Treat the reflux, chest pain will go away. Yet, something just didn’t sit right with me. He had seen a cardiologist about 3 years ago who gave him a clean bill of health. I referred him back to the cardiologist for a work-up. In the meantime, I prescribed nitroglycerin spray. I spoke with him on the phone a few days later. The spray helped immensely — it would if the pain was cardiac, as well as esophageal. He sees the cardiologist about 10 days later. The cardiologist’s report comes back — the exercise stress test was inconclusive, the chest pain was “probably” related to his GERD, but for completeness sake, the patient went on to have a nuclear scan. The nuclear scan revealed a massive defect in one area of the heart. It was partially reversible with rest. But it was big. The patient had an angiogram 1 week later. 90% blockage of his LAD (left anterior descending artery ) and the artery was ballooned the same day. I spoke with his daughter today. She thanked me for saving his life.
Yep, I’m patting myself on the back today for a job well done. Why? Because in this job, you have to take the victories, however small, and savour them when the come. Tomorrow, I might have to tell someone they have cancer.