Usually in this column, I recount the events of a week in practice. This month, however, I had an interesting morning that I will recount with you here.
7:00 a.m.
My practice handles our inpatient workload by rotating call and hospital duties a week at a time. This Friday morning heralds the end of my latest tour of duty, and it starts with FE, a 70-year-old gentleman I admitted 2 nights ago. FE has a long history of bipolar disorder, which has been significantly complicated: among the highlights are 45 admissions for electroconvulsive therapy by his psychiatrist. He was doing fairly well until a month ago, when he presumably suffered a stroke while visiting family in another city. Over the last few weeks, he had steadily deteriorated overall with slurred speech, unsteady gait, and tremor punctuated by auditory hallucinations. I was called by the family from an outlying hospital's emergency room, the family pleading for me to accept him at our facility. I gladly did so, of course being completely unaware of what was awaiting me in this 2:00 a.m. transfer admission.
To make the long story short, his CT scan actually showed no evidence of cerebrovascular accident, but he was lithium toxic. Psychiatry consultation did not arrive until yesterday after 5:00 p.m., after I had stopped his lithium and continued his venlafaxine, but added olanzapine. Now that his tremor is improved, his gait steady, and his demeanor less combative (though he is still disoriented to name and place), his psychiatrist has graciously offered to take him onto his service. Figures—just when I'm about to turn over the service!
9:30
I start office hours late because I was rounding. My first patient is a child, accompanied by his mother, in to discuss school difficulties. Fortunately, this mother is a teacher herself and has already done much of the legwork for me: learning disability screening and evaluation by a psychologist, who identified attention deficit without hyperactivity. Conservative measures having failed, we elected to start the young man on extended-release methylphenidate with regular objective reports from the psychologist. Wow—if only all of these kids were so straightforward!
10:30
After a gaggle of allergy sufferers and sore throats, I had a follow-up visit with TR. He is a college student who had been frustrated at his inability to finish design projects because he was repeatedly scrapping his work due to perceived imperfections. Accompanying these complaints were symptoms of insomnia, poor self-esteem, and “grumpiness.” A month ago, we began paroxetine. TR cut his dose to 10 mg after he experienced prolonged nausea with 20 mg. His girlfriend (who accompanies him today) says that besides now being able to finish his projects, he has quit mumbling—she can finally understand what he's saying! It amazes me how sometimes such a small dose of medication can have such a profound effect.
10:40
PT is a 34-year-old woman with a history of irritable bowel syndrome who presents today with a nebulous constellation of symptoms: fatigue, myalgias, and nausea beginning about 5 weeks ago. With a simple positive urine pregnancy test, her symptoms magically disappeared. Whew! I dodged a bullet with that one.
11:20
A few routine hypertension and diabetes checks followed that bullet I just dodged. A 52-year-old woman presented as a new patient to “discuss headaches.” When she moved to the area a year ago, the stress of the move began a series of tension headaches that sadly deteriorated into narcotic abuse and addiction. Her last doctor expelled her from his practice a couple of weeks ago. She stopped the hydrocodone cold turkey. Why is she here today? “Doctor, I'm a nervous wreck—my husband is threatening to leave me, and I refuse to let myself get so bad that I am admitted into a mental hospital like my mother and my sisters. Can you help me?” I'll keep you posted. I'm just glad that in 20 minutes I get to check out the inpatient list and start a long weekend.
Footnotes
Editor's note: Dr. Wolff is a board-certified family physician in private practice in Cornelius, North Carolina. He finished his family practice residency in 1997. He has graciously consented to share stories from the trenches of primary care. While his practice diary is taken from actual patient encounters, the reader should be aware that some medication references may represent off-label uses. We at the Companion are certain that these vignettes will inform, entertain, challenge, and stimulate our readers in their effort to address behavioral issues in the everyday practice of medicine.