Monday
The week's first patient is TR, a 30-year-old fellow who is new to the practice. He greets me clutching a book entitled You May Have ADD. He sits before me calmly reading from a list of symptoms that include distractibility and difficulty finishing projects at work. I have become somewhat jaded about the diagnosis of adult ADD, finding many individuals instead who search for a pharmacologic cure to poor work habits. This particular man caught my attention with his remark that he would often “be up writing poetry all night long, but [his] thoughts were so flowing that [he] couldn't finish one without starting another.” I asked him to fill out the mood disorder questionnaire developed by Dr. Robert Hirschfeld that was published in an earlier edition of the Companion. I was astonished to find that he answered every question positively except that of family history—he was adopted. I broached with him the idea that he may instead be suffering from bipolar disorder. To my surprise, he stated relief. Turns out he didn't take much stock in adult ADD, either.
Tuesday
HF is a middle-aged woman who returns today with a complaint of headache. Our practice has incorporated an “urgent care” service for “after-hours” emergencies, and she has apparently been trying to circumvent our procedure for managing a prescription for butalbital. Since my practice has 14 family physicians, a number of drug seekers have tried the strategy of calling after hours for refills of narcotics. To her dismay, each after-hours request for refills has been documented in her chart. A call to a chain pharmacy revealed that she had also been filling prescriptions from other practices as well. It can be so difficult to shepherd patients like these, especially when they express no desire to get better. I wrote her a prescription for nadolol for prophylactic therapy. I wonder if I will see her again.
Wednesday
Speaking of headaches, PA has been fighting tension headaches in addition to a number of other small medical problems. We had gone round and round for 3 to 4 months trying various therapies, with no success. Finally, even though he denied any depressive or anxious symptoms, I suggested to PA that we try an SSRI to treat the headaches. At 3-week follow-up today, his headaches have vanished. He also reports feeling “less stressed out.” He asked me if that meant that he was depressed. I suggested that he not get tied up in labels and continue the medication for at least 1 year.
Thursday
PD is an elderly gentleman who has been coming to me with somatic complaints on a monthly basis for about 3 years. Recently, he had been convinced he had a “virus” from a terrorist that was derived from malaria because he could predict that he would be ill every 3 weeks with fever and chills and yellowed eyeballs. He would come to see me only when his symptoms abated because he “felt too sick to come to the doctor.” (This statement always leaves me dumbfounded, by the way.) Results of thorough examination and blood tests had repeatedly been normal. Last week, he finally developed the strength to come in when he was symptomatic. By gosh, he had a fever of 102°F and bilirubin in his urine. I admitted him to the hospital that day and found studies consistent with cholestasis. Apparently, he developed a stricture of his common bile duct after his cholecystectomy that formed a ball valve that closed briefly about every 3 weeks. An ERCP cured his symptoms, which just goes to show that even wacky patients can have wacky illnesses. Today, in follow-up, he flashed me an “I told you so” grin. I reminded him that his general surgeon was not a terrorist, though I'm told that the OR staff might disagree.
Friday
TB is a 45-year-old fellow whom I had seen about 9 months ago when his parents brought him in for severe depression. He had not left the bed in 1 week. I started him on treatment with an antidepressant, and he had a nice smooth response as expected at 3 weeks. Indeed, he continued to improve at 2-month follow-up. However, he did not return for follow-up 2 months later. Today, his wife brings him in for help. Apparently he has mortgaged the house and started not 1, but 4 independent business ventures. All but 1 failed, and they have lost their health insurance. He sleeps 2 hours nightly. He also has been confronted about a pair of extramarital dalliances. I started him on therapy with olanzapine, and as he left I wondered: how many other treated depression patients lost to follow-up may have switched to mania and just think they feel so good that they don't need to come in for a recheck? From now on, I'm prescribing only 4 months of refills at a time.
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.