Monday
HT is a 35-year-old corporate attorney by day and a mother by night. She has been my patient for 3 years, and I have gotten to know her fairly well. Since she remarried last year and adopted a teenaged stepdaughter, I had noticed a significant increase in her frequency of appointments for a number of somatic complaints. At her last appointment, she came for a sore back, but spent most of her time lamenting her relationship with her stepdaughter. While I realize that newly minted teenaged stepchildren may have private personas that are at odds with their public face, I had seen this girl for about 5 years and knew her to be very courteous, considerate, and a good student. After arranging through their church for some counseling to open up communication, I was able to convince HT to take a 3-week trial of an antidepressant. She returns today with a beaming smile that I had not seen for months. Apparently the family merger is now accepted by all the shareholders.
Tuesday
Talk about the family tree—after successfully treating the anxiety disorder of a 24-year-old woman, I have, in the last week, seen her 2 sisters who have asked for the miracle cure that has transformed their “wacked out” sister. The kicker is that both have asked for advice on how to convince their mother to come in for a consultation. (I can't share the colorful phrase they both used to describe her.)
Wednesday
Today in the mail I have received my handheld computer and joined the other physicians in my practice in the information age. I am amazed that now I can have an up-to-date reference of insurance companies' medication formularies, complete with cost data and an application that alerts one to possible drug interactions. Additionally, the hospital where I do the bulk of my admitting installed a service that downloads all my patients' lab work, radiology reports, transcriptions, and active orders while I pour myself a cup of coffee in the doctor's lounge. All that and more at my fingertips! I have always thought that good doctors had a hint of obsession and compulsion about them. Electronics appears to be making that easier for me.
Thursday
JD is in today for her allergies but is very concerned about her husband. BD's depression had significantly improved with medication. He had weathered a layoff surprisingly well last year and responded by trying a new venture in self-employment. All was well until he tried getting health insurance—he was either denied or given exorbitant rates by several companies. After a friend told him it was because he was taking an antidepressant, he dropped his prescription. Now, his wife is telling me he has slipped back to where he was before and is refusing her pleas to come back and see me. She asks me to intervene, but not to tell him that she herself has intervened. The quandary is that he is a healthy guy and may not have another excuse to be in the office for a long time. So, while I scratch my head trying to figure out how to call him in without letting that cat out of the bag, maybe a reader with a bright idea can send in a suggestion via this publication.
Friday
As usual, some excitement rolls in on Friday at about 4 o'clock. JS is a 45-year-old woman who has bipolar disease that is managed by a psychiatrist in the area. She has been hospitalized twice before during manic episodes with psychosis. For the last year, she has been doing fairly well taking a combination of risperidone and sertraline and no other medications at all. Her complaint today is that for the past 2 weeks she has experienced progressive blurred vision, near-syncope, and excessive thirst. Her fingerstick glucose test was unreadable, but there was plenty of glucose in her urine. At the hospital, her serum glucose reading was 525 mg/dL. With sliding-scale insulin and hydration, she quickly recovered and has been quite stable on oral medication since discharge. Of interest is that she has no other risk factors for diabetes—no family history and no pregnancy-associated problems—and she is quite fit otherwise. I suppose that some people are going to become diabetic whether they like it or not. I suppose it's my job to manage those issues whether I like it or not. It's a good thing that that job is fairly straightforward.
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.