Monday
Hysteria. Mass hysteria. A slow news weekend prompted leading stories about a local influenza outbreak. Today, my office had standing room only in the waiting room as we fielded not only tens of patients with flu-like symptoms but 210 individuals who received the flu vaccine. Of course, back in September I couldn't persuade half those folks to get immunized if I had paid them.
Don't let anyone tell you that the media can't shape public opinion.
Tuesday
For several months I've been in agonizing negotiation with a 75-year-old woman regarding her use of clonazepam. AB came to me taking 2 mg, 4 times daily. Yes, you read that right, and getting her to cut back to 1 mg, 3 times daily, has been a Herculean task. So you can imagine my disappointment when the emergency room called and told me that she had fallen and suffered a Colles fracture. The emergency physician also relayed this tidbit: she was instructed by the patient to tell me that AB's fall had nothing to do with her medication.
I'll take that under advisement.
Wednesday
RE is a new patient here today for a “check me out, doc” visit. He is a 36-year-old alcoholic who has just left his third inpatient detoxification, where he was finally diagnosed with bipolar disorder. Now taking valproate, he says that he “never knew he could feel this way.” His new found mental peace has led him to want to “start fresh,” which includes screening for “every STD known to man.” As the visit went on, I could see him becoming increasingly at ease and smiling more and more. He finished the visit by saying, “Doc, I know it was the shrink who got me on mental level and I know that all we did today was talk. But I can't tell you how much better I feel now that I've been honest with a doctor.” I'm glad I could help. Now I hope he stays on the wagon.
Thursday
TL is a 35-year-old woman who is in today to follow-up on her treatment for posttraumatic stress disorder with paroxetine. To summarize her life story, she was born to a mother who used heroin and an alcoholic father. At 16, she married a fellow who suffered from bipolar disorder, and then she gave birth to a daughter at 17. Her then-husband was abusive to her and eventually incarcerated due to violent behavior toward others. She took that opportunity at 21 to return to school (eventually becoming an accountant), marry a supportive and loving husband, and begin exploring colleges with her daughter. Her concerns today are twofold: the recent parole of her ex-husband has induced a bout of insomnia, and though she says she feels “one thousand times” better than when we started medication 5 years ago, she still feels “flat.” I increased her dose of medication and suggested that she revisit her pastoral counselor, but her case had me thinking how easy it is to become complacent when patients appear to be improving. We don't tolerate half-treated diabetes or half-treated hypertension; why should we accept less with mood disorders?
Friday
GY, a 17-year-old male, is here with his mom for a follow-up. A month ago, they came in for him to be evaluated for attention-deficit/hyperactivity disorder as recommended by his school counselor. Though I was tempted to oblige the parent's request for a stimulant, lengthy discussion indicated that he was primarily suffering from depression. He now appears to be feeling significantly better while taking sertraline. As such, his interest and performance in school have improved. Just as soon as my busy practice starts to erode my attention to detail, a case like this comes along to reinforce that there are no shortcuts to good medical care.
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.