Monday

"Yes, yes, yes ... yes, yes," the woman chanted in her high-pitched, singsong voice. During rounds, we were checking in on a patient who is truly beloved by the nursing home staff, the residents, and me. Marta has a number of medical problems, including chronic paranoid schizophrenia, for which she has been in and out of mental health facilities most of her adult life. About three years ago, she suffered a stroke that resulted in complete left-sided hemiplegia. The stroke also caused a severe expressive aphasia, which left her able to say only two words. Luckily, she is in good spirits today, nodding and laughing as she repeats her first word, "yes," over and over again. Regrettably, her second word is not suitable for print. I have heard both words many times over the years and can instantly judge her mood depending on which word she chooses. It is remarkable how a patient can communicate her wants and needs with two simple words. One day she will smile and wave from across the room, exclaiming "Yes, yes, yes!" in such a way that makes me feel like I am her best friend. The next day, if she has a problem, or is upset, that unprintable word is repeated with true conviction. What is most endearing to all of us is that despite tremendous disability, Marta shouts out "yes, yes" a lot more often than the other word.

Tuesday

Everybody feels depressed sometimes, but not usually all the time. I thought about this as I reviewed the chart of my next patient, a 45-year-old woman who suffers from dysthymia. She had been on several antidepressants over the years, with varying success, but lately nothing seemed to help. This patient is a successful woman by other measures--she has a good job (which she does not like) and two grown children who are independent and successful. She always complains that her children rarely visit, but with her gloomy disposition, I can understand why. The patient has tried counseling ("no help"), aerobics ("makes my knees hurt"), meditation ("too strange"), and yoga ("can't concentrate"). I am running out of ideas about how to help her. Luckily, today, she is feeling a little better. "I am going on vacation to Las Vegas," she reported, and went on to describe her trip with some enthusiasm. We talked about her chronic insomnia and achy back for a few minutes, and she left the office with a little smile. I did not write a prescription, order a test, or make a single recommendation. Mostly, we just talked. It seems that some people are born with a pessimistic personality. Every time she comes, I feel lucky for having been born with a normal disposition. I wonder if my children would agree with that statement.

Wednesday

"This 68-year-old man is scheduled for hip replacement surgery in two weeks and is here for surgical clearance," the second-year resident explained in a frustrated voice. I nodded sympathetically. It is indeed a challenge to clear an older patient for surgery, especially during a 15-minute appointment. A review of the patient's chart revealed that he is a healthy man whose only medical problem is well-controlled hypertension. The patient does not smoke and exercises four times per week despite significant hip arthritis. "Ask your nurse to get an electrocardiogram," I recommended, "while I pull up an article on the Internet that will help you." I went to the American Academy of Family Physicians Web site (http://www.aafp.org), typed "preoperative evaluation" into the search engine, and had the article I was looking for. After taking a few minutes to review the article, the resident felt confident about clearing the patient for surgery. "My patient has no cardiac history, only minor clinical predictors of cardiac risk, and good functional capacity," he reported. "I can let the surgeon know today that he is ready to go." I could tell the resident was pleased because what initially seemed like an insurmountable problem was easily solved. "Document your recommendations carefully," was my last bit of advice.

Thursday

The idea of starting an 86-year-old woman on warfarin (coumadin) makes me nervous. This active woman is in wonderful health except for new-onset atrial fibrillation. her thyroid function tests, electrolytes, and echocardiogram are normal. Otherwise, the patient has systolic hypertension that is well controlled with a low-dose diuretic. The emergency department physician started diltiazem (cardizem) for rate control and sent her to see me. "I feel fine," the patient insisted, "but I can assure you that I do not want to have a stroke." This woman knows about strokes because she lives with her younger sister who has been wheelchair bound for more than eight years after a severe stroke. With the help of a dedicated caregiver who comes in every morning, they somehow manage to live independently. My patient feels a tremendous responsibility toward her sister, and any sort of disability would be devastating to them. The risk that an 86-year-old hypertensive woman with atrial fibrillation will have a stroke is in the moderate range (about four strokes per 100 patient-years). After discussing the pros and cons, we decide to start anticoagulation on a trial basis. "You need to come in at least once a week until we get the dose regulated," I warned. Now I will worry about her driving across town to see me every week.