The big picture is critical, but so are the details

When I read a case report in a journal or whenever a patient comes in to see me about a new symptom, all my senses are tuned in, and I know there is a diagnosis to be made.

But on regular clinic days with “routine” follow ups, I find myself not being as tuned in as I would like to be. I know my patients well; we are all growing older together. They change gradually over the years, just as I do. A few times last year, I found myself surprised and ashamed that someone else made a new diagnosis in a patient I saw on a regular basis.

Stella’s world shrank since her husband died a couple of years ago. She never learned to drive, so without Roy to take her places, she became virtually housebound. Her spinal stenosis went from moderate to severe, and she couldn’t take care of her home in the way she had always prided herself. She admitted she was depressed, but didn’t want to take an antidepressant and wouldn’t hear of seeing a counselor. Her whole demeanor had changed. She never smiled, and she was less animated in all her facial expressions and body movements.

It was her neurosurgeon who saw it. He had nothing to offer for her spinal stenosis, but he suggested she talk to me about the possibility of her having Parkinson’s Disease.

I saw her again the other day. On Sinemet, she looks almost like her old self again.

Fred’s health declined for years. After going through both an operation for a fractured hip and emergency bowel surgery for perforated diverticulitis last year, he never recovered his old level of functioning. He came back from rehab the second time using a walker. Two months later, he was still using it. His affect was flat, and he couldn’t keep track of his medications the way he had a year earlier. His enlarged prostate seemed to bother him more and more, but he moved too slowly to always make it to the bathroom.

It was my partner, Dr. Wilford Brown, who made the observation that Fred had dementia, gait disturbance and urinary incontinence — the classic triad of normal pressure hydrocephalus. Fred is going in to have a shunt placed to drain his ventricles at the end of this month.

Our challenge is, in the hustle and bustle of everyday practice, to look beyond the issue at hand often enough to “see the big picture” in each patient and at the same time keep a constant vigil for small changes that could mean a new disease is evolving.

“A Country Doctor” is a family physician who blogs at A Country Doctor Writes:.

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