Three Patients, Three Diagnoses, and a Pat on the Back - A Week in the Life of a Primary Care Physician

If you’ve read my first three blogs you’ve gleaned that I complain a lot, and I think I do it fairly well... LOL. But this last week was a pretty good one, from my perspective anyway.

A male patient in his 50s came to see me because he left his other PCP, whom he thought was arrogant and just wasn’t helping him. The patient told me that he had very low testosterone and had tried patches but it just didn’t help. He had tried to reach his doctor but couldn’t get through and get any answers, so he came to see me after being recommended by a friend. His testosterone was indeed low, under 100. Further workup revealed he had a pituitary adenoma. I reviewed the case with my favorite endocrinologist, who felt that surgery might be avoided since the patient’s prolactin was only minimally elevated. The endocrinologist said the patient could possibly be treated with cabergoline (Dostinex), a drug I had never heard of in over 33 years of practicing. But then, as far as I could remember, this was the first pituitary adenoma I had diagnosed. The patient was actually quite appreciative of the workup and finally finding out what was wrong. He’ll see the endocrinologist and a neuro-ophthalmologist this week.

Another patient, a 71-year-old female, surprised me with a diagnosis when I wheeled my stool to the end of the exam table and lifted the sheet to do her pap smear. I had never seen this either. Her labia minora had somehow fused together and had covered her clitoris, urethra, and upper part of the vagina. I tried to explain it as well as I could, that with low estrogen levels and lack of “use” (it had been six years), her labia minora had stuck together, leaving an opening approximately 5mm in diameter. She really didn’t have any idea anything was wrong; she had been urinating normally and said it wasn’t spraying all over. To be honest, I was perplexed. She allowed me to photograph the area in order to show her the anatomy. I asked a gynecologist about it and found out the name of the disorder is “vaginal agglutination” and that it may be effectively treated with estrogen cream. Needless to say, she was relieved to find out she might not need surgery.

I also found a systolic murmur in a 40-year-old male who had not had one mentioned before in his chart. Workup revealed a bicuspid valve and mild left ventricular hypertrophy. I discussed the details with him and assured him he could continue his usual activities since he was asymptomatic. I did start him on a low-dose ACE inhibitor as well as a statin for his elevated cholesterol. He had no other questions and even asked me for my doodling of his aortic valve to show his wife. On the way out, I put my hand on his shoulder and reassured him that everything would be okay. He turned back to me and said, “I’m really glad you’re my doctor.”

That made my week.