Off Course

“Elsa Bruegger has seemed a little unsteady in the morning lately”, the charge nurse told me at my boarding home rounds two weeks ago. “Her morning blood sugars have been a little low. Do you think we should cut back on her insulin?”

“Sounds reasonable”, I answered. Let me look at her chart.” Elsa is on valproic acid as a mood stabilizer and sees her psychiatrist every three months. Her drug level was just about due to be checked, so I ordered a fresh set of labwork and decreased the dose of her long-acting insulin.

We continued our stand-up rounds, going through dozens of reports and issues on the many residents who were not scheduled to be seen that day. I then did two admissions and saw a couple of patients for their scheduled visits.

The next time I went to the boarding home, I checked on the results of Elsa’s blood tests and reviewed her blood sugar log. Everything was well within range.

“How is she doing?” I asked.

“The girls still find her a little off balance now and then, especially in the morning.”

“Tell me again how long this has been going on…”

“Probably a month or a month and a half.”

“Any urinary symptoms? Anything else going on?” I flipped through the chart again. My eyes fell on some insurance paperwork. There, two months ago was a rejection letter for a Prior Authorization request for a brand-name drug Elsa had been taking for urinary frequency.

“Well, she’s incontinent sometimes, but that’s not new, and she has no dysuria. But we did have to switch her to that generic drug for her urine two months ago”, the charge nurse answered.

“Well, if she’s still incontinent, let’s stop the pill, because that could cause her to be dizzy”, I said, “so let me write the order for that.”

Yesterday I stopped in at the boarding home again to speak with the family of one of my patients. While standing at the nurses’ station I happened to see Elsa coming down the hall with her walker.

With every step Elsa took, she and the walker veered more and more to the right until she came to a stop with the right front wheel against the wall. She then lifted the walker toward the middle of the corridor and started walking again. Eight or ten steps later, she was back against the wall. She stopped and lifted the aluminum walker toward the middle of the corridor again and repeated the same procedure.

“Look”, I whispered to the nurse.

We watched as Elsa repeated her zigzag veer and correction half a dozen times until she came to the TV room half way down the hall. After she settled into her chair, I asked to borrow her walker. She seemed bemused.

I picked it up and spun the wheels, which rolled without any apparent resistance. I checked the length of its four legs and the tightness of all its bolts.

“Let me just take it for a spin”, I said. Elsa grinned as I started walking.

The moment I put even the slightest pressure over the front wheels, the walker started turning towards my right. I hit the wall just as fast as Elsa had. She giggled. The nurse sighed with her hands on her hips.

“Let’s get you a new walker!” I said as I returned the defective unit to Elsa. She smiled and nodded.

I didn’t know whether to feel good or bad about my diagnosis. It had taken more than two weeks, but really only took a minute to arrive at once I got on the right course.

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.



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