Diary from a Week in Practice



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Am Fam Physician. 1998 May 15;57(10):2358-2363.

Monday

Today, JSR was working with a fourth-year medical student who was rotating through our practice. One of the first patients they saw was a four-year-old girl accompanied by her mother. Both were new to our practice. A father of two young girls himself, JSR quickly recognized the fear of the unknown on the little girl's face. So, the first few minutes of this visit were spent “playing dolls” on the floor with the child. Soon she was quite disarmed and began relating to her new physician the names of her brothers, her dog and her best friends at preschool. The rest of the examination was not only easy but also fun. After the visit, the medical student commented about the remarkable change in the girl's disposition. “That was amazing, I wish we could get more of this practical training in medical school.” Sounds like a good argument for mandatory rotations in family medicine.

Tuesday

A 68-year-old man presented to SEF with hemorrhoids. He had tried over-the-counter preparations as well as prescription medications without much relief. SEF decided that internal hemorrhoids were causing his problems. He was scheduled for rubber-band ligation, which is a simple office procedure. This method involves placing a rubber band around an internal hemorrhoid. The ensnared tissue then undergoes necrosis and sloughs. Patient tolerance is much better if only one set of hemorrhoids is treated at a time. Hopefully, this simple and quick procedure will improve his problem without the need for surgery.

Wednesday

Being an avid University of Tennessee football fan, CAG has taken a lot of ribbing from the many Florida Gator fans in the area. His first obstetric patient in Florida was accompanied at each visit by her husband, whose love of the Gators was matched only by his excitement at the approaching delivery of their first child. He never missed the opportunity to wear Gator blue and orange to every prenatal visit. At the time of delivery, his wife was able to labor naturally as she had hoped, with her husband coaching her the entire way. A baby girl was delivered, the cord was clamped, and bandage scissors were readied for the new dad's big moment. However, by then the dad had seen enough, and he was slumped in a nearby chair—having taken on a pasty, white appearance. Not wanting his new friend to miss this opportunity, CAG threatened that a Tennessee Volunteer was about to cut the cord. Hearing this, the new dad staggered to his feet and cut the cord himself. He then provided a weak yet smug smile and settled back into his chair. The new dad and CAG are hoping to attend the next Tennessee–Florida football game together. CAG hopes that the new dad will be weak and pasty again—at the end of the game.

Thursday

TBS has found the recent explosion of information on the Internet to be a double-edged sword. Today, she saw a young infant (whom she had delivered) for a two-month well-child check-up visit. The parents, both college-educated, brought numerous pages of articles pulled from Web sites concerning the dangers of childhood immunizations. TBS found these parents to be difficult and spent over 30 minutes trying to educate them about the importance of immunization. After she had provided them with some information on immunizations from the Centers for Disease Control and Prevention, TBS agreed to postpone the immunizations at this visit. At this point, TBS still struggles with the decision of whether to continue to care for this infant if the parents make the decision not to immunize their child.

Friday

WLL was intrigued by a report on reducing the pain of injection for adults and children. The study was published in the Journal of Pain Symptom Management (1996;12:52). The investigators state that “their study is the first to evaluate the use of simple pressure applied to a site prior to an intramuscular injection as a method of decreasing pain.” They applied a consistent force with the tip of a finger for 10 seconds before injection with a standard 22-gauge, one-half inch needle. The patients in this three-month study were randomized to a group receiving pressure before injection and a group receiving no pressure before injection. After injection, the patients were instructed to rate their pain. The patients who had received the pressure had significantly lower pain scores. The investigators speculated that this finding could be useful in children—although only adults were included in the study.

Saturday/Sunday

This weekend produced another chapter in the annals of our ever-shrinking world. A concerned mother, trying not to sound panicky, called JRH just before lunch. Her daughter, while studying abroad, had developed acute abdominal pain, which was thought to be appendicitis. Not knowing anything about the medical system in the Netherlands, she first asked for JRH's advice about the symptoms and then about the need for and timing of surgery. Surgery was contemplated for later that evening or early the next day. Should she drop everything to try to be there or sit tight and hope that all would be okay? Furnished with the telephone number of the hospital, JRH was able to talk directly with the daughter, his patient, and to reassure her that surgery was indeed the right thing to do. Later in the day, the surgeon called to discuss the case and share his concerns with JRH before he performed the surgery. The next day, JRH received another telephone call from the surgeon, this time to reveal the results of the laparotomy and to update him on the condition of the patient. A quick telephone call to her mother was priceless reassurance and a quick answer to the mother's hasty prayers. Not only did those telephone calls make the world a lot smaller, but they also made the bonds that link us all together stronger.

This is one in a series by Walter L. Larimore, M.D., John R. Hartman, M.D., Theresa B. Shupe, M.D., Stephanie E. Frisbie, M.D., J. Scott Ries, M.D., and Chad A. Griffin, M.D., six family physicians in private practice in Kissimmee, Fla.


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