Diary from a Week in Practice



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Am Fam Physician. 1998 Jun 1;57(11):2669-2670.

Monday

A youth baseball coach recently shared with TBS a technique he uses for treating minor ankle sprains in young athletes. He previously found that applying ice bags to these small players was often cumbersome and, therefore, the athletes were not cooperative. Also, he was aware of the danger of leaving ice on the injury for a prolonged period, but he found it hard to time the application during the game. He now takes three-inch bandage wraps, soaks them in water and then loosely rolls them back up and puts them in the freezer. During the game, the “frozen” wraps are kept in a cooler. If a player sustains a sprain, he or she is immediately wrapped with the bandage—providing both compression and cooling that last about 20 minutes.

Tuesday

There's a lot to be said for “timing” in family practice. Today, a patient returned with his most unfavorite problem—balanitis. Together he and JRH have searched for a nonsurgical approach to the treatment of the underlying associated problem: phimosis. Today's recurrence happened just two months after his last recurrence and 25 years after his first incidence of balanitis. Cephalexin was prescribed for the previous incident, but this time he told JRH that gentamicin ointment was helping, even as he pleaded for reassurance that nothing more would be required. Yet, neither he nor JRH believed that to be the case. Reluctantly, he was now ready for JRH to perform dorsal slit surgery one day soon. It took another recurrence of balanitis to make him ready for this office procedure. It took “timing” to make sure he was psychologically ready as well as physically ready.

Wednesday

A previously distraught patient arrived at the office all smiles. It was the first time in three years that she had been free of her severe aphthous ulcers. JSR had seen her for the first time three weeks ago as a new patient, in tears because of relentless suffering caused by severely inflamed canker sores on her buccal, lingual and gingival surfaces. A short course of prednisone and oral rinses were initially prescribed. Also, JSR had recalled reading in the Prescriber's Letter about a study that showed an 81 percent reduction in the occurrence of canker sores with the use of toothpaste that did not contain sodium lauryl sulfate (SLS). JSR was only aware of one toothpaste formulation that is SLS-free. He suggested that the patient try it. Today, she credits this SLS-free toothpaste with her recent oral health. When given the alternative of toothpaste substitutes such as baking soda (also free of SLS), which would be much cheaper, she adamantly refused to make the switch. JSR hopes this simple change will keep her from returning to the painful state she was in during her initial examination.

Thursday

Compliance with a medication regimen can be difficult, especially when the patient does not feel sick but must take antihypertensive medications. One of CAG's patients devised an interesting solution to his problem of forgetting to take his hydrochlorothiazide by enlisting the help of his three children—ages six, nine and 11. He offered to give 25 cents to the first child who reminded him to take his pill each morning. Since that time, he has not missed a single dose. Now, his only problem is keeping enough quarters in the house! CAG suggested that he change his strategy and offer all of the children a quarter on any day that he fails to remember to take his medicine. WLL used a similar strategy to remember to wear his seat belt. When his children were young, they would both get a quarter if mom or dad was not buckled up when the car was started. Although they lost a lot of quarters that way, their kids helped teach them to be compliant with a healthy habit.

Friday

Did you know that you may be able to improve functional outcomes in patients with hemiplegic stroke by prescribing fluoxetine and physical therapy? One study from Italy published in the May 1996 issue of Stroke (p. 1211) showed that the fluoxetine/physical therapy approach was superior to either physical therapy alone or physical therapy used in combination with a tricyclic antidepressant (Ludiomil in the study). Although the study was small (only 46 patients), the difference in treatment outcomes was significant. After three months, the patients in all three groups showed improvement in their walking and performance of daily activities; however, the group receiving fluoxetine (20 mg daily) had by far the best response. In addition, the number of patients receiving fluoxetine who experienced good outcomes was significantly higher than the number in either of the other groups. In the past, WLL has only used antidepressants after a cerebrovascular accident for dealing with the mood disorders that often accompany a major disability. However, he may now have another treatment option with the selective serotonin reuptake inhibitors.

Saturday/Sunday

Unfortunately, even when on vacation, we do not get to forget that we are physicians. SEF has been going through a rather difficult experience with her mother. Six months ago, she was diagnosed with metastatic adenocarcinoma of unknown primary and was given only six months to live. Despite the odds, she decided to fight the cancer and underwent a rather aggressive course of chemotherapy that affected her bone marrow too much and caused other side effects (e.g., nausea, vomiting, weight loss, hair loss). She changed to a less aggressive form of chemotherapy and was feeling much better. SEF and her family returned to the Midwest for a visit and were happy to find her doing well. Her original presenting problem (a compression fracture of her lumbar vertebrae) was finally healing, and she was tolerating her chemotherapy well. Throughout the visit, though, SEF had to review all of the blood work and tests and discovered that her tumor marker was still increasing. Her oncologist was consulting his colleagues to explore new avenues of treatment. SEF and her family are certainly grateful for the reprieve that she has already received and are hopeful that it continues.

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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