Diary from a Week in Practice



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Am Fam Physician. 1998 Sep 1;58(3):687-689.

Monday

Because of the old adage that everything comes in threes, SEF is waiting for the third case of a rather unusual condition. SEF delivered a baby boy who had inherited his father's trait of polydactyl of the fingers. SEF had not seen a case since medical school and had never had the opportunity to treat it before. This infant had a simple form with soft tissue masses connected to the pinkies by soft tissue pedicles. SEF performed a simple tie and excision before the baby was discharged home. Later, at another hospital in which our group takes nursery call, SEF discovered a second baby, this time a girl, with the same problem. Again, only the simple form of the deformity was present, but the extra pinkies were a little more developed, with fingernails, although the pedicles were just soft tissue. Feeling comfortable with her new skill, SEF performed the simple excision, and mother and baby were on their way. SEF wondered when the third case would present itself.

Tuesday

Success sometimes comes when it is least expected. Today, an elementary school teacher arrived at the office complaining of severe pain in his elbow. Immediately, JRH thought of tennis elbow, but the examination failed to substantiate that diagnosis. The patient could not fully extend his elbow, lacking as much as 20 to 30 degrees, and he could not fully flex the elbow without eliciting pain. The next step was an x-ray. When the patient returned from having the x-ray, he was smiling. Some sort of magic must have occurred, for he was pain-free and moving his arm fully for the first time in quite awhile. JRH viewed the x-ray and found it to be normal. The examination was repeated, and it too was normal. In the final analysis, it seemed that this patient, after many years of athletic participation, was suffering from a “loose body” in the elbow joint—an unattached piece of articular cartilage that floated suddenly into his joint space, making life miserable for him. Just as suddenly, our x-ray technician, while positioning the patient for the proper views, allowed the loose body to float free again. This time, however, the loose body passed into a more favorable area of the joint space and out of harm's way. Of course, it's good to be good at what one does (i.e., proper diagnosis and appropriate manipulation under traction would have helped), but sometimes it helps to be lucky. Success is always a friend, no matter what guise it comes under.

Wednesday

TBS saw a 55-year-old man who is a truck driver with chronic symptoms of carpal tunnel syndrome. He has received numerous anti-inflammatory drugs, injections, etc., but has decided not to consider surgery. Today, he reported that he has found something that significantly helps. When the pain occurs at night, waking him from sleep, he immediately gets up and applies an ice pack in the form of a plastic insert from his cooler, which holds soft drinks. The plastic insert is rounded and fits nicely around his arm. He wraps this up for 20 minutes and has significant improvement of his symptoms. He is usually able to go back to sleep without difficulty.

Thursday

WLL was walking down the hall and talking with a mom whose four-year-old had just been seen for an ear infection. The child had already gone out to play with the toys in the children's waiting area. The mom remarked how much she had appreciated a book on parenting skills that WLL had “prescribed” for her and her husband to purchase. He had also “assigned” the parents some homework—to read to each other one half of a chapter each night before going to bed. They had agreed to do this. She said that they had so enjoyed the time together and learned so many applicable principles that they were reading another book on communication skills as parents. Interested in what they had learned, WLL asked the mom which principle had meant the most to her. She thought for a second, then remarked with a mischievous grin, “I think the most important thing I learned about parenting was that thousands of years ago, God gave us the most substantial advice that any mom can have.” The now-curious, but somewhat suspicious family physician asked, “What might that be?” With a twinkle in her eye, she remarked with much confidence and pseudobaritone, “Thou shall not kill!”

Friday

Forged prescriptions are a problem that has plagued physicians for years. Today, one of our local pharmacists telephoned JRH not to say that someone was trying to get drugs illegally but to say that they had discovered a prescription slip that was left under the copier at their store. It seems that a 16-year-old patient had asked for and received an “out-of-school” excuse while being seen in our office earlier in the day for a cold. We routinely validate doctor visits on a prescription slip, but we had no idea until today how valuable this commodity was. Apparently, the patient had driven himself to our office and was then able to go to the pharmacy to have his prescription filled. Meanwhile, by making three or four copies of the doctor's excuse, he could spend the rest of the day with his buddies, who would now have their own vouchers. This is certainly a step up from another observed forgery: the school note that was written in crayon by “JRH.”

Saturday/Sunday

JSR recently went on a medical mission to Lima, Peru. A team of five physicians, several nurses, medical students and support staff had a tremendous experience providing much needed medical care in a maximum security prison in one of the poorest areas of the country. Built to house 1,500 inmates, the facility had over 6,500 prisoners and enormous problems with sanitation, proper nutrition and untreated medical illness. Extensive fungal and bacterial infections were the most common problems, along with a host of gastrointestinal conditions, inadequately treated acquired immunodeficiency syndrome and undiagnosed active tuberculosis. One memorable case involved a 25-year-old man with an indwelling suprapubic catheter who had developed a large scrotal abscess. Intervention in a sterile operating suite was out of the question, so JSR and a surgeon from Houston operated right in the prison cell. With local anesthesia and the best sterile conditions they could obtain, they drained and packed the abscess. Arrangements were made to see the patient daily, and by the end of the week, JSR was delighted to see that this procedure, followed by antibiotic therapy, had worked. The patient expressed his appreciation through tearful eyes. This grateful spirit was often demonstrated to the medical team who came to share their medicine from their minds and hands, and their faith from their hearts.

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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