Diary from a Week in Practice



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Am Fam Physician. 1998 Sep 15;58(4):869-870.

Monday

Today, SEF saw a 48-year-old woman who had been suffering from depression for many years. She had failed therapy with several antidepressant medications and had almost resigned herself to a life with “the black monster” of depression. Three weeks ago, SEF started her on a new antidepressant. Today her first words were, “So this is what normal feels like!” Physicians must always keep in mind that there's always hope, even in cases that seem hopeless. It just requires effort, wisdom and creativity to find it. However, the satisfaction that can be obtained from touching someone's life is certainly worth the effort. Indeed, the physician without hope to dispense is no real physician.

Tuesday

In past Diary entries, we have mentioned some strange uses for nitroglycerin patches or ointment. One we have not yet shared is the use of nitroglycerin ointment for the treatment of chronic anal fissures. WLL first heard about this treatment when he started practice in the early 1980s in the mountains of North Carolina. Anecdotally, it seemed to work and relieve pain (within minutes of application) and, thus, reduce or obviate the need for surgery. WLL has the pharmacist compound a 0.2 percent ointment 50:50 with white petroleum jelly or Aquaphor. A “dab” the size of a pea is then applied into the rectum two to four times a day for up to eight weeks. Potential side effects could be headache or dizziness, but we've not had any side effects reported.

Wednesday

“To know diabetes is to know medicine,” is a maxim we all learned. But as JRH found out, to know diabetes is to know behavioral science. One of JRH's 12-year-old patients recently arrived at the ER with severe headache and a blood glucose level over 400 mg per dL, a concentrated hematocrit and ketones in her urine. During the intensive follow-up that this diagnosis of diabetic ketoacidosis mandates, JRH made sure that all of the concepts were understood, proper practice in glucose meter testing and insulin injection was occurring and, most importantly, that the patient was accepting her diagnosis. He ended each visit with “Is there anything else I can tell you?”“Sure,” was the answer today,“when can I get my ears pierced?” JRH knew that this was not a medical question. It seems that when she was in the ER, she bargained with Mom to cooperate with the staff (while they struggled to stabilize her) if she could have her ears pierced. However, Dad didn't know this, and at today's visit showed resistance at this request. Sensing the confusion, JRH motioned for Dad to follow him outside the room. JRH mentioned how many newly diagnosed patients with diabetes wince from this twist of fate, and he raised these questions: “Would having her ears pierced help her to feel good about herself again?” “Would it be important for her to have something else to talk about with her friends?” After giving encouragement, JRH left the details of the request to the parents.

Thursday

The many hazards of smoking tobacco are not always well known to our patients. For this reason, we spend extra effort counseling our patients about the dangers of smoking. Today, JSR saw a woman he had counseled about smoking cessation, and for whom he had prescribed a nicotine nasal spray as part of a multimodality treatment plan. She had returned with a tip for her doctor. Unable to tolerate the irritating pressure of the spray, she had found another way to use it. A cotton-tipped swab was coated with the nicotine spray, then held into one nostril while lightly applying lateral pressure to the nostril using the other index finger. This method was much less irritating, yet she still received the benefit of alternative nicotine supplementation when needed. JSR will remember this alternative route of administration and hopes it proves successful for his patient.

Friday

An interesting aspect of practicing in central Florida is the cultural diversity. Today, CAG saw a family who had recently moved from Germany and wished to become established with a family physician. Although the mom only speaks German, she was accompanied by her teenage daughters who speak fluent English but have no medical training. The mom brought her old medical records with her—the only problem was that they were in German. While reviewing her laboratory results, CAG learned that German is a Latin-based language. The patient's leukocyten, hemaglobin, hamatokrit, bluttzucker (blood glucose), kreatinin, natrium and kalium were all normal. However, her harnsaure was 9.3 mg per dL (normal being 2.3 to 6.1 mg per dL), and this stumped both the doctor and the daughters. One of the daughters pointed out that the word literally means “urine acid,” and when the mom affirmed a history of gout, it was decided that the word means uric acid. CAG was thankful that her harn-stoff (“urine stuff”) was normal at 28 mg per dL, assuming that was her blood urea nitrogen. The laboratory profile results were a year old, so a new laboratory profile was ordered—in English.

Saturday/Sunday

This Sunday was the fifth birthday of JSR's oldest daughter, Grace. As JSR, Grace and Lauren (JSR's two-year-old daughter) were driving to church, in came a page from the labor and delivery unit informing JSR of another impending “birthday.” Not only was the patient in labor, but she was also completely dilated and crowning. Because JSR's wife, Jodi, was already at church preparing to sing, there was no alternative but for the girls to accompany dad to the hospital for the delivery. They waited obediently at the nursing station coloring on progress notes while JSR delivered a healthy baby girl. Afterward, JSR obtained the new mother's permission to show his own girls what all of the commotion was about. The awe was apparent in Grace's face, who excitedly sang a chorus of “Happy Birthday to You” to this new child who shared her same birth date.

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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