Diary from a Week in Practice



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Am Fam Physician. 1998 Oct 1;58(5):1108-1111.

Monday

When it rains in Florida, there is grass to be cut, hedges to be trimmed and plenty of other yard work. Today, a young woman came to the office sporting a unique attraction that she had acquired while working in her garden: a grid-like pattern from an insect bite on her forearm that produced pain from her shoulder to her wrist. There was slight erythema, but no swelling. JRH immediately recognized this distinctive mark as being from the puss caterpillar (Megalopyge opercularis). Just as quickly he called for the antidote: the best adhesive tape in the office. By applying the tape right over the sting and removing it, he was able to pull out the tiny spines or hairs. The pain immediately subsided and, after several hours, was completely gone. The marks, however, would stay for a few days so that show-and-tell sessions could be bestowed on anyone interested.

Tuesday

Recently, an eight-year-old girl was in the office to see WLL for a follow-up visit. She had some difficult medical problems that were finally waning. Today would be her last visit, hopefully, for some time. On leaving the examination room, she gave WLL a big hug and then said, “Hey, Dr. Walt, know what my favorite two words are in your office?”“No, what?” queried the physician. “Well, they are ‘bye-bye,’” she enthusiastically responded.

Wednesday

TBS received a call from a pediatric neurosurgeon who reported that the brainstem biopsy on a young patient of TBS's showed a high-grade glioma. The child, whom TBS had delivered three years ago, had appeared healthy and developed normally until approximately six months earlier when he first developed some typical-looking molluscum contagiosum lesions. TBS reassured the parents that these were benign and would probably go away on their own. However, one month ago, Dad brought the child into the office for treatment, because the lesions seemed to be enlarging and spreading over the child's chest, abdomen and upper arms. On examination, the child was gaining weight and appeared to be doing well. No abnormalities were apparent other than the skin changes. The lesions were treated with cryotherapy, and they healed quite well. Then, the child developed a fever and typical cold symptoms, but he was noted to have some slurred speech. An office visit was scheduled immediately. The child had slurred speech, and a facial droop on the right side of his face was noted. He was sent for a CT scan that initially showed a lesion thought to be an AV malformation. The child was admitted for care by a neurologist. TBS has kept in close contact with the parents during the hospitalization and shares in their grief over this unfortunate diagnosis and poor prognosis.

Thursday

Recently, JSR saw a 19-year-old college student who was concerned about a lump that suddenly appeared in his groin. This freshman basketball player was noticeably relieved to find out that the “lump” was in fact a femoral hernia, not cancer. However, a cloud of apprehension again passed over his face when he considered the prospect of surgery in a hospital he had never visited, by a surgeon he had never met. JSR offered assurance and explained that he would be there for the surgery. This morning, when JSR arrived in the preop area, he was greeted with a big smile from his patient, obviously relieved at the sight of a familiar face. That smile itself made this early morning trip worthwhile. We find that many family physicians are no longer assisting at surgery for their patients. Although we can understand the economics of the decision, we can't understand the reasoning. In our experience, rare are the patients who, whenever possible, don't want their family physician by their side during an admission or a surgical procedure. As much as possible, we try to provide this service to our patients.

Friday

Does it ever surprise you that your patients are as considerate of you as you are of them? JRH saw one of WLL's patients today. Actually, she came in for treatment of an upper respiratory infection, but JRH noticed a tiny scar at the base of her neck and asked if she had had a tracheostomy for some reason. “Oh no,” she said, “that's from the surgery Dr. Walt did.” JRH replied that it really wasn't noticeable, and to that she agreed. She went on to explain that because of the keloid and subsequent steroid injection, the skin had atrophied and became hypopigmented. Then, however, a plastic surgeon very astutely tattooed this area to match her normal skin tones. “You are right,” she agreed, “no one ever says anything, but still I keep it covered up when I come to the office, because it makes Dr. Walt feel bad.”

Saturday/Sunday

CAG has been happy to get through certain first procedures during his initial year of practice. The first delivery, the first sick newborn resuscitation and the first circumcision at each hospital are examples of procedures that help a young family physician earn the confidence of the nurses and staff. Early this week, CAG was in the emergency department about to perform his first lumbar puncture at that particular hospital. The patient was a five-year-old boy with a high fever, neck stiffness, mild lethargy and an elevated white blood cell count, and the only possible source was a purulent nasal discharge. Various emergency department staff members introduced themselves and offered assistance. In addition, the patient's mother and father were friends from CAG's church, and the pastor was there to let them know that the “telephone prayer chain” had been “activated” to inform other members of the church. CAG found that the silent prayer he says before each procedure had a bit more urgency than usual. After conscious sedation was performed with intravenous midazolam, the tap was done with a return of clear fluid. All of the studies on the fluid were normal, and the patient was sent home on oral antibiotics. Thankful that the procedure went well, CAG was even more pleased to see his son playing with the five-year-old at a picnic this weekend.

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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