Diary from a Week in Practice
Am Fam Physician. 1998 Oct 15;58(6):1309-1310.
Every physician has his or her own bag of tricks—a collection of remedies, insights or diagnostic aids through which he or she sifts to have just the right approach to each individual patient. Today, JRH was able to use one of these on a patient: a young mother of two who is pregnant with her third child but has a complete placenta previa complicating the gestation. Because she has already had her first bleed, she was ordered to bed rest. So it was that JRH made a very appropriate home obstetric visit, and because our office is Doppler-deficient, he brought out from his bag a 1970s model fetoscope. (Some of our nurses had never seen one of these before.) It worked just fine. The only complaint was from the patient who was disappointed that she couldn't hear her baby's heartbeat.
We've read of similar cases, but this was our first experience with one. WLL cares for a family of four. He delivered both of the children and has wrestled with recurrent URIs in them. Although allergies run rampant in the family, allergy therapy, including allergy shots, didn't seem to forestall the recurrent infections. Cultures of throats and noses were almost always positive for Pneumococcus, Pseudomonas or Acinetobacter bacteria. “This is too weird,” thought WLL more than once. Appropriate antibiotics worked—but only for a few weeks. Sinus and chest x-rays were normal. There were no signs of tuberculosis, anemia or malnutrition. Measures of immunity were normal. Infectious disease and allergy consultants had a number of suggestions that were tried without success. Finally, after battling a particularly difficult URI in one of the children, WLL had a brainstorm. “Do you have any pets?” he asked the mom. “Sure, we've had a dog for years,” she responded. WLL suggested that the dog be cultured. The mom and the veterinarian thought it was nuts—that is, until the dog's throat and nose cultures returned positive for Pneumococcus, Pseudomonas and Acinetobacter. All of the organisms were sensitive to Augmentin. So, all five family members were treated at the same time. After treatment, all five had normal cultures, and all five have been well since then. Indeed, the family physician's role involves the whole family—sometimes even the pets!
While browsing through journals, SEF came across an item that struck a personal note. The news brief, titled “Water Tubing Stirs Safety Concerns” was in the July 1997 issue of The Physician and Sportsmedicine (p. 25). The author discussed water tubing (i.e., pulling a rubber inner tube behind a boat), which seems like a safe and easy sport. However, the same apparent lack of need for water skills that makes the sport seem easy also contributes to an inherent lack of control. The author notes that the U.S. Consumer Product Safety Commission in Bethesda, Md., reported that there were 3,262 water tubing injuries requiring emergency department visits in 1995. Fatalities included 10 drownings and two collisions with other boats. Most accidents seemed to occur when the tube came too close to the shoreline, and the driver misjudged the path of the inner tube. It can strike a submerged object, come loose from the tow rope or even explode. According to the article, following a few simple safety tips can make this a much safer sport: boat drivers should know the shoreline and avoid all shallow areas; two people should be in the boat at all times—a driver and a spotter; the rope and tube should be inspected for frays and defects; and water tubers should always wear a life jacket. Unfortunately, accidents cannot always be avoided—as SEF once discovered: the rope burns between her toes took a long time to heal.
A young woman came in to see TBS for a follow-up visit, and she was ecstatic about her recent positive pregnancy test. She and her husband had been married for five years and had planned about six months earlier to attempt pregnancy. She had come in after the first month disappointed that she had not conceived and was worried that there was something wrong. She had no history of risk factors for infertility and had a history of normal menstrual cycles. TBS reassured her at that visit that this would not yet qualify as infertility and told her that even in normal couples with intercourse exactly at mid-cycle, the chances of conception are only between 25 and 35 percent, at best. TBS reviewed some of the physiology of the normal menstrual cycle and ovulation with the patient, and encouraged her to not be concerned about infertility for at least six to 12 months. The patient reported today that she had finally conceived. Interestingly, she believed that the conception was helped by the two teaspoons of plain over-the-counter guaifenesin syrup that she took every day. A friend had told her that this syrup would thin her cervical mucus and help her to conceive. TBS was not sure that this had truly made a difference.
One of the joys of group practice is the sharing of patients. Not only does it allow each of us to take time off without worry over the care that our patients will receive, but also it allows for variety in our case mix and adds spice to our day. Today, a young mother came in for mastitis, a condition she had suffered through twice before while pumping her breasts for her premature infant, her “miracle baby” (the smaller of a set of twins with twin-to-twin transfusion syndrome). JRH learned that the patient's previously successful remedy had not worked this time, and she was seeking antibiotics. JRH asked her what the first remedy was. “A cooled cabbage leaf,” was her answer. “Really?” JRH responded. “Yes, in fact, my lactation consultant recommends packing both breasts in cabbage leaves for a short period for those who want to stop breast-feeding or who don't begin, in order to prevent engorgement.” And while JRH dutifully wrote out a prescription for antibiotics and advised her to continue breast feeding, he made a mental note to look for future successes with the cabbage leaf treatment.
Recently, we experienced another “first” for the practice—the first wedding! JRH and his wife are finally getting back to normal after the marriage of their daughter. Amid the frantic pace of getting everything ready for the wedding, they were surprised by the generosity of friends and coworkers, who graciously did yard work, ran errands, prepared the church, decorated the house, printed programs and, most of all, rallied around JRH, his wife and the couple, showing them the love and support that we all need to nourish our relationships. As much as receiving all of this support did to make them happy, it was nothing compared with the happiness JRH and his wife felt at seeing their daughter looking so radiant and full of joy. What a great day it was.
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.
Copyright © 1998 by the American Academy of Family Physicians.
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