Diary from a Week in Practice



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Am Fam Physician. 1998 Nov 1;58(7):1571-1575.

Monday

From time to time, medical students and family practice residents visit our practice. Remembering how removed from reality our rotation experiences were when we were residents, we strive to give these visitors a taste of what life is like “on the outside.” On this particular day, a medical student from the University of Southern Florida was accompanying JRH while he was seeing a young woman with strep throat for whom he prescribed a penicillin shot. As he usually does, JRH asked if anyone else at home was sick. “No, there's only my husband and he has gone off. It's the beginning of deer season, you know.” JRH remarked how ironic it would be if he “shot a dear” before her husband did. Then, quickly sensing that she might not be in the mood for puns, he apologized, explaining that it was the end of the day and humor tends to slip a bit by then. “That's okay,” was her reply, “I only hope your aim is good.”

Tuesday

CAG has found that of the bonds he forms with his patients, the strongest are often with patients for whom he provides maternity care. One such patient had a large pyogenic granuloma that developed on her finger after delivery of her baby. A shave excision was performed with curettage of the base of the lesion, and it was sent to pathology to confirm that melanoma was not present. A couple of weeks later, the patient reported that the lesion had returned “with a vengeance.” CAG discussed this with a dermatologist friend who agreed that these lesions can be difficult to treat and often recur unless every cell is removed. He suggested three to four cycles of cauterization followed by curettage after shave excision. The patient was offered a repeat procedure in the office versus a dermatology referral, and she adamantly refused a referral, saying that she had full confidence in the doctor who delivered her baby. The procedure went well, and at a recent well-child visit, the patient was still lesion-free. As she expressed her thanks, CAG was struck by the confidence she had placed in him. It is these trusting relationships that can make the family doctor's life very satisfying.

Wednesday

One of WLL's patients had bilateral peripheral lower extremity neuropathy that just wouldn't get better. He ruled out diabetes, vascular disease, neurogenic claudication, lumbar disc disease, alcoholism, uremia, liver disease, B12 or folate deficiency, etc., and it still persisted. A nerve conduction test was done, confirming what WLL suspected, and the old standby Triavil was tried, with doses adjusted using serum level monitoring. No improvement was noted. He recommended multivitamins, prenatal vitamins, another antidepressant and even an antiseizure medicine—all to no avail. Finally, WLL read a report from the 13th Annual Meeting of the American Orthopaedic Foot and Ankle Society in the April 15, 1998, issue of American Family Physician (p. 1930) about an antiarrhythmic agent that might help relieve the pain of neuropathy in persons with diabetes (in the study, 32 of 35 patients averaged more than 50 percent relief of their symptoms). Today, the patient returned smiling and happy. The trial of 150 mg of mexiletine twice a day had resulted in almost complete diminution of the symptoms in less than two weeks. The dosage will be slowly increased to 300 mg every eight hours with very close monitoring. The patient was delighted with the response and, based on the information in the meeting report, WLL will try tapering off the medication in three months.

Thursday

Learning new tricks from her patients is one of SEF's favorite educational situations. Today, a 34-year-old woman presented with complaints of very tender hemorrhoids. Before consulting her physician, she had tried everything that was available over the counter for relief. She had used creams, baths and even medicated pads, but what struck SEF as interesting was that she stored her medicated pads in the refrigerator to improve the cooling effect. She seemed to be surprised that everyone didn't normally do this. SEF thanked the patient for this interesting advice and then proceeded to help her with her current problem.

Friday

“It's itchy and it's spreading,” was the complaint. It was clear to JRH that the patient was getting right to the point. Not to be outdone, JRH replied, “Well, let's see what it looks like!” Before his eyes he saw a fine vesicular rash that had a faint erythema as an undercoat for every one of the multiple tiny vesicles. They spanned from her pubic bone to above her navel and had even spread to her upper thighs. Being as frank as she was terse, she said, “What is it and what can you do for it?” Soon JRH was explaining about herpes gestationis, advising her of its time-limited course and reassuring her that a round of prednisone would most likely resolve the rash and the discomfort without adverse effects to her baby or her breast milk.

Saturday/Sunday

Maternity care is a rewarding part of family practice; however, some deliveries offer the most reward and relief when they are over. This weekend, TBS celebrated the arrival of the newest member of our practice after an uneventful vaginal delivery. This patient's pregnancy had been a challenge for TBS, because both parents were very apprehensive about going to a hospital for delivery. They had moved to town during the 32nd week of the pregnancy. Mom had been raised in Australia, and the dad in the United States. Mom had read numerous stories on the Internet about women experiencing loss of control in a hospital situation, and she was worried about the high rate of cesarean deliveries. She had consulted TBS on a referral from some friends and had discussed philosophies for quite some time before scheduling her maternity care with our group. TBS had assured her of a noninterventional delivery except in the case of an emergency. Significant time had been spent counseling the couple and preparing written orders for the hospital regarding the couple's preferences. TBS has been filled with apprehension about the need for intervention, and she was relieved today that labor had gone well. The patient had presented to the hospital dilated to 6 cm, and she rapidly progressed to complete dilation, with spontaneous delivery of an 8 lb, 1 oz girl over an intact perineum without complications. She was discharged home 12 hours later, and all was well.

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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