Diary from a Week in Practice

Am Fam Physician. 1998 Dec 1;58(9):2011-2012.

Monday

“Dr. Walt,” expressed the grateful patient, “It actually worked!”“Do I detect a bit of disbelief in your voice?” asked WLL. “Well, not really,” came the rejoinder, “It's just so nice to find something so old-fashioned and so effective—and so inexpensive!” With a hug and a smile, the former migraine sufferer was off and out of the office. This middle-aged nonsmoker had been having mild to moderate classic migraine headaches over the past 20 years. Migraine prevention medicine (beta blockers, serotonin selective reuptake inhibitors, anti-seizure medication, etc.) had not been of much help. Sumatriptan helped but cost too much for her. Migraine abortion medications either had side effects or were too expensive. Most recently, WLL had suggested a one-month trial of vitamin B2 at a dosage of 400 mg per day for migraine headache prophylaxis and two tablets of an over-the-counter medication that contained acetaminophen (250 mg), aspirin (250 mg) and caffeine (65 mg) every four hours for headache, based on reports in the neurologic literature (the report on B2 was in the February 1998 issue of Neurology [p. 466], and the report on the over-the-counter analgesic was in the February 1998 issue of the Archives of Neurology [p. 210]). By the way, in the study from the Archives of Neurology, the over-the-counter product had an effectiveness of 59 percent at two hours after ingestion and 79 percent at six hours.

Tuesday

Occasionally, WLL has a patient with recurrent thrombosis of an external hemorrhoid. He has learned from our surgical consultants how to perform an excision of the offending hemorrhoid and thrombosis in one fell swoop (as opposed to incision and drainage, or enucleation of the thrombosis). He is impressed that healing from the excision is usually faster than from the incision and drainage, but he knows of no studies to support that observation. Either way, the recovery is less than fun for the patient, although not treating the painful, thrombosed hemorrhoid seems to be worse. Now a report in the January 17, 1998, issue of Lancet (p. 169) suggests that “ . . . prophylactic metronidazole is effective in reducing pain in patients who have undergone same-day haemorrhoidectomy.” According to the study, it is not uncommon for patients to note an increase in rectal pain that can last for several days after hemorrhoidectomy. The authors hypothesized that the pain is related to infection. They conducted a double-blind, placebo-controlled trial in which 40 patients were randomly assigned to metronidazole, 400 mg, or placebo, three times daily for several days after discharge. “Patients in the metronidazole group had significantly less pain than those in the placebo group on days 5, 6 and 7,” the researchers reported. They added that patients taking metronidazole “were able to resume normal activities or return to work” more quickly.

Wednesday

You've heard it said, “If at first you don't succeed, try, try again!” While its application is broad, in a family physician's office it may be true most frequently when the clinical problem is pruritus. JRH saw the lively embodiment of this entity today for the fifth time! Previous visits ended with advice to use diphenhydramine, triamcinolone cream, prednisone and cyproheptadine—all to no avail. This visit concluded with the working diagnosis: PUPPP (pruritic urticarial papules and plaques of pregnancy) and another “try”: doxepin cream. A week later, the young woman reported the first improvement she had had in weeks. Was it the cream or JRH's persistence that paid off? Who knows, but the patient is grateful and so is the new baby who now has his mother's undivided attention.

Thursday

Every year, Kissimmee plays host to a national invitational boy's high school basketball tournament. The tournament features top-quality teams from Florida to Alaska with nationally ranked high school basketball players. Our practice has had the privilege of serving as “tournament docs” since its inception 17 years ago. This year, JSR was the tournament doc during a memorable semifinal game. A key starter from one of the teams took an elbow to his mouth while grabbing a rebound. After the blood was cleared, a laceration to the upper lip was found. The laceration did not extend to the vermillion border, and there was no evidence of mandibular fracture or tooth avulsion. Because it was almost halftime, JSR took the player back to the training room and sutured the laceration, allowing him to return to play in the second half. His team struggled, but with two seconds left, an outside shot sent the game into overtime. The overtime period was a battle fought fiercely but, with just one second left, a three-point shot secured the victory for the exuberant team. Guess which player made both the “at the buzzer” shots?—the one sporting four knots of nylon in his upper lip.

Friday

A 26-year-old woman presented to SEF for follow-up of Reiter's syndrome. She originally had a urinary tract infection with Escherichia coli that developed into acute onset of polyarthralgia, conjunctivitis and back pain. Her laboratory tests were essentially negative except for the urine cultures. This was a difficult diagnosis to make, because she did not have the classic triad of reactive arthritis accompanied by urogenital symptoms, and mucocutaneous and ocular inflammation. Review of the literature showed that the classic triad is rarely complete, and laboratory findings are nonspecific. She was treated originally with antibiotics, non-steroidal anti-inflammatory drugs and a short burst of steroids. At first she did well, but she had a relapse when tapered from the steroids. She was then placed on a longer taper of steroids and has done quite well. Today, she was ready to discontinue the steroids again. SEF explained to her that her prognosis was good but there was a potential for recurrence of chronic arthritis symptoms. Both patient and physician hope that this will not be the case.

Saturday/Sunday

WLL has been trying to learn the skill of taking a spiritual history, and his patients have been very open to these inquiries. He is interested in knowing where the patient is spiritually and how their belief system might affect their views and healing. Systematic reviews of the medical literature have looked critically at the relationship between our patients' spiritual health and their physical and mental health. In general, these studies suggest that infrequent religious attendance or poverty of personal faith should be regarded as a consistent risk factor for morbidity and mortality. David Larson, M.D., the research director of the National Institute of Healthcare Research, has called personal faith “the forgotten factor in physical and mental health.” An article on this subject in the March/April 1998 issue of the Archives of Family Medicine (p. 118) is an excellent review for interested readers. In addition, WLL has learned that over 30 percent of American medical schools have added courses teaching the relevance of spirituality in the practice of medicine.

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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