Diary from a Week in Practice



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Am Fam Physician. 1999 Feb 1;59(3):571-572.

Monday

WLL argued valiantly, but the parents-to-be refused to have vitamin K administered intramuscularly to their yet-to-be newborn. These parents were concerned about reports that pain experienced during the neonatal period may have long-term effects (i.e., the March 1, 1997, issue of Lancet, p. 599). They knew that vitamin K has been recommended for newborns within the first six hours after birth following initial stabilization. They knew that no significant complications have been reported after intramuscular administration of vitamin K to newborns. However, they countered that the psychologic effects of intramuscular injections on newborns and their parents are unknown. They also noted that intramuscular administration of vitamin K does not provide complete protection from hemorrhagic disease of the newborn. WLL searched the Internet and found this recommendation: “For newborn infants whose parents refuse an intramuscular injection, the physician should recommend an oral dose of 2 mg of vitamin K1 at the first feeding. Use of parenteral vitamin K for administration is all that is currently available (for oral use). This should be repeated at two to four weeks and six to eight weeks of age.” The guidelines in the November/December 1997 issue of Paediatrics & Child Health say that parents should be cautioned about the risks involved. The guidelines can be found at http://www.pulsus/Paeds/home.htm.

Tuesday

“Tell Dr. Larimore that the clear nail polish worked!” said the mother of an eight-year-old girl whom CAG was currently seeing for a sore throat. The girl had been seen a few weeks earlier by WLL and was diagnosed as having a single tinea corporis lesion. Although a topical antifungal agent had been prescribed, the patient's mom instead used a home remedy that is popular in our neck of the woods—clear fingernail polish. She applied the polish daily for a week until the lesion disappeared, never filling the prescription. No evidence of the lesion could be seen today. We've never heard of this remedy outside of our region and can find no literature on the subject. Nevertheless, this “n-of-one” study has piqued our interest. We'll let you know what we learn.

Wednesday

Even though we don't market our office as a center for occupational medicine, it is inevitable that this aspect of family medicine touches our patients and the practice. Today, a woman in her 50s came in for a get-acquainted visit, but it was soon apparent to JRH that the pressing agenda for this visit was nagging wrist pain that had persisted for the past two months. JRH diagnosed de Quervain's disease and was able to give quick relief by injecting a combination of triamcinolone and lidocaine around the tendon sheath of the extensor pollicis brevis. How did she get this condition? JRH found out that she is a nail technician who sculpts nails for customers every day, but recently her schedule has even been busier. Because she seemed reluctant to take time off, JRH suggested a modification of both her technique and her client list to allow for some rest so that the triamcinolone would have a chance to work and relieve her tenosynovitis.

Thursday

A 24-year-old woman presented to SEF for a second opinion on her secondary amenorrhea, because she and her husband really wanted to have a baby. She brought with her the laboratory results from her first evaluation several months ago at another physician's office. The laboratory results were normal with the exception of a prolactin level of 130 ng per mL. She had not had any symptoms of galactorrhea or visual field disturbances. A repeat prolactin measurement showed a level of 140 ng per mL, and a magnetic resonance imaging scan revealed a pituitary macroadenoma that was encroaching on the cavernous sinus on one side and touching the optic chiasm. Formal visual field tests were normal. Consultation with a neurosurgeon was obtained, and medical versus surgical management was discussed. The neurosurgeon favored at least attempting medical management, but the patient and her husband really desired pregnancy. Surgical management offered the fastest and surest resumption of her menses, so the patient chose this option. Hopefully, soon she will return to SEF for a new pregnancy examination.

Friday

A bit of levity in the workplace can be just the cure for hectic days. This morning, during a particularly busy time, JTL had the opportunity to meet a new patient who was completely deaf. He presented with the complaint of a painful mass in the axilla for the past week. JTL, who is not proficient in sign language, was trying to obtain a history from this patient and his wife, who could communicate only by writing or signing. Recognizing from the examination that the patient had lymphadenitis, JTL brought in JRH to get another opinion. “Cat scratch?” inquired JRH. JTL quickly wrote out, “Was he scratched by a cat?” for the patient and his wife. They looked at us quizzically. JTL wrote once again, “Cat scratch?” Again, no response. JRH took one look at the paper JTL was using to convey his messages. “Well, it looks as though we're dealing with two disabilities here—the patient can't hear, and the doctor can't write!” Touché! Following a more readable attempt to convey his thoughts, JTL obtained a positive history for cat scratch, and the patient was pleased to leave with an appropriate course of antibiotic therapy. Thanks, JRH, for both the diagnostic acumen and the pitch for improving one's penmanship.

Saturday/Sunday

The international community of family physicians is made up of a wide array of wonderful and singular individuals. Recently, we heard of a family physician whom we want to welcome to the family practice community and cheer on through her residency. She dropped out of high school 30 years ago to take a job as a waitress, then as a motel desk clerk, then as an insurance saleswoman. She's married, is a mom and is in the residency program in Chattanooga, Tenn. Following completion of her residency, she wants to practice in her hometown of Pigeon Forge, Tenn. While a working mom, she got her GED. In her late 30s, she obtained a nursing degree while continuing to work. Encouraged by professors, she changed to premed and graduated from the University of Tennessee in Knoxville. Then, she was accepted into East Tennessee State School of Medicine in Johnson City. The first year, she had to leave her family during the week, commuting over 100 miles to school and returning home on the weekends. It was so difficult that she almost quit. But, she kept at it and, in May 1997, Shirley Trentham became Dr. Shirley Trentham. One of her professors said, “(Her story) speaks a lot about her work ethic, perseverance and probably to some very important deep-seated issues about what separates the truly remarkable physician or healer from those who just want an M.D. behind their name.”

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., John T. Littell, M.D., and Chad A. Griffin, M.D., seven family physicians in private practice in Kissimmee, Fla.



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