Diary from a Week in Practice



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Am Fam Physician. 1999 Feb 15;59(4):813-815.

Monday

In a previous “Diary,” we mentioned that aphthous ulcers of the mouth might be prevented in the majority of patients by avoiding toothpaste containing the detergent sodium lauryl sulfate (SLS). Now, WLL has come across another study in the European literature (Acta Odontol Scand 1994;52:257) that showed “a 70 percent reduction in canker sores in patients who used toothpaste without SLS.” A quick trip to the store will confirm that most brands of toothpaste sold in the United States contain SLS. However, a couple of brands are free of SLS. It couldn't hurt for patients to try avoiding SLS. In the past, we have mentioned other possible preventatives for recurrent aphthous ulcers, such as taking cimetidine at the first sign of occurrence (December 1995 “Diary”) and taking colchicine daily to prevent ulcer formation (January 1995 “Diary”).

Tuesday

CAG was in for a pleasant surprise during a routine visit today. He had prescribed methimazole for the treatment of Grave's disease in this young woman, and she was in today for a follow-up visit. At one of their first visits about three months earlier, she had asked for prayers and support as she and her husband began the process of adopting a child. Today, CAG noticed two charts in the door, one with the patient's name and the other for a two-week well-child examination. On entering the room, the new mom smiled broadly and proudly showed off her son. CAG was thankful to share the joy of these new parents and noted that it was a feeling somewhat similar to being at the delivery of a newborn. The mom was also happy that the thyroid medicine was working, although her newly found ability to sleep has again been interrupted.

Wednesday

With increasing frequency, JTL sees children with complaints of chronic mouth breathing and nocturnal snoring who also have abnormalities on inspection of the nasopharynx, including nasal polyps, nasal septal deviation and hypertrophied turbinates. At a recent continuing medical education function focusing on upper respiratory allergic disease, JTL learned about the association between chronic nasal obstruction in children and subsequent orthodontic abnormalities, including a high-arched palate and malocclusion. This association became even more relevant when JTL (at a recent and long overdue visit to the dentist) was diagnosed with malocclusion. Realizing that the sinus surgery he underwent at age 30 did not eliminate nearly 25 years of chronic nasal obstruction, JTL vowed to be a bit more aggressive in finding a definitive therapy for his patients with nasal obstructive symptoms, including referral to an ear, nose and throat consultant when indicated. He hopes to help his patients avoid potential long-term sequelae from this problem.

Thursday

While every birth is an occasion for great expectations, some newborns are greeted with more joy than others. This may be true because of the parents' great longing for a child, an overwhelming sense of relief at the end of a long pregnancy, or a healthy childbirth after facing great odds against a successful pregnancy. Several years ago, JRH traveled to a seminar in Omaha, Neb., and learned about NaPro Technology (see J Reprod Med 1998;43:499–502), which uses natural methods and compounds such as natural progesterone to cooperate with the basic physiology of a woman's reproductive system. He recently applied the approach to a couple in their late 30s. The wife had woefully short luteal phases of eight, six and five days over successive cycles. Knowing that the basic defect was inadequate progesterone, JRH supplemented her corpus luteum from the third day after fertilization through the end of the first trimester. Today saw the arrival of Samantha, a plump, rosy-cheeked and much-awaited baby girl. Both parents and doctor beamed with joy.

Friday

Today, SEF saw a six-year-old girl who had an unusual earache. She had been swimming quite often and had a greenish discharge from her ear, but she did not have cold symptoms. SEF thought this would be a simple case of otitis externa until she looked into her ear. There was so much discharge that she could hardly see anything. SEF's nurse started to irrigate the girl's ear, but the view became even more obstructed and hardly anything would come out. Finally, using a curette, the nurse discovered that there was actually something solid in the ear canal. After removing the object, they both inspected the bit of foam and realized that it was a piece of the patient's ear plug that she had been using to prevent ear infections. Sometimes the cure can be worse than the original problem.

Saturday/Sunday

Every family physician must deal with death and dying, but it is often a lesson we find ourselves reluctant to learn. We would rather spend our time learning about life and how to preserve and restore it. When we do encounter death, we are often ill-prepared and certainly ill at ease. This weekend, one of JRH's patients died of metastatic cancer. It was much sooner than either he or the family would have predicted. In fact, JRH had been planning to make a home visit this weekend, only to find out that she had died at 2 a.m. Saturday morning. JRH decided to call and make a visit anyway, if the family so desired. They did, and JRH drove to the modest house in a quiet neighborhood that the couple had called home for the past 15 years. Not knowing what to say, JRH decided just to go and listen. What he found out was the following: (1) Listening is very important—the family needed to talk about their loved one and her life; (2) being present is more important than knowing what to say—the family wasn't looking for advice, just comfort; and (3) taking the time to honor her was better done sooner than later—the family in turn honored JRH with kind words that have made a lasting memory.

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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