Diary from a Week in Practice



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Am Fam Physician. 1999 Mar 1;59(5):1157-1159.

Monday

Certainly the 90s are the decade of the informed consumer. It's expected that patients will want to know all about their treatment, their options, their prognosis, their ability to have consultations, etc., and many of us believe that this shift is good and progressive. At the same time, there is often a tendency for patients to want the physician to evaluate every little complaint, no matter how trivial. This is especially true in patients with capitated care. However, when a patient of “the old school” comes in, the contrast is sometimes so startling that we just stop and scratch our heads in wonder. Today, JRH was greeted by one of his longtime patients whose sole objective was to get a refill of furosemide, which she uses for blood pressure control. When JRH happened to notice a small scrape on her skin, she replied that it happened when she got a bump on her head. “The bump?” JRH asked. “Yes, now that you mention it, I've been worried about my VP shunt acting properly, especially when I started getting headaches.” “It could be related,” JRH replied. “Why didn't you say something about it sooner?” he asked. “Oh, doctor, I didn't want to bother you!” was her answer.

Tuesday

In a previous “Diary” entry, WLL told of his anecdotal observation that the fullness of a metered-dose inhaler could be determined by floating the canister in water. This observation has now been confirmed with an objective study presented at the last WONCA meeting in Dublin, Ireland, and reported in the September 1, 1998, issue of Family Practice News (p. 18). The canister, when placed in a bowl of water, will “consistently assume one of four positions.” If it is 70 percent full, it will lie on its side below the surface. If it is 30 to 70 percent full, it will float vertically just under the surface. If it is 15 to 30 percent full, it will float “at about a 30-degree angle, with roughly half of the device in the air and the valve end entirely submerged.” At less than 15 percent fullness, most of the canister is above the surface “at roughly a 30-degree angle and a corner of the valve is exposed.” The flotation test was shown to be 90 percent sensitive and 99 percent specific with all brands of metered-dose inhalers that were tested. This test is important to patients because most users of metered-dose inhalers are unable to determine the fullness of their container, especially when only a few puffs are left.

Wednesday

CAG often hits a roadblock in treating his morbidly obese patients, because our office scale cannot measure beyond 350 lb. A consistent measurement of “350+” on the chart at each visit does little to help a patient who is trying to lose weight. The answer to this problem has come in the form of the local grain and feed store. True, their scale only measures in 10-lb increments, but it seems to be accurate. Today, a patient was in for an examination and was proudly holding his last three monthly measurements showing a steady drop from 450 lb to 410 lb. This weight loss was confirmed by a loosening of his pants and a tightening of his belt. Both doctor and patient were encouraged to see an actual numerical measurement of weight loss and, at a feed store, no less.

Thursday

TBS has struggled over a year with treating a 45-year-old woman who has Crohn's disease. Because of multiple previous surgeries, she had an ileostomy that had been problematic because of high output of fluids, resulting in frequent episodes of dehydration. Two previous attempts at subcutaneous/subclavicular venous access ports for home intravenous treatment resulted in sepsis and subsequent removal of the ports. Despite trying numerous medications, nothing seemed to control the ileostomy output and provide fluid balance. TBS became frustrated and decided to obtain a consultation from yet another gastroenterologist—just to see if a fresh look at this problem might help. This particular consultant, of Indian background, suggested a trial of oral glucose powder mixed with table salt, to be taken three times daily. He said that this form of oral rehydration solution was frequently used in his country for dehydration and was very inexpensive. He recommended to the patient a trip to a local Indian supermarket to purchase the purported remedy. The solution has worked quite well. On follow-up today, the patient's sodium, potassium and glucose values and balance were normal, and she seemed much happier drinking the glucose and salt and water preparation three times a day than when she was faced with the prospect of an IV and all of its potential complications.

Friday

Every family physician realizes the importance of regular exercise and usually discusses this aspect of health care with patients. It seems to us that more often than not, patients have excuses about why regular exercise just doesn't fit into their lives. Today, SEF was performing a physical examination on a 42-year-old woman who had high blood pressure and was overweight. Her excuse was somewhat unique. In Florida, there is an insect commonly known as a “love bug,” so named because when its mating season comes around, the male and female insects fly around in swarms connected rump-to-rump. These swarms will cover cars, houses, people—whatever gets in their way. SEF's patient stated that the only reason she could not go outside and start a simple walking program was because, “I just hate those love bugs!” SEF reminded her that the mating season lasts only a few weeks, and the patient promised that as soon as the coast was clear, she would start her walking program.

Saturday/Sunday

WLL first met him at the Silver Spurs Rodeo over a decade ago. His family helped found our county, and his ranch and the quality of his cattle were known across the nation. “Geech,” as he was known, was now confined to an electric scooter. His arthritis resulted from too many years of formidable falls. At this rodeo, which he helped found over 50 years ago, he came to the first aid area to better watch the cowboys he loved. WLL sauntered up to both greet and meet this local legend. During their conversation, WLL listened and learned. At one point, the cowboy quipped, “You'd understand all this a lot better if you were from here.” WLL inquired, thinking that he was from here, “Well, how long does it take to be from here?” Geech grinned, then responded, “You're from here once I know your grandpappy—and know him well!” WLL felt that this was a club into which he would never be accepted, that is, until not too very long ago. The cowboy rested at home in bed as WLL made home visits. His patient's life was ebbing. At their final conversation, the patient, now seemingly fond of his friend and physician, said, “Doc, pretty soon I'll be in another pasture. I suspect I'll get to meet your grandpappy. If he's at all like you, I know I'm gonna like him.” This patriarch of our county had attested that WLL was now “from here.” This is about as high an honor as a physician for cowboys can ever obtain.

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


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