Diary from a Week in Practice



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Am Fam Physician. 1999 Mar 15;59(6):1451-1452.

Monday

This morning, while diagnosing and treating a patient with acute bronchitis, JTL used the occasion to counsel this young father about the benefits of quitting smoking. “That sure would make my little boy happy, since he's been hounding me so much!” remarked the patient. After further reflection, JTL mused about the potential implications of children attempting to “correct” their parents' behavior. “If your boy knows that one should wear seat belts while in a car, and you, the father, refuse to wear seat belts . . . then wouldn't that child have to make a decision as to who is ‘right’—his schoolteacher or his parent? Do we want to put our children in the position of having to choose between authority figures at school and at home when trying to decide between ‘right’ and ‘wrong’?” JTL asked. He added, “If your son is hearing that cigarette smoking is ‘bad,’ and you choose to smoke, wouldn't this create the same dilemma for him?” Clearly, the chief role models for children should be their parents. Was this conversation convincing enough to motivate the patient to quit smoking? One can only hope.

Tuesday

We see lots of patients with plantar fasciitis. It seems many of them are in their 40s and 50s and are quite active, a factor that no doubt keeps the condition from healing on its own. Today, a patient in that age group arrived and, like most, was befuddled about what could possibly be causing his terrible heel and foot pain first thing in the morning and when he gets up from the conference table at work. JRH typically spends a few moments explaining the pathophysiology and then also asks a few questions probing for factors that contributed to the overuse/abuse. His patient noted that he now walks only on tile floors. “Why don't you have carpet? Everyone here in Florida has carpet these days,” JRH inquired. “I did have, but I had to take it all out because of my hives,” he replied. Then JRH remembered the one-year ordeal of treating the patient for chronic urticaria, trying a number of medications before finally referring him to an allergist for immunotherapy. As Roseanne Roseannadanna would say, “If it's not one thing, it's another.”

Wednesday

Family physicians often receive an outpouring of support from their patients for special occasions. CAG experienced this when the University of Tennessee (his alma mater) won the national championship in football this year. He has received cards, telephone calls, shirts, hats, cups and even newspapers from various cities. He is often greeted with congratulations as though he had just had his first child. With all the fun, CAG hopes he is as well known for being a good family doctor as he is for being a good Tennessee Volunteer.

Thursday

WLL has been waiting for an easy screening test for the symptoms of clinically meaningful sleep apnea, an often undetected and under-treated malady seen in primary care. Dr. Helena Schotland, a pulmonologist in Philadelphia, has studied a quick and simple screen that consists of four questions (Do you snore? Do you often fall asleep when you don't intend to? Do you ever struggle for breath during sleep? Do you snort or gasp during sleep?) and two physical findings (a body mass index of more than 27 and retrognathia). Patients who answer yes to two or more questions and have at least one physical finding are candidates for formal sleep laboratory testing. In a pilot study of the screen, performed by eight primary care physicians and reported in the September 1, 1998, issue of Family Practice News (p. 16), 27 patients had positive screens. Eight patients had mild sleep apnea, and seven had moderate or severe sleep apnea. Until more complete studies are performed, this screen may be a reasonable tool for family physicians to consider using in their practices.

Friday

A 55-year-old woman receiving hormone replacement therapy presented to TBS for follow-up. The patient had tried several oral estrogen replacements, all of which produced some nausea, and finally had changed to an estrogen patch that relieved her symptoms quite well. When she began an exercise program, and subsequently was sweating more, she started having difficulty keeping the patch on for a week at a time as it was prescribed. Her insurance company would not cover the cost of more than one patch per week, but if she left the patch off she began to experience hot flushes and insomnia. She reported today that she had found a way to readhere the patch. She applies hot air from her hair dryer to the edges of the patch when the edges begin to detach from her skin. She uses the hair dryer for one minute. She initially discovered this process by trying to dry out her patch after exercising. The heat appeared to reactivate the adhesive. We don't know if it has any other effects on the patch or on the absorption of the medication, but so far so good.

Saturday/Sunday

Being a family physician who attends a small church in which the only other doctor is a pediatrician, CAG is often called on to help with medical emergencies that happen at church. He has thus become aware of the medical problems of a number of the older people in his church, even though most of them are established patients with other physicians. One elderly woman in particular has frequent presyncopal episodes, often on Sunday mornings. Her internist has performed an extensive work-up and has sent her to multiple consultants, but these episodes have remained a mystery. She always brings copies of her laboratory and radiologic reports for CAG to review, just in case he has any ideas. This Sunday, while working in the church nursery, CAG was called to help with another of this woman's “spells.” He was amused to find two of her friends already going through the standard routine—feet elevated, cold compress on her forehead, complex carbohydrate snack with juice at the ready. CAG only had to visit awhile to provide moral support.

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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