Diary from a Week in Practice
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Am Fam Physician. 1999 Apr 1;59(7):1795-1797.
A local family physician who is a tai chi master has taught WLL and some of our patients about the health benefits of this ancient Chinese martial art. WLL became interested in tai chi after one of his elderly patients had several falls and a broken hip. Her daughter had read a report in the Journal of the American Geriatric Society about a trial of tai chi that showed that the risk of falling was reduced by almost 50 percent in a group of elderly patients who took tai chi classes twice a week for 15 weeks (J Am Geriatr Soc 1996;44:489–97). After starting tai chi, the patient reported that she feels more stable, confident and relaxed with ambulation—and she has not fallen again.
Apparently these benefits are achieved by improving flexibility, balance and strength, using a non-impact, low-aerobic method. If patients are healthy, ambulatory and willing, especially those over 65 years old, they may want to consider a trial of tai chi to reduce the risk of falling. An article in New England Journal of Medicine reminds us that nearly one in three of our elderly patients will fall in a given year (one half will fall repeatedly). Furthermore, hip fracture is the sixth leading cause of death in women over age 65. The article notes that elderly patients who fall are at increased risk of becoming fearful and withdrawn and experience social and functional deterioration—the most serious concern of all (N Engl J Med 1994;331:821–7).
The nonverbal communication skills of toddlers as young as eight months of age continues to amaze CAG. He had once read a book about child rearing that introduced the idea of using sign language to communicate with infants. He was impressed at how quickly his eight-month-old son picked up the sign language and started “speaking” his mind. The same has been true for some of CAG's young patients. Discussing sign language at a routine six- or nine-month well-child visit has also provided a nice extra touch appreciated by many parents. CAG has found that the signs for “more,” “all done,” “down,” “please” (to really get what one wants) and “thank you” are the most popular. Each child also usually makes up some individual signs. Today, a 14-month-old girl greeted CAG with the “more” sign, followed by what looked like a puckering of her lips for a kiss. Bending down to get his kiss, he was chagrined to be rejected as the child turned to her mother for her true goal—more crackers.
Today CAG had his first experience with the new cyanoacrylate topical skin adhesive. The patient was a two-year-old boy with a 1.4-cm laceration on his forehead. With minimal difficulty or discomfort, the wound edges were approximated and sealed with the “glue.” Part of the gauze was caught in the edge of the adhesive, along with a few strands of the patient's hair, giving the surrounding area of the wound a fuzzy appearance. However, despite the final appearance, the mother was ecstatic at the ease and speed of the procedure and said she could tolerate a little debris. They will follow-up in one week so CAG can see the final result.
As the physicians for an invitational basketball tournament that attracts high school teams from across the nation, each of us enjoys the opportunity to provide a variety of remedies to the ailing and injured athletes and to witness exciting and competitive basketball. At one recent game, JTL went on to the court to evaluate a player who had gone down to the floor and was writhing in pain. Once it was evident that the player did not have a significant injury, JTL stood up to leave. The 6-ft, 6-in tall 230-lb athlete, lying supine on the floor, in turn reached up to grab the hand, not of his teammates or coach, but of JTL—all of 5 ft, 9 in tall, and a strapping 150 lb. JTL envisioned himself writhing in agony on the floor with a herniated disc, but fortunately both JTL and the athlete were able to witness the rest of the game without pain.
“Doc,” the beaming patient exclaimed as WLL walked into the examination room, “that pepper cream did the job! Boy, do I feel better!” With that, the former truck driver slapped WLL on the back, nearly knocking him over. WLL appreciated the positive feedback, but would have preferred just a bit less enthusiasm. The patient (a recovering alcoholic) had bilateral neuropathy of the lower extremities, which had resisted a number of therapeutic trials. WLL had read about the benefit of capsaicin cream (with hot pepper extract) in some patients with diabetic neuropathy, postmastectomy pain, psoriatic itching and pain, pruritis associated with hemodialysis and postherpetic neuralgia. A month earlier he suggested that the patient try applying the over-the-counter cream four to five times a day for at least four weeks. WLL had warned the patient that using the cream only two to three times a day had been reported to increase the pain, and he had warned the patient to be sure to wash his hands after applying the cream and to avoid contact with the eyes, mouth or nose. WLL was delighted that the patient had improved using a noninvasive, inexpensive, fairly low-risk preparation.
Today JRH visited with a very special patient, who knows he doesn't have long to live. Recently diagnosed with lung cancer, the patient had opted to forgo both chemotherapy and radiation therapy. On previous visits he had earnestly asked that JRH not try to dissuade him from this course of action and had done so in the presence of his wife of over 40 years. JRH inquired about end-of-life issues, especially about how the children were reacting to the news of their father's condition and to the prognosis. He replied with full confidence that his relationship with his three children was richer now than it had ever been. His wife nodded in agreement. “There's something about the diagnosis, Doc, that allows you to get to the heart of the matter,” he said. And it could also be said that the heart of the matter is quite often a matter of the heart.
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.
Copyright © 1999 by the American Academy of Family Physicians.
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