Diary from a Week in Practice
Am Fam Physician. 1999 May 1;59(9):2469-2470.
This past Sunday night, at 11:57 p.m., JTL introduced 7-lb, 4-oz Olivia Rose to the world, his first delivery since joining Heritage Family Physicians earlier in the year. The poignancy of this event was magnified by the news, learned earlier that same evening, that JTL's grandmother had died peacefully, at the age of 92, at her nursing home in Long Island, N.Y. JTL reflected on the many privileges he has had as a family physician, including the chance to escort new lives into the world—sometimes on the same day as sharing final moments in the lives of elderly patients.
From time to time, we are fortunate enough to have medical students or residents train with us. We find this to be fulfilling and affirming for all involved. This week a senior medical student named Angela Potter was our guest, spending time with each of our doctors. When introducing our guests to our individual patients at the beginning of each visit, we find that our patients are very receptive and, indeed, eager to participate in the education of young doctors. Today, however, one of JRH's patients took this process a step further. “Would you like a word of advice?” she said. Both JRH and AP turned an attentive ear her way, as she proceeded: “Don't be a 10-minute doctor, even if you have just 10 minutes. Dr. Hartman isn't a 10-minute doctor.” What a warm compliment JRH had just received! And how nice to be so honored in front of a colleague.
SEF saw a 54-year-old man today for a follow-up visit after removal of an inclusion cyst from the ear-lobe. The wound had healed well, and the patient had no further problems. SEF was glad to see the wound's progress in view of the problems that had occurred during the procedure. From the very first needle stick, the patient had had quite a bit of bleeding. After much struggle and an attempt at electrocautery, SEF finally removed the offending cyst. She held pressure and tried cautery again but was getting nowhere quickly. Finally she remembered that the clinic had just received a shipment of Surgicel that had been ordered to help stop bleeding associated with circumcisions, and she decided to try it. She inserted the material into the wound and was very pleased with the effect. The bleeding stopped almost immediately, and SEF repaired the wound. This will probably not be a daily occurrence, but it is always nice to have a new weapon in the arsenal.
As advocates for our patients' well-being, we often have to make difficult therapeutic decisions. Witness the 67-year-old man and his wife who recently visited JTL to become acquainted with their new family physician. During the interview, JTL was particularly struck by the husband's repetitive, jerking movements of both arms, his obvious dysarthria and the manner in which his head was angled to the right (torticollis). Glancing at the list of medications this patient was taking—which included high doses of trazodone and other agents with known extrapyramidal side effects—JTL asked the patient's wife whether she had observed any changes when the patient began taking these medications. “Oh, certainly I saw a change! He became much easier to live with—no more angry outbursts!” It became evident that she was willing to tolerate any degree of extrapyramidal and related side effects in her husband, just to have peace in her home. After much discussion, JTL convinced the couple to try to reduce the dosage of at least one of the medications in a gradual manner, in the hope of eventually finding an alternative drug regimen for the patient's chronic problems with anxiety and anger.
A letter to the editor in the January 14, 1999, issue of New England Journal of Medicine described a new use for the stethoscope: to follow the healing of tenosynovitis. Now, all of us have felt the crepitus of tenosynovitis. What if there is pain over the tendon and no crepitus? According to this letter, auscultation over the involved tendon while contracting and relaxing the involved muscle resulted in an auscultable sound “similar to a bronchial breath sound.” The sound is described as persisting after crepitus resolves. With this new pearl in mind, WLL was delighted to see a patient two weeks ago for follow-up of de Quervain's tenosynovitis. The patient was indeed doing better with treatments of hot compresses, oral nonsteroidal anti-inflammatory drugs, topical capsaicin and a wrist/thumb splint. The previously palpated crepitus and nearly all of the pain were gone. However, when listening with the stethoscope over the tendon, a clear sound could be heard with movement of the thumb. WLL recommended continued therapy. At today's follow-up, the patient felt well, and there were no auscultable sounds over the tendon. One of the treats of the profession of medicine is that there is always something new to learn.
Our patient information sheet ends with the comment, “My philosophy of life is. . .” and patients often write comments such as “Go for the gusto” or statements of personal faith. Today, CAG met a 63-year-old man as a new patient who wished to discuss his recently diagnosed prostate cancer. The patient gave a summary of his personal history. Abused as a child, he was raised in an orphanage in Brooklyn until he married at a young age. His first wife and son were killed in a car accident, and this led him into a battle with alcoholism. After a heart attack in his 50s that left him with chronic atrial fibrillation, he was diagnosed as having throat cancer, which appears to have responded to surgery and multiple radiation treatments. “Now,” he says, “the doctor wants to cut out my prostate.” His written philosophy: “Stay the hell alive.” CAG hopes he can help the patient do that—and more—in the future.
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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