Diary from a Week in Practice
Am Fam Physician. 1999 May 15;59(10):2756-2758.
Today a father came in after “go-carting” with his son and daughter over the weekend. It had occurred to him that by following the go-cart on his dirt bike, he could gauge the cart's speed by following at the same speed himself. The theory worked just fine, and the peak measurement registered 30 mph. At that point his daughter slowed down and inexplicably turned left, blocking the path of the dirt bike. The father went head over heels and came to an all-too-quick stop, landing on his shoulder, arm, hip and head. Unfortunately, he was not wearing a helmet. X-rays showed a fracture of the third rib, but, fortunately, no pneumothorax. The pain, the bruising and the road rash were painful enough. Worse yet, however, was the embarrassment he felt for not being more careful and prudent. After proper prescriptions for pain and advice for the injuries, JRH also applied salve to the patient's spirit, assuring him that, in time, all his injuries would heal.
WLL has had several patients tell him of the usefulness of the botanical kava for the management of symptoms of anxiety. So he decided to do a little research into the substance. Kava is a psychoactive member of the pepper family. Very little scientific evidence supports its use. No controlled, clinical trials had been performed in the United States, but he found five trials with human subjects in the German medical literature. Although trial numbers are small, they all attest to the anxiolytic effects of the active substance, kava lactone. Physician's Desk Reference for Herbal Medicines (Montvale, N.J.: Medical Economics, 1998) advises against the use of kava in patients who are pregnant or breast-feeding and in patients with endogenous depression. Kava is indicated for anxiety and insomnia and there are no known health hazards with “the proper administration of therapeutic dosages,” although observational studies have reported side effects such as gastrointestinal discomfort, headache, dizziness and allergic skin reactions. Interactions with benzodiazepines and cimetidine have been reported. Herbal experts recommend that it not be used for longer than four to six weeks and that it should not be used while operating equipment or in conjunction with prescription medications, valerian or St. John's wort. In the future, Kava may be another tool for the family physician's armamentarium.
This week, SEF saw a 26-year-old teacher for a new maternity care examination, which normally would not be unusual except that SEF had delivered this woman's last child about one and one half years ago. SEF had followed the family throughout this time and was pleased to see her patient back for this reason. Also this week, SEF delivered the son of a patient to whom she had previously delivered a son about a year ago. After only two and one half years in private practice and two repeat customers for maternity care, SEF began contemplating how satisfying it must be to deliver the children and perhaps even the grandchildren of one's patients.
Today, SEF returned a phone call to a patient who recently was diagnosed with breast cancer. Immediately after diagnosis, the surgeon urged the patient to proceed quickly to radical mastectomy. Dazed, the patient agreed, and then later had second thoughts. She had arrived to undergo medical clearance for surgery, and it was obvious to SEF that she was unsure about what to do. Sensing more and more hesitation as the interview went on, SEF outlined the patient's options, including taking time out to get a second opinion. SEF could see the relief on her patient's face as she discussed this option, understanding that the patient had been reluctant to voice her feelings. The patient took a week to get a second opinion, and then underwent a modified radical mastectomy, feeling much better about her decision. Today, she called to discuss her options for chemotherapy. Again, she was uncomfortable with the oncologist who was managing her case and sought SEF's guidance. This time she was not reluctant to voice her desire to have a second opinion, and SEF was quick to offer a referral to another physician. At the end of the conversation, both patient and physician were confident that whatever happened, everything possible had been done to help the patient to recognize all of her options and to make an informed decision about her health care.
No news is often good news. CAG received a visit today from the second patient he had seen on his first day of practice in Florida. At that initial visit, CAG had used a steroid injection to treat the patient's recalcitrant plantar fasciitis. The elderly gentleman had been unhappy with the pain of the injection and had had little relief immediately following the treatment. When he did not show up for his follow-up visit for a physical examination, CAG had guessed that he would never see this patient again. Over one year later the patient returned, accompanied by his wife. She had apparently done some arm twisting to get him to come in for the long-awaited physical examination, saying, “Since you fixed his foot with that injection, I was hopin' you could fix the rest of him.” CAG has learned that a missed follow-up visit may be a sign of a patient doing well.
This Saturday morning, JTL received a message via his pager stating, “Patient with chest pain, please call ASAP.” After repeated attempts to reach the patient on the cellular phone number, he finally got through. The patient had been waiting for the return call from JTL rather than driving to the nearest hospital. “I wasn't sure which hospital my insurance would allow me to go to,” commented the patient, who was still having chest pain. Ultimately, JTL directed him to the nearest hospital emergency department, where he was diagnosed with an acute myocardial infarction and treated appropriately. It is indeed a sad state of affairs when patients wait to hear from the doctor's office or the insurance company before going to the nearest hospital for care—even in the middle of a myocardial infarction.
Copyright © 1999 by the American Academy of Family Physicians.
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