Diary from a Week in Practice

Am Fam Physician. 1999 Aug 1;60(2):449-453.

Monday

WLL has found that many patients who participate in outdoor activities do not take precautions against poison ivy, poison oak and poison sumac before they go into potentially contaminated areas. He has found that most patients do not realize that there are steps they can take before they head outdoors to protect themselves from the itchy, uncomfortable rash caused by the toxic oil in these poisonous plants or, failing this, to remove the oil after they've been exposed. He recommends a prophylactic topical medication called bentoquatam. Bentoquatam is the active ingredient in IvyBlock lotion, the only product he knows of that is approved by the U.S. Food and Drug Administration for the prevention of rashes from poisonous varieties of ivy, oak and sumac. Another product he tells his patients about is IvyCleanse, which effectively removes poison ivy toxins. Not only is IvyCleanse excellent for emergency use on the skin after unexpected contact with poison ivy, oak or sumac, it is also invaluable for washing the poison ivy toxin from tools and gardening and athletic equipment.

Tuesday

Some weeks earlier, a distraught patient visited JRH with concerns about her polycystic ovary condition. JRH mentioned a 1998 report in the New England Journal of Medicine touting metformin as a medical treatment for this condition. A few weeks later the patient returned with articles from the Internet giving a lot more detail and rationale for this treatment approach. After reviewing the advantages and drawbacks, including the fact that metformin is not labeled by the U.S. Food and Drug Administration for this indication, a joint (and hopefully fully informed) decision was made to begin a therapeutic trial. After ascertaining that this drug was classified as pregnancy category B, a prescription for one month of therapy was written. Today the patient returned, all smiles. The reasons were clear: her blood pressure had normalized on just 250 mg of methyldopa taken twice daily, her menses had spontaneously reappeared, presumably as a result of the metformin therapy, and she had lost 4 lb. It remains to be seen if the patient will become pregnant, but she has made good progress along that path.

Wednesday

An 18-year-old woman visited SEF today with an unusual injury that was inflicted by a golf ball. The patient had been on the golf course finishing her game when a ball hit her shoulder, bounced up and hit her head. Luckily, her only real injuries were moderate contusions on both areas. Since she was a star player for the high school team, the worst part of the whole experience was embarrassment in front of her friends as well as the fact that she would probably not be able to swing a golf club for a week. Since Florida is the land of golf courses, SEF shouldn't have been surprised.

Thursday

Sometimes it feels pretty good to be a family physician. Television glamorizes the life-and-death situations of medicine, but most days the average primary care physician deals with colds, flus and chronic medical problems. Today, however, SEF saw a two-year-old boy with a life-and-death diagnosis. He had presented earlier in the week to one of her colleagues with an upper respiratory infection and otitis media, and was treated with antibiotics. The mother then returned with the child, since his fever was worse and he was sleeping more than usual. The mother feared dehydration. SEF looked at the child sleeping in his mother's arms and noticed that his neck was hyperextended. During the examination, SEF realized that the boy continued to hold his neck this way and that it was extremely rigid. Taking no time to perform a lumbar puncture in the office, SEF arranged for the emergency department physician to do the procedure. Although he doubted the need, the test was performed, and results showed a cerebrospinal fluid cell count of 980 white blood cells, elevated protein and a markedly decreased glucose level. Later the rapid screen came back positive for Streptococcus pneumoniae, and the boy was given appropriate intravenous antibiotics. Today the child was laughing and running up and down the hall. That picture certainly spoke for itself.

Friday

While eliciting social histories from two new patients, both women over 50 years of age, JTL learned a bit about the mixed blessings of “grandmotherhood” in 1999. After hearing that the first grandmother, now retired, had raised six children who were all still living in the area, JTL commented, “I imagine it's nice to be able to have your children take care of you, after all your hard work raising them.” The patient laughingly replied, “You've got it all wrong, Dr. Littell. Now I've got all the grandkids to take care of while their mamas are out working.” Later in the day, JTL visited with another grandmother who commented on her exhaustion while trying to care for two of her infant granddaughters. JTL sensed the need to be more cognizant of the pressures confronting many grandparents who are helping their children raise their families.

Saturday/Sunday

CAG got an earlier start than usual this morning to visit a patient in the intensive care unit before a busy day began. This particular patient has had a complicated course, with severe ischemic cardiomyopathy following two recent myocardial infarctions and coronary artery bypass grafting. After a review of the patient's laboratory results, CAG adjusted her diabetes medications and thought about the usefulness of hospitalists and extra sleep. On entering the patient's room, he found the patient and her daughter very eager to see him. The daughter expressed her concern that her mother was depressed, but the patient laughed it off. Quite familiar with the patient from numerous office visits, CAG had previously seen this patient cover her emotions with a jovial face. Further evaluation did indeed reveal depression, and therapy with brief bedside counseling, clarification of the patient's medical situation and medication was begun. Improvement was seen by both physician and daughter over the next few days, and CAG finds that he has fewer thoughts about the need for hospitalists.

This is one in a series by Walter L. Larimore, M.D., John R. Hartman, M.D., Stephanie E. Frisbie, M.D., Chad A. Griffin, M.D., and John T. Littell, M.D., five family physicians in private practice in Kissimmee, Fla.


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