Diary from a Week in Practice
Am Fam Physician. 1999 Sep 1;60(3):796-798.
WLL recently learned about a new digital camera device that can instantly identify eye problems in infants and toddlers. This camera may help detect conditions that are the most common causes of preventable blindness in children. The device, called EyeDx, works by using a lens to capture a high-resolution color image of the patient's eyes. The image is downloaded to a computer and screened for such conditions as cataracts, tumors and nearsightedness, as well as amblyopia. Results of the tests are available in minutes, and parents can be told if their child's vision is normal or if a visit to the ophthalmologist is necessary.
Being a family physician can sometimes provide a unique insight into a situation. Today, SEF saw a six-year-old boy who presented with symptoms of nausea, abdominal pain and vomiting. It seemed like a pretty typical case of viral gastroenteritis, but SEF also knew that on the previous day the boy's mother had been admitted to the hospital with acute cholecystitis and that she had undergone surgery just that morning. SEF asked the boy if he was worried about his mother, and he responded shyly that, yes, he was. SEF and the boy's father offered reassurance that his mother was going to be just fine and the nausea improved. Physicians are reminded every day of the ability of the mind to affect the body.
A young girl had visited WLL three times for urticaria on her forearm that had failed to respond to a variety of conservative therapies. Today, WLL noted some linear scratches on the youngster's forearms. Wondering if the marks represented excoriation or contact dermatitis, WLL inquired about their origin. The girl informed him that the scratches were from the spines of her new pet—a hedgehog. He recommended that she continue treatment with an oral antihistamine, oral histamine H2 antagonist and topical corticosteroid, and instructed her not to handle the hedgehog for one week. WLL recalled that a number of skin disorders had been reported in persons who handle hedgehogs, and he knew that these animals were becoming increasingly popular as pets. A search of the medical literature turned up a recent report of three cases of “hedgehog hives” (Fairley JA, Suchniak J, Paller AS. Hedgehog hives. Arch Dermatol 1999;135:561-3). The report indicates that such reactions are being treated more frequently by dermatologists. In addition, more study of the cross-reaction of animal antigens is needed, since allergies to other pets may be predictive of hedgehog hives. A second look at the patient's medical record showed that she was allergic to cats and dogs. He did not look forward to the follow-up visit the next week, knowing he would have to tell her to try to find another type of pet.
“It's working, Doc.” “What's that?” JRH replied. The patient answered, “That medicine that begins with a ‘P.’” After ruling out Prozac, penicillin, Pepcid, Proscar and prednisone, JRH zeroed in on the intended drug: potaba. This is one of the few treatments that holds any promise for patients with Peyronie's disease. Following the advice of one of our local urologists, JRH had prescribed an extensive regimen of six tablets four times daily, hoping that the patient would give it a fair trial of three months. Although the goal of treatment was relief of pain on erection, the 45-year-old man was happy to report that the medication was working well. Now he was enthused because he felt that the initial stages of plaque resolution were beginning. Taking this medicine for another three to six months was worth the trouble to this patient. If you aren't familiar with potaba, be sure to read about it before prescribing it, as there are significant interactions and adverse reactions you and your patients need to be aware of.
A patient visited CAG for follow-up of obesity, hypertension and obstructive sleep apnea. Three months earlier, sleep studies had shown severe sleep apnea, which explained the patient's chronic fatigue. One month after starting treatment with continuous partial airway pressure (CPAP), his fatigue had resolved and his blood pressure was improving, and work was begun on weight loss and weaning antihypertensive medications. During this visit, the patient again reported fatigue and sleep problems, but this time with a smile. He was accompanied by his wife and new daughter, delivered by CAG two weeks ago. CAG could empathize, since he has been sleep deprived by a four-week-old daughter of his own. They compared notes and agreed that the present joy was well worth losing a little sleep. CAG reminded the new dad that these moments of being awake in the middle of the night can give a dad the chance to pray for his daughter. The patient laughed and asked, “Can I pray for the boys who will try to date her?” CAG and the patient both laughed, knowing that they now shared more of a bond than the usual “doctor-patient” relationship.
Patients often call after hours requesting that prescriptions be telephoned in to pharmacies. One of the policies at our practice is that the physician who is on call does not phone in prescriptions for patients, with the possible exception of patients with whom the physician is well acquainted. Today, a man insisted that a prescription for a controlled pain medication be called in for him after hours, and he seemed very dissatisfied with JTL's refusal to call in the prescription. Since the man was a patient of JRH, JTL felt the need to discuss the case with JRH first. JRH related his response to a patient who had made a similar plea in the past and who had refused to understand the prescription would not be called in: “Let me put it to you this way. If you were my own mother, I wouldn't call in this prescription for you. It's simply not the best medicine, and I want you and my mom to get the very best medicine. So, to get this medicine, a doctor needs to see you. It can be the emergency department doctor tonight or me tomorrow. Which would you prefer?” JTL smiled at this suggestion and the caring way the denial had been administered. The patient finally gave up and, presumably, waited to be seen the following day in the office. One of the skills that every physician must master is learning how to deny a patient's request when it is not in the patient's best interest and, while saying no, providing other, safer options for the patient to consider.
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.
Copyright © 1999 by the American Academy of Family Physicians.
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