Diary from a Week in Practice

Am Fam Physician. 1999 Nov 1;60(7):1965-1966.

Monday

In a previous Diary entry (August 1994), WLL reported the anecdotal success of a supersaturated boric acid solution applied to the toenails twice a day for six to 12 months to treat onychomycosis. Today, he learned of another topical treatment for this problem when he saw a local rancher for a follow-up visit about his onychomycosis. “I told you it would work. You owe me a quarter,” bragged the patient. “My mama always knew what would work.” Indeed, his toenails looked clean, with no sign of the thickened mycotic nails of only six months ago. WLL pulled a quarter out of his pocket and paid off the debt. What had worked? The patient had rubbed Vicks VapoRub on his toenails twice a day. Although this was WLL's first patient to try this therapy, it was not the first time WLL had heard of it. He had heard of this “home therapy” from Joe Graedon, a friend and author who had told WLL of a similar case. Vicks VapoRub contains camphor, menthol, eucalyptus oil, cedarleaf oil, nutmeg oil, petrolatum, thymol and turpentine oil. Joe says a number of these ingredients have antifungal activity, and he considers the treatment to be inexpensive and safe. It may be safe, but it was not inexpensive. It cost WLL a quarter.

Tuesday

CAG finds that a common complaint among his patients who take warfarin is the difficulty in knowing what dose to take. Combining 1-, 2- and 5-mg tablets can get confusing. In addition, a monthly copayment may be required for each tablet strength. Thus CAG found a recent article in American Family Physician quite helpful (Horton JD, Bushwick BM. Warfarin therapy: evolving strategies in anticoagulation. Am Fam Physician 1999;59:635–46). The article suggests using a single tablet strength and varying fractions or multiples of that tablet each day. Dosages may be changed as needed by adding or subtracting 10 to 20 percent of the cumulative weekly dosage evenly during the week. CAG has changed most of his patients' prescriptions to 5-mg tablets and uses variations on this, always monitoring the total weekly dosage. His patients have found it an easier, more economic and less wasteful way to take the medication, because tablets of varying strengths are not left over.

Wednesday

It seems that as each year passes, we try to select methods and procedures to serve our patients better than we did the year before. One of the greatest joys of being a family physician is the ability to continually learn throughout one's career. With this in mind, JRH performed a pilonidal cystectomy in the office according to the method detailed by Dr. Robert B. Benjamin (Benjamin RB. Atlas of outpatient and office surgery. Philadelphia: Lea & Febiger, 1994). All went well, and both patient and doctor found this approach to be particularly successful. Benjamin's suggestion to use gauze and Monsel's solution to pack the wound was a fresh approach for JRH, and one that made the treatment of pilonidal cysts less forbidding and more gratifying.

Thursday

WLL is seeing more and more men over the age of 40 years who are coming in for preventive medical examinations at their spouse's urging. These examinations allow WLL to not only check the prostate but do a complete preventive evaluation, including age-appropriate risk screening, immunization and cancer screening. Our local referral urologists (one of whom is the past president of our state's chapter of the American Cancer Society) are encouraging us to use “age-specific” prostate-specific antigen (PSA) levels when evaluating patients. WLL uses a formula to remember the critical numbers. Take the patient's age and round it down to the nearest decade, and then divide by 10 and subtract 1.5. For example, WLL is 47 years old. So, round the 47 down to 40, divide by 10 (result = 4.0) and subtract 1.5 (result = 2.5). In other words, for men between the ages of 40 and 49 years, a PSA above 2.5 should require more investigation. For men 50 to 59 years of age, the PSA requiring investigation is 3.5; from 60 to 69 years, it is 4.5, and from 70 to 79 years, 5.5. A PSA that increases more than 0.75 in one year requires investigation. Because there are no data, to WLL's knowledge, to conclusively prove that these values are “right,” you may want to check with your consultants before using them.

Friday

Today, a 12-year-old girl and her worried father visited the office. After seeing several other physicians, the daughter still had the sinus symptoms that had led them to seek treatment for her. None of the previously recommended remedies had worked, and her father was convinced that something was terribly wrong. JRH decided to listen first and act second. This proved to be a good strategy because the patient and her father had some pent-up frustrations that needed an outlet. After an appropriate interval, JRH clarified that the excess mucus being produced was the beginning of the cascade of symptoms, so he prescribed 1,000 mg of vitamin C twice daily for short-term use and ordered pertinent sinus radiographs. A week later JRH was pleased to receive a handwritten note of thanks from the patient's father and the news that the vitamin C worked great—no more mucus, no more symptoms and no more frustration, just gratitude.

Saturday/Sunday

It was near bedtime on a Sunday night when CAG received a call from his office nurse. She was having severe back pain associated with subluxation of a rib and hoped CAG could manipulate the rib back into place the way JRH had done a few months earlier. Although CAG had never performed this maneuver (we call it the “butterfly” maneuver), he quickly called JRH and was given a lesson over the telephone. He then met his nurse, her husband and their three sleepy boys at the office. The subluxed rib was reduced and her pain was relieved “by 80 percent.” CAG was thankful the next morning not only for a well-rested nurse but also for a partner who is a great teacher, even over the telephone.

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


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