Diary from a Week in Practice

Am Fam Physician. 1999 Nov 15;60(8):2267-2268.

Monday

Today was one of JRH's psychiatry days. Several patients came to visit for management of depression and a few for help with anxiety disorders, but the most intriguing patient came for something entirely different. During the course of the social history, JRH discovered that she had recently and successfully quit smoking. JRH paused and inquired how she was able to break this habit. She was quick to respond, because her story intrigued even her. Less than a year ago her father had been diagnosed with lung cancer and was not given long to live. In short order, the patient noticed that she had developed a constant pain in her left arm. As her father's disease progressed, she made the decision to stop smoking. As soon as she did, the arm pain abated and disappeared. JRH marveled at how the human mind played such a powerful role not only in creating “disease” but also in encouraging wellness.

Tuesday

Which is a truer saying:

“Experience is the best teacher,” or “It's the exception that proves the rule”? JRH saw his first patient of the day, a young girl of 17 years who wished to have a piece of glass removed from her heel. She had stepped on a sliver of glass, which broke off in her foot. Several attempts to remove it had been fruitless. After three days, walking was still painful and, according to the patient, she “could feel it going deeper” into her foot. JRH began to numb her heel, all the while pronouncing that his 20 years of experience made him cautious to predict success in this endeavor. Just as he was warming up to his soliloquy, JRH injected a little more lidocaine and lo and behold, the remainder of the sliver began to appear right before his eyes. Responding to the moment, JRH quickly changed the story line from “No guarantee of success” to “How wonderful it is to be blessed with success from such a simple maneuver.” What would you say is the take-home message for JRH?

Wednesday

A friend of WLL's, Gil Solomon, M.D., wrote, “Last March, I ran the L.A. marathon (well, actually I ran half and walked half). During training, I had a mild tendinitis in my Achilles tendon. Oral nonsteroidal anti-inflammatory agents (NSAIDs) were not an option because of a previous gastritis. I curbside consulted with an orthopod who suggested ice and topical ketoprofen gel (20 percent). After 10 days of treatment, my Achilles tendinitis was resolved.” After reviewing the positive European literature on topical NSAIDs (BMJ 1998;316:333–8), WLL found a compounding pharmacist who will mix the gel for his patients. A 2.5 percent gel is commerically available in Europe, but the American compound of that strength is not as effective. Start with a 10 percent gel and then try 20 percent if necessary. Although other NSAIDs have been used in gels, WLL elected to try ketoprofen because it has performed better in comparative trials (Clin Ther 1996;18:497–507). He prescribes the gel to be applied three times daily for the treatment of acute soft tissue injuries (occurring within 48 hours) or mild osteoarthritis. So far, he and his patients have been delighted—especially the “weekend warriors,” who always seem to prefer to rub something on over taking a tablet. If you don't have a compounding pharmacist near you or your pharmacist wants more information, call St. John's Pharmacy in Santa Monica at 310-453-6553.

Thursday

Because of problems with emerging antibiotic resistance, family physicians are repeatedly reminded to use antibiotics appropriately. A woman visited CAG for management of a sore throat, low-grade fever and mild rhinorrhea. A rapid streptococcus test was negative, and after some discussion she agreed to a throat culture and symptomatic treatment without antibiotics. Three days later, her culture results showed “heavy growth of methicillin-resistant Staphylococcus aureus (MRSA)” and “normal respiratory flora.” However, when the patient was called at home she was asymptomatic and feeling back to normal. She did note that her husband was paraplegic and had been hospitalized multiple times, thus providing a possible source for her colonization. CAG was pleased that he had not tried to “kill off ” any competition the MRSA will have for survival. In an interesting sidenote, CAG learned in a later discussion with an infectious disease subspecialist that if his patient's colonization with MRSA continued, a film of mupirocin cream applied to the back of the throat with a cotton swab might help eradicate the organism. A follow-up culture could then be performed.

Friday

A 52-year-old woman visited CAG for evaluation of recurring bouts of abdominal cramping with occasional bright red blood in her stool that she related to hemorrhoids. The patient had a previous diagnosis of irritable bowel syndrome. A colonoscopy three years earlier had shown “mild inflammation” at the ileocecal junction, and she was assured that all was well. Her medical history included hypertension and a hysterectomy performed seven years previously, and her only medications were a beta blocker, oral estrogen and a calcium supplement. With her worsening symptoms and a family history of colon cancer in her father, repeat colonoscopy was recommended. Colonoscopy demonstrated an irregularly shaped mass in the cecum that was at least 2 cm in diameter. Biopsy revealed a tubular adenoma. A computed tomographic scan was negative. The patient continued to have sporadic worsening pain and she was becoming anemic, so surgery was recommended. The surgeon performed a right hemicolectomy, describing two lesions that “obviously penetrated through the entire wall, but could not tell cell type.” As all involved braced for the diagnosis of colon cancer, the pathology report caught us by surprise, revealing endometriosis as the culprit with no evidence of inflammatory bowel disease or cancer.

Saturday/Sunday

Bernie and “Barney” (her nickname) met on a ballroom dance floor in Chicago more than 50 years ago and went on to become quite distinguished in their field, teaching hundreds of others to dance over the years. This past week Bernie passed away at home rather unexpectedly, and JTL was called to their home to pronounce the death and to be with Barney and their daughter, who had just arrived from out of state. JTL, who had enjoyed hearing Barney speak of her memories of Bernie, the dance master, now listened as Barney said, “I don't know what to do . . . he always took care of me.” After a time of prayer with the family, JTL gave Barney a hug and let her know that he would make himself available whenever she needed him. Yet, as he left their home, JTL reflected on how difficult it would be for Barney to enjoy the dance without her lifelong partner.

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.


Copyright © 1999 by the American Academy of Family Physicians.
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