Diary from a Week in Practice
Am Fam Physician. 2000 Feb 1;61(3):668-670.
After 20 years of practice, JRH has days when, with just a few clues, the diagnosis seems obvious. Last week, a middle-aged woman (a mother of three) with pain in the right upper quadrant came in for evaluation. Physical examination quickly showed a positive Murphy's punch. What could be easier? JRH ordered an ultrasound of the gallbladder, gave the patient a prescription for codeine-based pain medication, advised avoidance of high-fat foods and scheduled a follow-up visit in one week to discuss surgery. Today, however, the sonogram was negative, the pain was still present, and a new clue appeared: grouped vesicles on a red base in a dermatomal distribution. Alas, after 20 years of practice, this diagnosis was also easy. The only trouble was that it was not the same as the first diagnosis. JRH realized once again that the practice of medicine teaches us not only wisdom but also humility.
JTL truly enjoys the challenge of working with patients who smoke or chew tobacco. His experience with smoking cessation programs has been extensive, particularly during the course of his military medical career. Today, one of his more successful patients commented, “I'm smoking ‘OPs’ only.” Wondering if he had missed something, JTL inquired about the phrase “OPs.” “Other people's,” exclaimed the patient, obviously pleased that he had made such progress.
Our first check-up for newborns is usually one week after birth. This gives us a chance to spot any emerging problems and to encourage the new parents. After practicing medicine for 23 years, JRH occasionally thinks he has heard of just about everything. He felt that way once again when the mother of four children arrived for the first office visit of her born-at-home son. JRH noted discharge from the infant's left eye and mentioned how a small nasolacrimal duct was the cause of the discharge. JRH mentioned that it was rare to need antibiotics for this condition. Just then the mother said, “It's not necessary at all. I put a drop or two of breast milk in his eye and the whole thing clears up.” JRH learned later that night from his daughter, who is also breastfeeding, that this remedy is mentioned in Breastfeeding Your Baby, by Sheila Kitzinger (New York: Knopf, 1998).
One of WLL's patients with psoriatic arthritis particularly appreciated the effects of methotrexate, with a significant reduction in joint symptoms and improved mobility. However, he began to experience increased frequency and intensity of his previously infrequent attacks of aphthous stomatitis. Methotrexate-induced stomatitis is not an uncommon side effect. An oncology colleague who uses allopurinol mouthwashes for management of fluorouracil-induced stomatitis (Porta C, Moroni M, Nastasi G. Allopurinol mouthwashes in the treatment of 5-fluorouracil-induced stomatitis. Am J Clin Onc 1994;17:246–7) has anecdotally found it to be helpful for methotrexate-induced stomatitis. He recommends that patients dissolve a 300-mg allopurinol tablet in 60 mL of water (5 mg per mL) and “swish and spit” (without swallowing) 5 mL four times a day starting at the initiation of the first ulcer and continuing for three to five days until the pain is resolved and the ulcers are healing. WLL's consultant says the literature on this therapy (at least in stomatitis associated with fluorouracil therapy) states that it is well tolerated, inexpensive and has no effect on the underlying disease (Elzawawy A. Treatment of 5-fluorouracil-induced stomatitis by allopurinol mouthwashes. Oncology 1991;48:282–4), although it is not labeled for such use by the U.S. Food and Drug Administration.
Three years ago, JTL had the opportunity to spend three days at a seminar with Dr. Eric Odeblad, a biophysicist and gynecologic researcher from Sweden who has spent nearly 40 years investigating the properties of the uterine cervix that are instrumental in the normal fertility of women, including the production of cervical mucus. Since then, with each Papanicolaou smear and colposcopy, JTL has had the opportunity to educate women about this much-ignored component of fertility. Previously, JTL had considered the watery, stretchy, clear fluid that remained attached to the spatula or brush to be nothing other than a nuisance. Now when performing speculum examinations for reproductive-aged women of normal fertility (not those using oral or subcutaneous contraceptives), JTL informs them of this essential component of their fertility, without which any sperm introduced into the vagina would die within a matter of minutes. Today, one of JTL's patients commented that she had always considered this vaginal discharge to be a sign of poor hygiene or infection. More regrettably, she had, on more than one occasion, been diagnosed with vaginitis by previous physicians and received prescription therapies for this normal sign of fertility. JTL wondered how many other family physicians were also ignorant of the essential role of the cervix and cervical mucus in human fertility.
Today, JTL again experienced being with one of his patients at the time of death. In this case, JTL had been at home with his family on Sunday when he received a call from the nursing home where he had admitted a patient on the previous day. The patient, Bill, had multiple medical problems but had been in notably good spirits with no signs of imminent deterioration. The nurse had called to alert JTL that Bill had developed sudden respiratory distress. JTL was able to speak with Bill, who was clearly in dire straits, likely because of pulmonary edema. After instructing the nurse to have him transported to the nearest hospital emergency department for definitive care, JTL hung up the telephone and awaited the call from the emergency physician. However, a small voice told JTL to go to the nursing home rather than waiting for the ambulance transport and hospital evaluation. Arriving at the nursing home just as Bill went into cardiac arrest, JTL was able to assess the situation, pray quietly over this now deceased patient, and call an end to the resuscitation based on his knowledge of Bill's medical condition and wishes. Certainly, JTL reflected, it is a privilege to share in the final moments of our patients—and he was thankful for the “small voice” that prompted him to leave his family to be with his patient.
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 © 2000 by the American Academy of Family Physicians.
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