Diary from a Week in Practice



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Am Fam Physician. 2000 Mar 1;61(5):1313-1315.

Monday

During the cough and flu season, the treatment of URIs is our bread and butter. Although we see many cases each day, we try not to be lulled into a sense of complacency. Indeed, each patient seems to add a new wrinkle to an age-old problem. Today, a particularly familiar patient presented. It was JRH himself, who had been putting up with several annoying symptoms for one day too long. WLL listened attentively and prescribed the hoped-for Bicillin. And then, just as JRH thought the encounter was completed, WLL mentioned how important it has become for him to wash his hands frequently and how this one practice has helped him avoid catching germs himself. JRH nodded in agreement. WLL then delivered the final take-home message: “It might be a good thing, too, to change your white coat.” JRH looked down, seeing the discoloration around his cuffs. “I guess you're right, Walt. I'll get a clean one right now!”

Tuesday

One of WLL's patients who has autism is blessed to have a mom who stays connected to a large network of parents of autistic children via the Internet. She has shared with WLL several recent case reports that claimed improvement in autism. One such intervention involves the intravenous injection of secretin, a gastrointestinal polypeptide. This association was first suggested by a mother who noticed improvement in her child after a gastrointestinal endoscopy, during which secretin was administered. Inexpensive and reasonably free of side effects, this substance is now undergoing clinical trials at a number of medical centers (http://www.autism.com/ari/secretin2.html). A small randomized clinical trial has shown that a single dose of synthetic human secretin is not an effective treatment for autism or pervasive developmental disorder (N Engl J Med 1999;341(24):1801). However, the authors of that study found several weaknesses in their own work. Given that family physicians caring for children with autism have so few options to offer and that virtually every month of development is crucial in children, secretin may be an option family physicians will want to know more about. A reasonable Web site to explore for more information is: http://www.autism.com.

Wednesday

Have you heard of the “AB/CD Rule” for antihypertensive prescriptions? (Lancet 1999;353: 3008–13). WLL thinks this gives family physicians a great new rule for starting antihypertensive agents in patients under age 50 and switching between single agents, before adding a second antihypertensive drug. This large crossover study of untreated hypertensive patients 22 to 51 years of age in the United Kingdom examined rotating patients through the four main classes of antihypertensive agents: (A) the ACE inhibitor lisinopril, (B) the beta blocker bisoprolol, (C) the calcium channel blocker nifedipine and (D) the diuretic combination of hydrochlorothiazide and triamterene. Each patient was given one of the medications at random for a month. After a one-month wash-out period, the second medication was tried. The process was repeated until each patient had tried each of the four medications. Thirty-nine percent of the patients achieved target blood pressure with their first drug. However, this response rate rose to 73 percent with rotation of the drugs—meaning that 73 percent of the patients achieved target blood pressure levels with one of the four single drugs. The most significant responses were to A and B and to C and D. In addition, treatment responses were better to A and B than to C and D.

Thursday

CAG was thrown a curveball by one of his patients today. This 40-year-old man was eager to help CAG understand his chronic low back pain and therefore brought in some old back x-rays for CAG to review. However, the large envelope contained only one film that appeared to be an oblique and rotated view of the thoracic and upper lumbar vertebrae. The vertebral bodies were small, and the sternum appeared segmented. Perplexed and thinking that perhaps this was the x-ray of a child taken from a strange angle, CAG checked the name on the film. Although the last name matched the patient's name, the first name was different. “Who's Chase?” asked CAG. Dismayed and embarrassed, the patient exclaimed “Oh man! I brought the wrong x-ray. That's my dog!” Embarrassed, the patient let CAG who enjoyed stumping the other doctors in the office with the canine x-ray, keep the film.

Friday

One potential long-term consequence of abdominal hysterectomy is the development of urinary incontinence in later years. Today, JTL evaluated a postmenopausal woman who, despite having had a total abdominal hysterectomy 30 years before, demonstrated no signs of stress urinary incontinence. After he commented on her good fortune in this regard, JTL went on to obtain a social history, at which time he discovered that the patient had spent the past 30 years as a bugler in a drum and bugle corps. JTL, himself a vocalist, recognized that this occupation would have enabled her to perform literally thousands of “Kegel exercises” as she exhaled, with the need to slowly and smoothly “squeeze” the air out of her lungs from the most inferior aspect of the diaphragm upward (much like a trained singer does). JTL wondered if there is, in fact, a lower incidence of stress urinary incontinence in trained vocalists, brass instrument players and the like.

Saturday/Sunday

The birth of a newborn child is usually a uniquely blessed event in the life of every father, and JTL's experience this past month provided important lessons for him, as a father and as a family physician. At the births of each of their three daughters, JTL had marveled at the strength and self-control of his wife, Kathleen, in using only “natural childbirth” techniques, including the help of a doula (a female labor support person) with the third daughter's birth. Yet, throughout her fourth pregnancy, JTL's wife had shared her desire to “be present” at this next delivery, rather than have to “focus” on something other than the childbirth experience to cope with the discomfort and intensity of labor. This time, once she had achieved adequate cervical dilatation, a “light” epidural block was administered at her request by a highly competent anesthesiologist. For the first time, JTL was able to work with his wife as her “coach” and assist her with pushing in the second stage. Most importantly, Kathleen was able to enjoy the process of delivering a vigorous infant of 8 lb, 7 oz. JTL was doubly surprised: first, by the ability of the epidural to enhance (rather than detract from) this particular experience of labor and delivery, and second, by the added blessing of yet another beautiful little girl!

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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