Diary from a Week in Practice
Am Fam Physician. 2000 Apr 15;61(8):2367-2368.
It's always hard to deliver bad news. With practice, we learn ways to soften the blow, so there won't be as many pieces to gather up afterward. Today, however, JRH dealt with perhaps his youngest case of disappointment. A weary and worn six-year-old boy arrived with his equally weary and worn mom, seeking help for a “really bad cough.” JRH diagnosed bronchopneumonia and prescribed an antibiotic, fluids and extra rest. Then mom asked the question on both of their minds: “What activities will he be allowed?” Our rule here has been that symptoms above the neck do not preclude athletics, but those below the neck do. “Does that mean no baseball?” When JRH replied yes, the devastation wrought by that news was almost too deep and intense. The downcast face and the prominent lower lip told JRH that for some wounds, there is no salve. Without ever coming to bat, mighty Casey had just struck out!
In visiting with the Hungarian parents of an infant during a well-child visit today, JTL discovered that the infant had been transitioned from breast to bottle since their last visit. After having difficulty with choking and spitting up during and after bottle feeds, the parents had turned to a “slow-flow” nipple that they had found in a local department store. The couple added that, in Hungary, all baby-bottle nipples are sold “closed,” so parents can punch as many holes as it takes for their baby to feed well. Generally, the number of holes increases as the infant matures. JTL was intrigued to hear of one solution to the common problem of “quick feeding,” which frequently frustrates infants being weaned from the breast to the bottle. Infants feeding from the breast are accustomed to the stronger, more prolonged sucking required; if they are transferred to a bottle without a “slow-flow” nipple, they are subjected to a stronger flow of formula than they can accommodate.
CAG has found skin surgery to be an integral part of his practice. It seems to him that it is much easier to persuade a patient to return for excision of a questionable lesion when the patient is returning to familiar surroundings and does not have to wait for a referral. Sometimes, the ability to expedite the process is useful as well. CAG has been treating an 89-year-old lady who had a “by the way” comment on a routine visit about a bothersome “pimple” just beneath her right nares. The nodule was 4 mm and, according to a family member, growing rapidly. She was scheduled for an excision in the following week. At her follow-up visit, the lesion seemed significantly larger, with heaped-up borders and the formation of a central keratotic plug. Fusiform excision was performed. The pathology report diagnosed keratoacanthoma with squamous cell carcinoma in situ at its base, fully excised. CAG was pleased with the result and convinced that this lesion might have become more invasive and its removal more disfiguring had she gone through the usual wait in seeing a subspecialist, especially considering her hesitancy to have the procedure done in the first place.
Most family physicians are involved with the community where they live and work. For most of us, the involvement is multiple and varied. We serve the community we live in, with motives that personify the motto “Caring for America.” Today JRH traveled to the local high school with some of the tools of his trade: a blood pressure cuff, stethoscope, otoscope, eye chart, tongue blades, etc. His purpose was to perform a few sports physicals for some high schoolers who had missed the summer physicals given by a consortium of providers in this area. When all was said and done, and all the forms filled out, JRH was treated to one of the intangible rewards of community service: the high school was holding an assembly and press conference for two of the athletes who were signing scholarship grants as they graduated to the next level. They both beamed because their accomplishments had won them this honor. JRH found himself beaming, too. The rewards for being a family physician are often without price.
WLL has had a number of patients with severe yeast vaginitis who have achieved symptomatic relief after a single oral dose of 150 mg of fluconazole, only to have their symptoms recur three to five days later. Virtually all of these patients have complete resolution of symptoms with a second 150-mg dose of fluconazole. Therefore, WLL has begun to prescribe two tablets for patients with moderate to severe infection. He tells the patient that if a single tablet works, save the second tablet for a second infection—and return for an office visit if the symptoms do not resolve. If the first tablet does not completely relieve the symptoms or if the symptoms recur after a few days, the second tablet can be taken. He also recommends using probiotic capsules of lactobacilli GG (LGG) in these cases. However, WLL's experience with this “two-dose fluconazole” plan had not been scientifically evaluated, at least until recently. Dr. Jack D. Sobel, chief of the division of infectious disease at Harper Hospital in Detroit, performed a controlled trial of single- versus double-dose fluconazole for severe and recurrent monilial vaginitis. In severe disease, the cure rate was 73 percent with the single dose and 86 percent with the double dose (Fam Pract News, October 15, 1999:48).
During the annual health care maintenance visit, or preventive medical examination, JTL frequently reminds his patients that the “physical exam” component of the visit is generally not nearly as informative as the history. Today, JTL was surprised by a remark made by a 38-year-old woman who, returning to him after a recent maintenance examination, was concerned that he had neglected to obtain the “usual” screening laboratory tests (i.e., a comprehensive metabolic panel, complete blood cell count and lipid profile). Despite JTL's review of the many consecutive years of completely normal laboratory tests previous physicians had obtained, and his reassurance that the patient is in excellent health, she remained dissatisfied and commented, “I thought 90 percent of the physical was the lab work!” Ignoring the obvious incongruity of this statement, JTL shared his concern that this patient had been “programmed”—by previous physicians and her insurance company—to expect a (free) battery of tests on an annual basis, even in the absence of data supporting this practice. JTL hopes that family physicians in training will try to reverse this trend and place more emphasis on their ability to obtain a thorough history and perform a relevant physical examination, while de-emphasizing the role of nonessential tests.
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