Diary from a Week in Practice
Am Fam Physician. 2000 May 1;61(9):2664-2666.
A 24-year-old mother of two who had undergone bilateral tubal ligation visited JTL following hospitalization for the evaluation of right lower quadrant pain. The hospitalist and general surgeon concluded that her pain was likely psychogenic, because the results of the computed tomographic scans and laboratory tests were normal. JTL, reproducing the pain on palpation of the right adnexal region, had referred the patient for diagnostic laparoscopy (to rule out post-tubal syndrome), yet no underlying pathologic condition was revealed. After the patient returned with severe pain at the same site, particularly with prolonged standing or walking and again with reproducible tenderness, JTL obtained a bone scan and studies of the hip and pelvis. These studies were also normal. Today, JTL was prepared to send the patient (who had incidentally lost 12 lb) for a gastrointestinal work-up, when he once again placed his fingers on her thin abdominal wall and elicited the pain. “Bear down,” he requested, and the patient noted worsening pain as he pushed gently along the inferior, lateral aspect of the right rectus sheath. After referring her that day to a general surgeon, JTL learned that his patient had a spigelian hernia, a rare hernia of the abdominal wall that is easily corrected with surgery—adding another diagnosis to that list of causes of right lower quadrant pain in women.
Today, a 35-year-old woman came to the office for evaluation of wrist pain, thinking she sprained her wrist while lifting a large, heavy speaker system up a staircase in her home. The transport job did not go quite as planned and, apparently, at a critical moment, she came close to dropping her end and tumbling down the staircase, speaker system and all. JRH carefully examined her hand and the radiograph, and then examined her hand once again. Right at the base of the third metacarpal, there was significant pain. In addition, the patient could not flex or extend her wrist, lacking 20 degrees of range of motion in each direction. Drawing on a manipulation technique learned in an orthopedic continuing medical education course he attended recently, JRH applied strong traction at the wrist and, using a short quick downward thrust at the base of the third metacarpal, was able to return the out-of-place capitate bone to its proper position. A relieved young woman left the office that day, none the worse for her week of pain and disability. JRH was also much relieved, thankful that he could help her out of the trouble she got herself into.
Some research has suggested that 2 to 15 percent of patients have restless legs syndrome (RLS). After reading this statistic, WLL began to ask patients about RLS and discovered that it was alive and well in his practice. Now, having found this syndrome among his patients, he needed to develop a tool bag to treat it. During his research, he discovered that recent studies support the use of the antiparkinsonian agents pergolide (Permax [Neurology 1998;51:1599–602]) or pramipexole (Mirapex [Neurology 1999;52:907–10, 938–43, 944–50]) for the management of RLS. After checking several studies and all of the numerous options, WLL began offering pergolide to patients. It is available in 0.05-, 0.25- and 1-mg scored tablets. Dosages of 0.1 to 0.5 mg per day seem to work, but the medication must be given in three divided doses per day. Remember to start the dose low and go slow. WLL starts with 0.05 mg per day for two days, then 0.05 mg twice daily for two days, then 0.05 mg three times daily until follow-up two to three weeks later. Further dosage increases can be in increments of 0.25 mg per day every three to five days. Two outcomes can measure the success of treatment: (1) Does the patient feel more rested during the day? (2) Does the patient's sleep partner believe that the medication is working? In WLL's experience, the second question is the most accurate tool for evaluation.
Through the continuity of care that is such a large part of family medicine, we are occasionally able to see a patient move beyond a difficult circumstance to a time of joy. One year ago, CAG was seeing a 28-year-old woman with polycystic ovarian disease and oligomenorrhea who had never been pregnant and had concerns that she and her husband would never conceive. Before progesterone was prescribed to induce a menstrual period, the patient underwent a urine pregnancy test, which was found to be positive. After a few minutes of celebrating, the office laboratory had some bad news—the wrong urine had been used, and the patient's test was negative. Although the patient tried to remain stoic, it was obviously a crushing blow. A year later, this same patient visited CAG to discuss laboratory test results at about the same time JRH saw her as a walk-in patient with fatigue, mood swings and continued oligomenorrhea. After seeing the result of her serum human chorionic gonadotropin test, CAG was careful to check the name, birth-date and record number before telling her it was positive. Her look of shock melted into tears of joy, although after her previous experience there was a hint of reservation and disbelief. Later that week, she returned with ultrasound pictures of her 12-week-gestation infant. The joy had become real.
Many of our patients are becoming Internet-wise. Today, a busy young mother came in with her three-year-old son, who was troubled with a rash. Being enterprising and yet rushed (as most mothers are these days), she decided to look up information about rashes on the Internet. Her differential diagnosis included scabies versus psoriasis versus “other.” Taking the first choice, she bought 1 percent permethrin (Nix) over the counter. She sought JRH's advice when the permethrin had no effect. He listened to her story, congratulated her on her curiosity and then examined her son and delivered the diagnosis: contact irritant dermatitis. Some oral prednisolone liquid and topical corticosteroid cream to be used on the rash were prescribed, and the young boy was back on the road to health. JRH was reminded that the Internet will never replace the indispensable combination of knowledge, experience and compassion that today's family physicians provide.
In our practice, CAG has observed a role for the family physician that he never previously considered—that of the surrogate relative. Distance now separates many extended families, and CAG has found that many of the calls he receives, especially during the night, deal with concerns that people used to discuss with parents or grandparents. Questions such as “Is it safe to use steam from a shower for my two-year-old's cough?” or “How do I check a rectal temperature?” that used to be asked of a parent are now asked of the physician. In addition, a new parent with a screaming child often calls looking for reassurance or an empathetic voice. CAG wonders if family medicine has always been this way or if this is a result of better communication technology that makes physicians available 24 hours a day, combined with the growing distance between family members.
Copyright © 2000 by the American Academy of Family Physicians.
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