Diary from a Week in Practice
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Am Fam Physician. 2000 Aug 1;62(3):536-538.
In the midst of a busy day, it is always helpful to have one or two “simple-to-handle” skin-care problems on the schedule—both for diversity and efficiency. Many times the diagnosis is obvious, and there is no need for confirmatory laboratory tests. This saves time, and it's a chance to ease the patient's fears through education. Today, JRH saw a child who had sores that had just erupted. “We found them on her hands and feet and buttocks,” the anxious parents exclaimed. JRH went to work and found more sores in her mouth and immediately gave the diagnosis: hand, foot and mouth disease. He explained how this rash comes in epidemics and generally is tender to the touch. He noted that he doesn't see this particular rash on the buttocks. JRH then advised the parents on how to deal with the mouth ulcers yet to form and dismissed the family, thinking how neatly the encounter had progressed and how he could get back on schedule if he had a few more cases like this one. After the family left, he decided to double-check his advice in one of the dermatology texts. And, there it was: “This rash sometimes appears on the buttocks.” JRH got the real patient education today! So, another truism of family medicine is evident: the family physician's education never ends.
Karen and her husband, attempting to achieve their first pregnancy, attended classes on natural family planning. They had patiently charted out her cycles, which had been marked by excessive premenstrual spotting and postmenstrual brown bleeding. After testing revealed the lack of adequate progesterone during her luteal phase, Karen had not tolerated an intramuscular progesterone protocol. JTL then turned to the literature on oral micronized progesterone, and requested a pharmacist to produce a slow release form of the progesterone. After months of adjusting the dosage of oral progesterone (now, 50 mg per day) during her postovulatory (luteal) phase, Karen had finally achieved two “normal” cycles, with normal menses. However, she had become increasingly despondent over her inability to achieve pregnancy and today requested a subspecialist referral. Glancing at her chart, JTL noted that Karen was 20 days into her luteal phase (four days longer than a normal luteal phase). “Why not obtain a urine HCG before we continue this conversation?” was JTL's advice. The reader can imagine the joy that Karen and her husband (not to mention JTL) felt when discovering that they had achieved pregnancy. After JTL's first ever “group hug” in the office, arrangements were made for Karen's first maternity care visit with JTL, and the consultation to the subspecialist was placed in the circular file.
It's especially fun to see the kindergartners and preschoolers come for their physicals in the days and weeks before school starts up again. Today JRH, while getting a cup of coffee, eavesdropped on a child's eye examination. His nurse had switched the eye chart with letters to the one with symbols for this little four-year-old girl. JRH found himself captivated by this child in particular because she was from England. She paused on the third line. Soon his nurse encouraged her to identify the rectangle with the star and four stripes coming off to the right. Still she hesitated. “What's wrong? Can't you see it?” her mother asked. “No, mummy, I don't know what it is!” Her mother then took a look and echoed “I don't know what it is, either” in her English accent. Peering around the corner, JRH stopped to look more closely, just as the nurse announced “It's a flag.” JRH offered that maybe we should have a more culturally correct eye chart—one with the Union Jack and not the Stars and Stripes.
Life sometimes has the oddest twists. Today, JRH saw one of his asthmatic patients who comes in frequently. His asthma was no more profound than usual, but this episode came on the heels of two broken ribs, making the asthma that much more difficult to tolerate. In inquiring about the how and why of this most recent relapse, JRH discovered the real reason for this episode. The patient had taken the “long white pill,” thinking it was a brand of theophylline, but instead it actually turned out to be the pain pill prescribed for his broken ribs. This mishap had occurred three times in the past three days. The mistake had taken its toll on JRH's patient. No further history was necessary—only treatment. Fifteen to 20 minutes later, after use of a nebulized bronchial dilator, the patient had acquired a measure of control over his breathing. Then, he and JRH discussed making a game plan to avoid this mishap in the future.
Once in a while, WLL will run into someone who claims to be allergic to Lidocaine. One of WLL's friends and mentors, Bob Persons, M.D., teaches that Lidocaine allergy is truly rare. He says that folks are allergic to the preservatives in the multidose Lidocaine solution. He goes on to say that by using the single-use Lidocaine ampule, which usually has no preservative, one is usually safe; however, you may want to try a small intradermal bleb of 0.1 cc and wait 10 to 15 minutes to be sure there is no reaction. In addition, you may ask (as WLL did), “What about Marcaine?” to which Dr. Persons would admonish, “Marcaine is also an ‘amide’ so Marcaine will probably cross-react with patients who are allergic to Lidocaine.” Dr. Persons says that chloroprocaine (Nesacaine) or procaine (Procaine, Novocain) should be safe in patients with true “amide” allergy because they are esters.
Nevertheless, remember that a person allergic to one of the preservatives found in multidose vials may still react to the preservatives.
There is no doubt that having a medical student or resident in the office adds to the day's work. But the rewards for this effort, although not monetary, are great indeed. WLL received a letter from a recent graduate. She said, “Your long-lost student is writing to give you an update on what has been happening since I left there. I interviewed at five obstetrician/gynecology residencies and nine family medicine residencies. After the interview process was under way, I felt even more confident that obstetrics/gynecology did not offer the spectrum of training in women's health for which I was looking. My rotation with you did much to help me in my decision to choose family medicine. By watching you, I saw total care for a woman and her family coordinated by one physician whom the patient trusted. Family medicine will give me the chance to provide care in a less fragmented manner. I also enjoy women and children's medicine and did not want to give up either. Graduation was June 4th. All of medical school came and went in a flash! It seems just yesterday that I was attending orientation for my first day of medical school. At the graduation convocation, I was privileged to receive the Outstanding Senior Award for the Department of Family Medicine. It was a wonderful surprise.” Congratulations Angela. You made us proud. Because of students like you we feel very confident about the future of family medicine.
This is one in a series by Walter L. Larimore, M.D., John R. Hartman, M.D., and John T. Littell, M.D., three family physicians in private practice in Kissimmee, Fla.
Copyright © 2000 by the American Academy of Family Physicians.
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