Diary from a Week in Practice
Am Fam Physician. 2000 Nov 15;62(10):2250-2252.
Researchers disagree about whether attempts should be made to eradicate Helicobacter pylori in patients who have nonulcer dyspepsia. WLL has one such patient who has not been helped by conservative therapies. Recently, he told WLL he had found a “cure”: taking a dietary supplement called Cynara-SL, which contains artichoke (Cynara scolymus) extract. WLL did a little research and found that there may be validity to this patient's anecdotal experience. High-dose extracts of artichoke leaves have been shown to increase bile secretion by up to 150 percent, what is believed to improve dyspeptic symptoms. The Commission E Monographs of the German Ministry of Health indicate that artichoke is “useful for dyspeptic problems.” Further, the Natural Medicines Database rates artichoke as “possibly safe when used orally and appropriately in therapeutic amounts” and “possibly effective when used orally for relieving symptoms of dyspepsia.” Symptomatic relief of “dyspeptic symptoms” (including reduced nausea, vomiting, flatulence and abdominal pain) occurs in 50 to 92 percent of patients (information accessed October 9, 2000, at http://www.nat-med.com/archives/artichoke.htm). Each capsule of Cynara-SL contains 320 mg dried artichoke leaf extract and one capsule can be taken once or twice daily as needed. At our local pharmacy, it sells for about $12 for 30 capsules.
In the practice of family medicine, JTL has found that patients frequently neglect to follow the physician's recommendations, with obvious ramifications for their health care. As a result, several years ago JTL, while still in solo practice, developed a discharge summary form which, printed in duplicate, allows him to write down his instructions to patients at the time of the appointment. At the end of each appointment, one copy is handed directly to the patient and another remains in the chart. Included on the discharge summary are the pertinent diagnoses, any medication changes, studies ordered and other specific recommendations, including instructions for follow-up. Today, JTL visited with a patient for whom this discharge summary proved useful. The young woman had amenorrhea and had been placed on oral progesterone therapy for seven days to achieve a withdrawal bleed. However, the patient had mistakenly taken the progesterone daily for the past six weeks and presented today complaining of no menses. JTL reviewed the discharge summary in her chart and showed the patient that he had recommended only a seven-day regimen. She then realized her error. This discharge summary has helped JTL avoid uncomfortable situations with many patients over the past several years.
Today, a 21-year-old man presented with hypotension and abdominal pain. ASW treated him for gastroenteritis with intravenous fluids and when he was feeling better, she sent him home. Later, ASW reviewed his medical record and discovered that he had been seen recently for “gastroenteritis with dehydration” four times by other physicians. She asked him to return for further evaluation. At the follow-up visit, he was feeling better but still complained of chronic fatigue and had postural vital signs. His mid-abdomen was tender, especially on the right side and he seemed to have a “natural tan.” Electrolyte testing showed a low potassium level and a normal sodium level. An abdominal computed tomogram was negative for any adrenal pathology. ASW then screened him for adrenal insufficiency with a baseline plasma cortisol followed by 0.25 mg adrenocorticotropic hormone (ACTH) stimulation, given intravenously. An abnormally low cortisol rise at 60 minutes was highly suggestive of adrenal insufficiency. After consulting with an endocrinologist, ASW started the patient on hydrocortisone and fludrocortisone, which greatly improved his symptoms. He then followed up with the endocrinologist for confirmatory testing and work-up for secondary causes of adrenal insufficiency. ASW felt satisfaction not only that she had correctly diagnosed the adrenal insufficiency, but also had been able to remedy a significant problem for this man.
According to a report from the U.S. Public Health Service (JAMA 2000;283:3244–54), most Americans who smoke want to quit but get little help from their doctors, who often don't ask if they smoke or offer treatments. WLL has aggressively treated smoking just like any chronic illness. He believes that spending just 15 to 20 seconds talking to patients about smoking habits can increase the chance that patients will quit. According to the report, a doctor isn't giving appropriate care if he or she doesn't ask two key questions: (1) “Do you smoke?” and (2) “Do you want to quit?” WLL agrees with the American Medical Association, which said the report was a “wakeup call for doctors.” The report stated that 70 percent of Americans who smoke have tried to quit at least once. More than 20 million Americans will try to kick the habit this year. Only 1 million will succeed. Remember that referring smokers for counseling may be important. The combination of medicine and counseling “is highly effective” in getting people to quit, according to the report. The guidelines also urged health insurance companies and government health programs to pay for tobacco cessation treatments and counseling. Only about one half of all insurers currently do so; Medicare does not cover antismoking treatments and only 22 states provided Medicaid coverage for tobacco dependence treatment.
Frequently, JTL finds it beneficial to “allow patients to ventilate” as they present with a variety of psychosocial concerns. Today, in evaluating a patient with a history of chronic obstructive pulmonary disease (COPD) and asthma, JTL found this to be especially true. The patient had initially presented with acute dyspnea and was fearing she may need more aggressive treatment for her underlying COPD. The patient was already taking prednisone for a COPD exacerbation just two weeks earlier. After listening to her lungs, JTL was perplexed given there was no evidence of wheezing or rhonchi, though the patient seemed to be short of breath. As he prepared to write an order for Solu-Medrol, JTL asked how the patient's life was going. She became tearful as she explained the stress she was under, leading to many conflicts with her husband. Following each of the conflicts, she found she was having severe difficulty breathing. Yet, paradoxically, she said she awakens each morning breathing comfortably. As the patient explained this, JTL was able to witness her improved ventilation, the slowing of her respiratory rate and resolution of her presenting symptoms. Clearly, allowing the patient to “ventilate” was all that was required in this patient's case. She left with a prescription of sertraline, which will hopefully assist her in dealing with many of the stresses in her life.
Is there a situation when a family physician can be faulted for taking a thorough family history? In meeting new patients, JTL commonly asks about the nature of the family structure, including placing an appropriate genogram on the master problem list. Today, JTL met a young woman who presented with her three children, each presenting with viral illness. JTL's usual line of questioning led to a genogram that depicted three children by three different fathers. JTL went on to examine each of the children and prescribe appropriate therapies. At the end of the day, JTL received a telephone call from the woman's husband, who felt JTL had “belittled” his wife by “prying” into her past life. Taking a deep breath, JTL shared his reasons for obtaining a family history. JTL emphasized the importance of this information, particularly when dealing with children of divorce or with children who have been separated from their biologic parents. Trying his best to defuse the situation, JTL told the husband, “I am very impressed by your call today, because you have demonstrated your love for your wife by defending her honor.” Thanks to this interjection, the tone of the conversation became much more civilized. JTL reflected that it may be prudent to consider that, in certain circumstances, the genogram could wait until he becomes more familiar with each patient.
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