Diary from a Week in Practice
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Am Fam Physician. 2001 Mar 1;63(5):877-879.
“To know diabetes is to know medicine.” JRH has had the opportunity many times to recall this adage, taught by one of his professors at the University of Miami. Today revealed one more facet of this story. After being called to the bedside of an unusually confused patient, JRH attempted to get a finger-stick blood sugar reading. Not only had the patient's family not been able to do this because of the patient's agitation, but they were prevented from helping him help himself despite two doses of haloperidol. JRH tried the middle finger first, but had no luck. The second and third tries in a different spot on his finger were also unsuccessful. Finally, shifting gears, JRH pierced the earlobe. The result read “HI” (greater than 600). Some hours later, at the local hospital, the blood sugar level was reduced from 744 to 192, and this elderly man was back to his old self—no more confusion, no more agitation, no more irritability. His grateful family greeted him the next morning, thankful that his usual charm and deference had returned. And, JRH was thankful to know that increased dosages of haloperidol were not needed—only a more normal blood sugar level!
Recently, our practice had difficulties promptly responding to telephone messages and prescription refill requests, as well as locating patient charts in a timely manner. Falling back on his previous experience as a quality improvement coordinator during his military medical career, JTL put together a “quality improvement team” for the purpose of addressing and, hopefully, remedying these and other problems in the office. The team consisted of the office manager, a nurse and a billing clerk/referral specialist, with JTL as the facilitator. After four one-hour meetings, the team's recommendations led to the development of a protocol for a triage nurse who will be responsible for handling all the prescription refill requests and urgent messages. The new role of the triage nurse also relies on the assignment of a daily “file clerk” who will ensure that all charts are filed and retrieved at the appropriate times. While JTL believes that the quality improvement team accomplished a great deal with relatively little investment in time or money, he can readily see that the greatest benefit is the opportunity to allow office personnel to share their ideas for improvement.
Premenstrual syndrome (PMS) is not only difficult for a patient to experience, it can be frustrating to treat. WLL has found a number of therapies that have seemed to help: (1) aerobic exercise (may improve mood and reduce fluid retention), (2) a diet with increased complex carbohydrates and omega-3 and omega-6 fatty acids with a dramatic reduction of saturated fats and simple carbohydrates (may improve mood and reduce food cravings—probably by increasing serotonin levels), (3) 600 mg of elemental calcium twice a day after meals (reduces cramping and moodiness), (4) magnesium, 200 to 400 mg daily (may help with headache, fluid retention and mood changes), and (5) vitamin E, 400 IU daily. WLL has also recommended spironolactone, 50 to 100 mg daily for two weeks, before menses to reduce fluid retention, breast tenderness and weight gain and selective serotonin reuptake inhibitors for women with more severe premenstrual mood changes. Now, new guidelines for treating PMS include the recommendation and the rationale for each of WLL's favorites. (Practice Bulletin No. 15, April 2000, J Am Coll Nutrition 2000;19:3) It's nice to have simple and inexpensive tools for treating this common and troubling symptom complex.
This morning's last patient proved to be a first for ASW. Convinced that he met all criteria to receive growth hormone, this young body builder was clear that he wasn't leaving without a prescription for it. During the interview, ASW discovered that the patient had a chronically draining, infected injection granuloma from using horse anabolic steroids. His psychomotor agitation made it challenging to hold a coherent conversation. ASW managed to convince the patient of his need for some laboratory work to ensure there were no side effects from his many different supplements, including Ephedra, creatine, several protein shakes and other over-the-counter workout enhancers. When he returned three weeks later to discuss laboratory results, ASW was pleased to meet a much calmer young man, now off all supplements except creatine and not the least bit interested in growth hormone. He confided that his job as a model and body builder was getting the best of him and that he was finding no joy in it at all. They talked about his real passion, painting, and he left the office determined to start doing more of the things he enjoys. ASW looks forward to watching this young man's future unfold.
During her time in the military, there was one family that taught ASW more than any other about the value of being a family physician. After several visits for diabetes and hypertension, the couple shared with her a deep concern that was tearing them apart: their 33-year-old son had severe neurologic deficits as a result of a craniotomy for a brain tumor. He had been an active young man with a marvelous future, but now required significant daily assistance. They mourned the fact that their family life would never be the same and grieved for many lost hopes and dreams. During the years that she cared for this family, ASW treated them for many minor medical problems and assisted them in improving their chronic medical problems. However, the most rewarding part of her many interactions with them was the opportunity to encourage them to begin discussing with each other issues of the heart—the real problems that were drawing them apart—and seeing them slowly start to come together emotionally and spiritually. They were her last patients on her last day in the military. This appointment was a great reminder to ASW of the marvelous privilege that patients give to their family physicians—the honor of being able to intimately observe and participate in their family—to assist them in reaching and maintaining not only physical health but also emotional and spiritual health.
One of the most delicate interactions that family physicians have with patients is when confronting mothers in a crisis pregnancy. Today, JTL met a 17-year-old mother (of a seven-month-old) who was again pregnant and in pain. On physical examination, JTL could easily palpate an enlarged uterus—at least 12 weeks estimated gestational age—and a 3-cm left adnexal cyst that was most likely a corpus luteum cyst. JTL then asked the patient, “Would you like to hear the heartbeat?” to which she tearfully responded, “No.” JTL needed to hear heart tones to confirm an intrauterine pregnancy. Heart tones were readily heard by JTL, his nurse, the patient and her mother. After obtaining specimens for sexually transmitted disease, JTL returned to the room to visit with this teenager about her pregnancy. JTL asked why she did not want to hear the baby's heartbeat. She responded, “I've already decided to place the baby for adoption. Hearing the heartbeat will just make that more difficult.” JTL shared with this young mother and her mother his conviction that her decision was a very mature and, indeed, heroic decision. Yet, he reminded her, babies in the womb need just as much love and bonding as newborn babies. JTL was thankful that the patient and her mother were receptive to these words.
This is one in a series by Walter L. Larimore, M.D., John R. Hartman, M.D., Amaryllis Sanchez Wohlever, M.D., and John T. Littell, M.D., four family physicians in private practice in Kissimmee, Fla.
Copyright © 2001 by the American Academy of Family Physicians.
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