Diary from a Week in Practice
Am Fam Physician. 2001 Apr 1;63(7):1323-1325.
JTL has always enjoyed the challenge of caring for patients with chronic pain syndromes. Yet, every so often, a patient presents whose level of dysfunction exceeds JTL's ability to provide a satisfactory therapeutic plan. JTL recently met a long-time sufferer of migraine headaches who claimed there was only one therapy that worked for her: an intravenous meperidine (Demerol) push. She even showed JTL a list of medications that she could not take—literally all of the available migraine headache remedies, including most narcotics. At the time of her first presentation with an acute migraine, JTL, after reviewing her patient file, gave in to her request for intravenous medication. After discussing his reservations in this case with JRH, JTL referred the patient to a neurologist, who would, in turn, assume the responsibility for a treatment plan. JTL was pleased today to receive a letter from the neurologist, who wrote, “Patient and I had honest discussion of what I do and do not have available within my knowledge bank. I can only treat her based on my knowledge bank. She relates intractable headache being treated with intravenous/intramuscular combination Demerol/Phenergan/Benadryl. This is out of my expertise. She is aware of this.” JTL was relieved to know that he now has even stronger grounds for refusing to give narcotics to this most challenging migraineur.
Do your asthmatic patients ask you about using alpha-linolenic acid (ALA) to reduce inflammation in their airways to lessen the frequency and intensity of their asthma attacks? WLL has one patient who swears it has helped her reduce hospital and office visits for asthma. A recent study seems to confirm the patient's experience. A Japanese team has reported that dietary sup plementation with perilla seed oil (Perilla frutescens) may help reduce levels of leukotriene C4 (LTC4) in certain asthmatic patients (Int Arch Allergy Immunol 2000;122:137–42).
This oil contains significant amounts of ALA, which may inhibit the generation of leukotrienes. To investigate, the researchers studied 26 asthmatic patients who were given 10 to 20 g of perilla seed oil daily for four weeks. Fifteen subjects (58 percent) showed a significant reduction in LTC4 generation by peripheral leukocytes at two and four weeks and were deemed responders. In the responders, there was also a significant improvement in lung function and other spirometric measurements. Not surprisingly, the responders also showed a significant reduction in serum levels of total cholesterol, low-density lipoprotein cholesterol and phospholipid after four weeks. WLL wonders if supplements of mercury-free fish oils or cod liver oil (in the capsule form) might not have the same effect—and be less expensive.
This morning, ASW examined a 45-year-old woman with oral leukoplakia. As part of the evaluation to look for associated systemic pathology, she inquired about a fairly extensive rash she noticed on the patient's legs. The vasculitic patches had previously been diagnosed by a dermatologist as Majocchi's disease, also known as purpura annularis telangiectodes. Unsure as to whether the leukoplakia may be related to the rash, ASW quickly did some research. ASW learned that Majocchi's disease is one of several pigmented purpuric dermatoses that are benign, nonsystemic and represent mostly a cosmetic problem. The rash can look fairly impressive, as in this case, and it is often mistaken to be a manifestation of vasculitis or thrombocytopenia. When drug-induced, the rash usually resolves within months of discontinuing the offending agent. This patient's presenting complaint was unrelated to this interesting rash, but ASW learned much from the examination. If our patients knew how much we learn from them, they might start charging us for visits!
The value of good training is that it's always there when you need it. Today, a 40-year-old man presented with a sinus infection. Just as JRH's nurse was beginning to summarize the visit and begin the patient education, JRH was asked if he would excuse the nurse, so that the patient could have a moment alone with him. It came as no surprise to JRH that the patient wanted to discuss a sexual problem. What was surprising, however, was the small and somewhat recent sore that had appeared on the tip of the patient's penis. No ooze or blisters were noted, no inguinal nodes were felt and no itch or scratch was observed.
There was, however, an certain indurated, painless 3 mm purple lesion. All of a sudden, the diagnosis came to JRH: this was a chancre! A few days later, the rapid plasmareagin and the microhemagglutination -Treponema pallidum tests returned, both positive in high titer, and the shot to cure was given. JRH said a silent prayer of thanks for his professors and the education he had received at the University of Miami and Duke University. He knew that if he had missed the diagnosis, the lesion would have gone away but its destructive course would have just begun.
This morning, ASW had an initial visit with a 59-year-old woman who had been driving through Florida with her husband on her way to Fort Lauderdale. A week before, she'd had an episode of slurred speech that resolved within a few minutes and was accompanied by some arm weakness that lasted several hours. The day before the appointment, the slurred speech had returned and had not fully resolved, and her arm weak ness had come and gone. Her husband refused to drive any farther until she reluctantly agreed to be examined by a physician. After the usual history and physical examination and some preliminary blood work, ASW explained to the patient why she needed further testing and that she was having transient ischemic attacks and likely a stroke. The depth of denial in this patient was such that ASW had to go into great detail about the possible outcomes of untreated strokes to get her to agree to a computer tomographic screening of the brain, carotid Doppler tests and a cardiac echogram. The patient fully recovered, but ASW wonders when she'll have another episode. Although it's often relatively easy to take care of our patients' acute problems, it remains an elusive challenge to help change their lifestyle or ensure appropriate self-care.
JTL has always been intrigued by the ubiquitous nature of herpes viral infections, and frequently educates his patients that many, if not most, herpes infections are not at all sexually transmitted (e.g., varicella, Epstein-Barr virus). When he drove himself to the emergency department at 3 a.m. one Saturday with high fever, shaking chills and severe dysphagia, JTL had a premonition. Sure enough, the endoscopy revealed a severe case of herpes esophagitis. During the days JTL spent in a hospital, he learned a few lessons: (1) don't ever get out of a healthy routine for the sake of work. (JTL had been skipping his usual spiritual and physical exercises to have more time for work); (2) don't ever expect patients to get rest in a hospital. (To JTL, who loves to visit with others, it seemed that someone entered his room every hour on the hour, day and night); and (3) don't ever prescribe to a patient medicine that you aren't willing to take yourself. (JTL cannot bear the thought of taking viscous lidocaine—not to mention children's acetaminophen—again!) Whoever wrote “a spoonful of sugar helps the medicine go down” surely got carried away while adding sweetness to children's suspensions. JTL, following a week's respite, was thankful to be back to work, but he vowed to make a few lifestyle adjustments for the rest of the journey.
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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