Diary from a Week in Practice
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Am Fam Physician. 2001 Apr 15;63(8):1529-1531.
As family physicians, we're supposed to be experts in the area of preventive medicine. The trouble is, all the ways to prevent catastrophe are not known. Today, JRH was examining a woman who had been in an automobile crash. She was driving 60 to 70 miles per hour in the rain and was using cruise control when the car she was driving began to hydroplane. Before she knew it, the car slid sideways and bounced several times off a concrete barrier separating active traffic from roadway that was under construction. A spin ensued and a front-end collision followed. The patient sustained a sprain to her liolumbar ligament and, consequently, was having a great deal of pain in her lower back. But how can we prevent these accidents in the future? JRH noted the obvious: “Slow down when it is raining.” She added another: “Don't use cruise control when it is raining.”
As WLL ages, so does his practice. He is seeing more men and women complaining of hot flushes. Although estrogen is one approach for treating hot flushes, many patients, especially men (and women with breast cancer), probably shouldn't take it. He has found several treatments that seem afe and effective. Clonidine is his favorite—especially for men with prostate cancer or women taking tamoxifen. However, the results of controlled trials have been inconsistent. Megestrol (20 mg once or twice a day) seems to work better than medroxyprogesterone (Lancet 1999;353:571–80) and reduces the frequency and severity of hot flushes up to 80 percent (J Clin Endocrinol Metab1998;1993–2000), but may cause weight gain. More recently, WLL has found venlafaxine to be helpful and studies show it reduces hot flushes by at least 50 percent in men and women (J Clin Oncol 1998;16:2377–81). WLL has found that starting with 12.5 mg twice a day (one half of the lowest strength tablet) works well. Others have found that other selective serotonin reuptake inhibitors work as well as venlafaxine; for example, paroxetine (Ann Oncol 2000; 11:17–22) or sertraline (Del Med J 1997;69: 481–2). At least one study (Neurology 2000;54: 2161–3) recommends gabapentin for hot flushes when the usual approaches aren't effective. WLL starts with 100 mg and works up to 300 mg three times daily if needed.
Over the years, JTL has learned ways to lessen a child's anxiety during office visits. In years past, JTL nixed wearing a white coat because of concerns that children might grow fearful at the sight of the coat. However, on joining this practice, JTL agreed, though reluctantly at first, to wear the white coat. Since doing so, JTL has discovered that children will, in fact, become more comfortable in the presence of the white-coated physician who manages to make the office visit an enjoyable experience. Playful interaction with the child always precedes any attempt to embark on the physical examination. For difficult ear examinations, JTL uses the “hug” restraint system, i.e., child sits on the parent's lap and gives a big hug, while the parent firmly restrains the child's arms beneath theirs. “Let's look for the birdie,” while whistling, has also been distracting enough to get through many examinations uneventfully. Many male toddlers and young children will resist the genital examination. During the testicular examination, JTL will say, “one, two buckle my shoe,” and then, “three, four shut the door!” as he pulls up the child's pants and zips them shut. JTL adds that this distraction technique would likely not apply for older boys.
Like most of us, ASW has had to learn the art of convincing patients with an “invisible” medical problem that they need medication; the ghost in many cases is the common diagnosis of hypertension. This week, she was involved in a some-what unique situation. An other-wise healthy and asymptomatic 48-year-old man came in for evaluation of recent high blood pressure. Not having been previously diagnosed with hypertension, he as adamant that he needed medication to bring it down immediately. He explained that he'd just had a preemployment physical and that he would not be hired unless his blood pressure normalized. After the necessary work-up and discussion of JNC-VI recommendations as well as treatment options, the patient begged for medication. ASW was saddened by how financial concerns can often take precedence over patients' medical needs and dictate their decisions. In this case, the possible side effects from the chosen beta blocker were not as important to the patient as the financial stability his new job would provide. However, this is one patient in whom ASW will never have to worry about compliance with the medication regimen.
Today, a case of creeping eruption (cutaneous larva migrans) presented on a patient of JRH's who works as a laborer. The patient had already tried his own remedies—green fingernail polish and mercurochrome—but nothing had stopped the itch. JRH went to work with ethyl chloride at the tip of the burrow and later he tried thiaben-dazole suspension. But, alas, the local pharmacists said they had no way of getting the medicine. A quick consult to Habif's dermatology text suggested ivermectin as an alternative. And thus JRH prescribed the drug, hoping it would work. If all else failed, he could be comforted by the hope that the infection would be self-limiting, since larva usually survive only two to eight weeks and are sloughed off with the epidermis.
On a recent Saturday, ASW evaluated one of JRH's patients in the end stages of pancreatic cancer. The patient's wife was concerned that his glucose level was too high. The patient felt fine and ASW could find no source of an infection that could be elevating his glucose level; she wondered if the change was caused by progression of his cancer and declining pancreatic function. The patient's oncologist had recently started him on indomethacin for pain, and his glucose level started increasing about one day later. ASW was able to get his glucose level within the usual range again by changing this medication. A few months later, JRH came in to our weekly lunch meeting a little late, having just returned from this patient's funeral. He reported on the remarkable eulogy given during the service, and ASW reflected on their brief encounter. She wondered how his wife would now spend her time, which for so long had been almost entirely devoted to caring for her husband. ASW grieved with her, and quietly whispered a prayer of goodbye to this kind man whom she'd met only once, and whom she was glad to have seen smile with gratitude on his way out that day in her office.
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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