Diary from a Week in Practice
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Am Fam Physician. 2001 May 1;63(9):1742-1743.
The value of a good history should never be underestimated. Today, a patient presented for an exacerbation of her asthma. ASW asked her how often she was using her albuterol (Ventolin) inhaler. She was surprised to hear that the patient wasn't using it at all. In fact, she was not using any of her three prescribed oral inhalers, and she asked ASW to prescribe tablets instead. As the conversation continued, an interesting story unfolded. As a five-year-old girl, this patient had a severe reaction to ether, which was administered to her via a facial mask. She could still remember the incident in great detail, and said she relived it whenever she attempted to use her prescribed oral inhalers. Grateful to have heard the whole story, ASW discussed with her some relaxation techniques in the hope of improving her compliance. Interestingly, ASW noticed that the patient seemed more willing to try the inhalers after sharing her real concerns. After some instruction by the nurse regarding their proper use, the patient walked out committed to using her inhalers. Not satisfied with just winning a battle in the war, ASW reminded her as she walked out: “Next time I'll get you to stop smoking, right?”
Rarely has JRH found exceptions to the advice, “don't put off until tomorrow what you can do today.” Interestingly, a young breast-feeding mother was in the office to discuss her recent rheumatology consult. Together, JRH and the patient had diagnosed rheumatoid arthritis 18 months prior, around the time that she became pregnant. After the delivery, JRH had sent her to a consultant to find out which medication should be started to treat her rheumatologic condition. When methotrexate was suggested, it appeared that the only choice was to stop breast-feeding, a choice that would have its own far-reaching effects. The patient and JRH, having waited this long, sought a second opinion. The result was revealed today. The diagnosis that was rendered was pauciarticular rheumatoid arthritis. This meant that treatment could wait until the patient stopped breast-feeding, and even then be directed at the troublesome joints first. The value of a second opinion was never so sweet! And, the importance of sometimes waiting to begin treatment was the exception to the rule, don't put off until tomorrow what you can do today!
Today, JTL found reason once again to reflect on the challenges and rewards of family practice. Sylvia, an 84-year-old patient with diabetes, was admitted to the orthopedic service for anticipated below-the-knee amputation of her remaining leg. Her other leg had been amputated just one month earlier because of gangrene. As a result, Sylvia had lost her will to live. “I feel useless with one leg,” she had told her husband. JTL had provided medical clearance for her anticipated surgery and readily recognized the signs and symptoms of depression. Knowing her state of mind, JTL felt it prudent to await the results of the surgery and rehabilitation process before addressing the need for a “do-not-resuscitate” status. But, Sylvia became suddenly tachypnea (likely from a massive pulmonary embolus) and then “coded.” In JTL's absence, the emergency department team quickly provided advanced cardiac life support care. JTL was close to the hospital at the time and arrived to call the code, knowing that Sylvia's death was, in many ways, welcome. Some hours later, JTL was able to escort 8 lb, 15 oz Asher into the world following a rather difficult labor. In the evening, while celebrating his daughter's eighth birthday, JTL once again pondered the many reasons he had chosen to become a family physician; indeed, a vocation richly blessed with the full range of human experience.
“Have you had any more seizures since the neurologist started you on that new seizure medication?” inquired WLL. “Nope,” responded the pleased patient, a college sophomore who had a complex seizure disorder that was difficult to control. “And furthermore,” she proclaimed, “I've not had a single migraine headache.” WLL was not surprised; he has had some success using antiseizure medications for prophylaxis of migraines for years. However, this was his first experience with this effect with tiagabine (Gabitril). This antiepileptic drug is said to be active at gamma amino butyric acid (GABA)-related sites. Now comes a report from the Diamond Headache Clinic, in Chicago, of an open-use trial of tiagabine in 41migraine Patients who had failed prophylactic treatment with divalproex (Depakote), either because of adverse effects or lack of efficacy (HeadacheQuarterly 2000;11:133–4). Thirty three of 41 patients experienced at least 50 percent improvement in their migraines with tiagabine treatment, the authors report, and two more patients reported partial response. Daily dosages of tiagabine ranged from 4 to 16 mg, with a mean daily dosage of 12 mg. Twelve patients experienced adverse effects, including fatigue, weight gain, confusion and poor memory, and nine patients discontinued tiagabine because of these effects. Needless to say, first-line prophylactic therapies should be tried first.
A worried grandmother brought in her grandson today. “We want him tested for diabetes,” she demanded. JRH, knowing the boy, was surprised. “Yep, he has been drinking a lot of iced tea and soda—and he has been peeing a lot, too!” Sensing the urgency of this situation, JRH outlined a plan of diagnosis even though he found nothing on the physical examination of this 12-year-old boy to suggest the disease. First, a glucose level determination and a dipstick urine test were done in the office, followed by a glycohemoglobin blood test. None of these was positive, and the family was relieved. Only later did JRH find out that the reason for all of this concern stemmed from one Sunday afternoon when all the grandchildren were around at the time that the grandpa was checking his own blood sugar level. Someone suggested that it would be a good idea if the grandpa checked everyone's blood sugar level, and so they did. It seemed only the 12-year-old's test turned out abnormal.
While on his run this Sunday afternoon, JTL reflected on the events of the past week. On several occasions, JTL realized that his patience had grown thin and he had responded to events in a less-than-charitable manner when things did not go “according to plan” either at work or at home. Physicians who expect things to go perfectly at the office or at home are doomed to a life of misery, JTL reflected. After all, we live in an imperfect world, with imperfect patients, imperfect office staff, and, yes, imperfect family physicians. Yet, JTL believes, perfection can be sought in this world, and can be experienced. JTL thought of a friend of his who, 20 years ago, chose to pursue a vocation in the religious life and, at the time of his ordination, shared with JTL the following words: “Be joyful and keep in delight the duty of delight, for all is Grace …” “The duty of delight—“ four words to remember during all those “imperfect” days in the life of the family physician, spouse and parent.
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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