Diary from a Week in Practice



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Am Fam Physician. 2001 May 15;63(10):1953-1957.

Monday

Year by year, family by family, we have promoted breast-feeding to all of our patients who become new mothers. Some are reluctant to breast-feed, some are coachable, and others are so determined that their focus is inspiring. It's to this last group that today's young mother belonged. She had already been through an exhausting pregnancy complicated by preeclampsia that led to the need for a cesarean section at 35 weeks' gestation. This was followed by postpartum depression. To complete the saga, breast-feeding had not come as easy as the books led her to believe; the milk was just not coming in fast enough for her newborn. Nevertheless, she was steadfast in her desire to breastfeed. So a quick call to our local lactation consultants allowed JRH to recommend the herb fenugreek in a dose of 600 mg: two capsules with meals for the first two days followed by one capsule with meals for three weeks thereafter. As a backup plan, metoclopramide (Reglan) at 5 to 10 mg was suggested, but wasn't needed. A weight check one week later showed a healthy and content newborn!

Tuesday

One of the more challenging rashes that JTL has treated occurred in a 30-year-old black man who presented with a nodular rash localized to his scrotum and proximal penis. The primary lesions were pustulonodular, and at times the patient expressed a bit of milky discharge from the lesions. After entertaining all the usual sexually transmitted diseases, JTL treated the patient for scabies. The rash persisted, and JTL remained mystified. Today, noting that the patient had shaved his scrotum, JTL inquired as to whether this was the patient's customary practice. The patient replied in the affirmative. Falling back on his military medical experience, JTL recalled a common skin condition affecting black soldiers, Pseudofolliculitis barbae (PFB, or “shaver's bumps”), an acne-like process characterized by nodular lesions, localized to the cheeks and neck as a result of close shaving. A related condition, acne keloidalis nuchae (AKN), folliculitis of unknown etiology, is characterized by similar lesions occurring at the nape of the neck as a result of crew cuts. JTL, recognizing that shaving was the likely cause of this patient's rash, advised him to discontinue shaving and prescribed a combination of a topical antibacterial lotion and a midstrength corticosteroid cream.

Wednesday

More patients are looking for natural medications for a variety of ailments—particularly insomnia. For several years, WLL has recommended valerian root, although he has also recommended hops and kava. Valerian is thought to work by stimulating the release of the neurotransmitter, GABA (Prescriber's Letter 2000;7:46). Most of the trials of valerian use200 to 900 mg at bedtime and have found that it can take several days to several weeks to improve sleep. The Natural Medicines Database has rated valerian “possibly effective when used orally for insomnia.” Several small-scale studies have shown consistent benefit in reducing the time to sleep onset and subjective improvement in sleep quality inpatients using valerian compared with placebo Valerian “seems to be comparable to low-dose benzodiazepines, but does not seem to work as fast as the benzodiazepines”(Natural Medicines Database 1999:926–8). Valerians old in the United States, is usually combined with other herbs, such as hops, which have been shown in several clinical trials to have a mild sedative effect (Natural Medicines Database1999:499–500). Kava has been shown in several trials to help some people who can't sleep because of anxiety and is rated as “likely effective… when extracts containing 70 percent kava pyrones are used orally” (Natural Medicines Data base 1999:549–50).

Thursday

We've all struggled with patients who have multiple risk factors, yet continue to smoke and are not ready to quit. Luckily, we've also had success stories that keep us trying to help our patients. Before joining our practice, ASW had been working at Hurlburt Field Air Force Base. During her years as a physician in the military, she witnessed what many studies have found that adjunctive therapies for tobacco cessation are much more successful when tied to a strong program stressing behavior intervention techniques. An extensive questionnaire was filled out by each patient and reviewed during a one-on-one interview by a trained technician who then offered specific behavior interventions for each patient. Each patient also participated in group sessions that were educational and offered a support network for the patients in their efforts to quit smoking. The patients were then seen by the physician who would prescribe the appropriate adjunctive therapy and be available for further support. ASW hopes to see more insurance companies start covering these programs After all, if such programs can lead patients to quit smoking they will be cost-effective in the long run and they are the right thing to do for our patients and their families.

Friday

When treating hypertension, do you use A, B, C or D as your first-line drug? A = angiotensin-converting enzyme (ACE) inhibitors, B = beta blockers, C = calcium channel blockers and D = diuretics. National guidelines encourage the use of B or D. Now, a study tells us that the use of a diuretic reduces the risk of stroke in patients with high blood pressure (Arch Intern Med 2001;161:37–43). According to this study, thiazide diuretics were associated with a lower risk of ischemic stroke, which makes them the best choice as first-line treatment for hyper tension. Researchers collected data on 380 pharmacologically treated hypertensive patients who had an ischemic stroke between 1989 and 1996. They compared these patients with 2,790 treated hypertensive patients who had no history of stroke. The adjusted risk of ischemic stroke, among 1,237 users of a single drug, was higher among those who used beta blockers (risk ratio: 2.03), calcium channel blockers (risk ratio: 2.30) or ACE inhibitors (risk ratio: 2.79) than among those who used a thiazide diuretic alone. According to WLL's understanding of the literature, these results are consistent with those of previous randomized clinical trials that suggest the benefit of thiazide diuretics in lowering the risk of ischemic stroke.

Saturday/Sunday

Making house calls has been a routine practice for JTL for many years. Perhaps the most important factor in deciding to make a house call has been the difficulty experienced by many patients in getting to the office. JTL shared his philosophy of making house calls with one of his new elderly patients this morning. He related that, while practicing in Michigan, he had enjoyed his house calls to the Amish community (in exchange for several dozen fresh eggs). Some of these house calls, particularly during winter, were a bit risky. JTL related the time his car hit a patch of ice and propelled into a ditch. A passerby gave JTL a ride to the farmhouse where he then visited his patient. “House calls sure can be dangerous,” shared his patient. “One doctor in Michigan paid a summer visit to one of his patients and noted a well in front of the home. Feeling a bit thirsty, he walked over to the well, took a drink and dropped dead on the spot!” As JTL considered the possible etiologies of such a tragedy, the patient went on to add the moral of the story: “Take care of the sick, and leave the well alone.” JTL knew he would enjoy more visits with this patient, whether sick or well.

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 is Kissimmee, Fla.



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