Diary from a Week in Practice



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Am Fam Physician. 2001 Jun 1;63(11):2178-2181.

Monday

One of JTL's patients presented today requesting referral to a cardiologist to follow up on her mitral valve prolapse (MVP). The 43-year-old woman had been experiencing palpitations with increasing frequency and was concerned that she might be developing organic heart disease. JTL was convinced that most, if not all, of her complaints were most likely related to an excessive level of stress and underlying anxiety. Despite the reassurance of a normal examination, an initial battery of tests and an echocardiogram, which did not identify the MVP, the patient insisted on seeing a cardiologist for further evaluation. Having learned over the years that it is almost always better to allow patients who insist on referrals to get their referrals, JTL, after writing out his cardiology consultation, provided the patient with information on the adverse sequelae associated with her presumed diagnosis of MVP (N Engl J Med 1999;341:1–7). The article concluded that adverse clinical outcomes rarely occurred in patients with isolated MVP. JTL, after adding his “two-cents worth,” looked forward to addressing the likely cause of her symptoms (i.e., anxiety) in the near future.

Tuesday

A few weeks ago, a young woman presented with a persistent supraclavicular node. Initially treated with antibiotics with no improvement, she was scheduled for a lymph node biopsy with JRH. ASW watched as JRH carefully dissected this node from a crowded anterior neck. The biopsy came back showing Hodgkin's lymphoma, and arrangements were made quickly for more definitive treatment. ASW saw the patient about one week later for symptoms of an upper respiratory infection, but knowing the background and having met the patient during the biopsy, she felt as though she should also address some of the patient's fears and concerns about the cancer and its treatment. ASW was glad to find that this young woman, although apprehensive about the future, had a positive attitude that they both hoped would help her through the difficult upcoming months.

Wednesday

This morning, while assisting a primigravida mother in the birth of her son, JTL had the unexpected opportunity to visit with another patient, the mother's grandfather, who had recently undergone coronary artery bypass surgery after presenting to JTL with new-onset angina. As he sat in the rocking chair waiting for the imminent delivery of his first grandchild, he told JTL that he had been having some chest and jaw pain during the past few days. JTL tried to remain focused on the mother-to-be who was giving birth to an infant whose estimated fetal weight was nearly 9 lb. JTL commented to his anginal patient that he would need to be evaluated as soon as possible by the cardiologist, given the possibility that one of the grafts might be occluded. Returning to the birthing room some time later, JTL was pleased to find that the grandfather-to-be was no longer present—having hopefully followed JTL s advice. JTL was pleased even more when, thanks to some incredible work on the part of the mother, he was able to escort 8 lb Rylan into the world.

Thursday

Mrs. D. was so proud of her husband that she was just beaming. “What's the reason for this excitement?” JRH asked. “Gerry and his group just performed for the hospital staff, and they were great!” Eager to know more, JRH pressed on, “I didn't know he was a musician!” In fact, Gerry had lost a lung to cancer not more that six months ago and was told that if he was to enjoy any quality of life after the operation, he would have to get serious about lung rehabilitation. One of the local hospitals, it turns out, had just such a program. Starting off with the basics, each patient progresses at his or her own rate. Eventually, each is encouraged to pick up the harmonica, for the practice of breath control and for the music. The group is now so large and successful that they are able to perform for the hospital each Thursday. And, on this Thursday, it was especially appreciated.

Friday

WLL is besieged by patients wanting to know which fad diet they should start. The Zone? Ornish? Atkins? Pritikin? A recent report from the U.S. Department of Agriculture found that any diet that limits food to about 1,500 calories per day can produce short-term weight loss, but that these fad diets do little to help lower cholesterol and blood pressure levels. According to the report, only a moderate-fat, high complex-carbohydrate regime can keep a person healthy and have a long-term effect of keeping the weight off. This report is the first from a continuing review of various popular diet programs by the government to help patients and their physicians sort through the facts and myths surrounding an amazing array of fad diets. According to the report, low-fat diets, including the Ornish and Pritikin plans, appear to lower cholesterol levels but are nutritionally inadequate. High-fat diets, such as the Atkins diet, are also nutritionally inadequate. Those programs that have put more demands on dieters—like those recommended by groups such as the American Heart Association—have the best scientific evidence to back up their success rates and health claims, the study says. The diets that the government study supports recommend consuming no more than 30 percent of calories as fat and limiting protein to about 20 percent of the diet.

Saturday/Sunday

The town of Kissimmee recently hosted the annual Florida Shoot-Out, a high school basketball tournament that attracts players from all over the country. Amid local newspaper reporters and professional scouts searching for good ballplayers, we covered the week-long tournament as the team physicians. ASW was impressed at the skills of the athletic trainer who was, without a doubt, much busier than the doctors. We treated some mild sprains, a ruptured Baker's cyst and a bad case of pharyngitis, but the real experience of being team physicians came from the interactions with the town, coaches and players. As we handed out the scholastic achievement awards to some of the athletes at the end of the tournament, we felt a sense of pride and gratitude to have been a part of such a community event. ASW talks about the experience with her teenage patients, hoping to motivate them to stay away from drugs, alcohol and tobacco, and to get more involved with activities that foster teamwork and a sense of community.

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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