Diary from a Week in Practice
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Am Fam Physician. 2001 Jun 15;63(12):2379-2381.
This past week, JTL was asked, at the last minute, to fill in for a grand rounds presentation for fellow staff physicians at the local hospital. Choosing the topic of natural hormonal therapies, JTL shared with his diverse audience (radiologists, general surgeons, urologists, internists) the same information that he routinely shares with his patients, including the difference between human estrogens (estradiol, estriol, estrone) and conjugated equine estrogens or synthetic estrogens, and the difference between true progesterone and the synthetic progestins such as medroxyprogesterone acetate and norethindrone. JTL was pleased with the response of a few of the staff physicians who shared with him their desire to see more academic discussions about various medical therapies during grand rounds. JTL was even more delighted to receive a telephone call today from the chair of the OB-GYN department, asking for more information about natural progesterone and estrogen therapy for one of his perimenopausal patients—a woman whose husband, a urologist, happened to be at the grand rounds presentation.
Recently, ASW saw a patient who would not use her asthma inhalers because of a traumatic childhood experience with an ether mask that led to a severe allergic reaction. As the patient was allowed to verbalize these feelings, she agreed to some behavioral interventions to help with the problem. She did much better and left the office determined to use her inhalers. On the patient's way out, ASW reminded her that she needed to stop smoking, to which the patient smiled and said, “maybe someday.” ASW was not terribly hopeful that the patient would quit smoking but was glad to at least have contributed to the patient's use of her asthma medications. Six weeks later, as ASW was getting into her car to go home, she caught a glimpse of somebody running toward her across the parking lot. As it turned out, on that day six weeks ago, the asthmatic patient had gone home determined to start taking better care of her asthma and to quit smoking. She looked great and said she hadn't felt so good in years. How rewarding it is when we happen to be the right person at the right time to meet our patients' needs.
Greg Warshaw, a colleague of WLL and JRH, was always a practical doctor with a deep interest in caring for the elderly. Dr. Warshaw believes that a constellation of six symptoms are characteristic of early Alzheimer's disease and should help primary care physicians recognize and treat the disease at an early stage (Arch Fam Med 2000;9:1066–70). His research suggests the mnemonic “Realistic Caregivers Recognize Dementia Numbs Judgment” for remembering these signs: (1) Recall of three words; (2) Calculation; (3) Repetition; (4) getting lost while Driving; (5) forgetting Names of relatives; and (6) poor Judgment. Greg and his colleagues at the University of Cincinnati identified 50 patients at least 60 years of age who met Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV) criteria for Alzheimer's disease, had a Mini-Mental State Examination (MMSE) of at least 23, who were not depressed and who had at least an eighth-grade education. Eighty percent of the patients missed at least two of three recall items on the MMSE, while 60 percent had difficulty managing their finances and balancing a checkbook. Families of 32 percent reported that patients often repeated themselves, and 30 percent would get lost while driving despite having directions or following a familiar route. Twenty percent of patients would forget the names of relatives, and 20 percent exhibited poor judgment.
On most days, there is no urgent reason to discharge patients from the hospital.Yet, election day was not like most days. A 49-year-old woman had been admitted through the emergency department during the previous night, after presenting with intermittent chest pain lasting several weeks. Her first two sets of cardiac enzymes had been negative, her electrocardiogram was also reassuring, and her history, as obtained by JTL, indicated a noncardiac etiology for the chest pain. As with many patients admitted with chest pain, a cardiology consult and treadmill stress test had been ordered as part of the routine “rule out myocardial infarction” admission. While assessing her at noon, JTL asked whether she intended to cast her vote. The patient emphatically replied in the affirmative. JTL then set about trying to get her discharge arranged so that she could get to the polls on time. This entailed canceling the cardiology consult and the stress test (which would be performed at a later date) and asking the day shift nurses to handle the discharge paperwork, rather than wait for the oncoming shift. Ultimately, the patient was able to cast her vote in what turned out to be the closest presidential election in the history of the state of Florida.
Sometimes things just do not go as planned. Today, a former employee arrived with her husband in tow. JRH had not seen the husband in some time, but it was apparent he was ill. After surveying his signs and symptoms, JRH ordered a shot of penicillin G. The nurse had the patient lean over the examination table and delivered the medicine. As the needle was withdrawn, the patient proceeded to fall backward. In an instant, he was on the floor before the nurse could catch him. When he hit, he hit hard, with a low-pitched thud serving as the panic bell to signal for help. Unfortunately, he suffered a concussion and had to be transported to the hospital for cervical spine radiographs and subsequent admission. All of this for a sore throat! Later, the patient confided to JRH that he usually faints when he sees a needle. Alas, JRH could have used that information a bit earlier.
Two weeks ago, ASW saw a five-year-old girl with a fracture of the distal radius. After her initial evaluation and radiographs, the girl was quite pleased with the neon pink cast she picked out. After casting, instructions were given to her mother, and they went home with a follow-up appointment scheduled in a few weeks. Last evening, ASW went to her three-year-old child's basketball game and saw a young girl with a pink cast skillfully playing one-handed basketball. As ASW looked closer, she was surprised to see that it was her patient. The smiling girl proudly came up to ASW at the end of the game and showed off the many signatures and drawings on her cast. As the Purple Team's coach (ASW's husband) rounded up the teams for sportsman-like handshakes followed by refreshments, the patient's mother approached ASW and thanked her again for treating her daughter. Practicing in a small town keeps getting more interesting and gratifying for ASW, who was glad to see her patient recovering so quickly.
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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