Diary from a Week in Practice
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Am Fam Physician. 2001 Oct 15;64(8):1351-1352.
ER, a third-year medical student, left an examination room with a concerned look on her face. “I'm worried about this 11-month-old baby boy,” she explained to PO, the clinic attending physician. “He's very fussy, and has a 102°F fever, but I really cannot find anything to explain his symptoms. The mother tells me that the baby won't take his bottle very well.” Acknowledging that evaluating unexplained fever in a young child is a common dilemma, PO asked a few pertinent questions. The mother reported no history of vomiting or diarrhea and no cough or congestion in the baby. According to the student, the physical examination was completely normal except for the loud crying. As they went to examine the young patient together, PO immediately noticed that the baby was drooling and fussing as the mother tried to comfort him with a pacifier. Looking in the back of the baby's throat, PO noticed several small ulcers on the posterior pharynx—and then a few vesicles on the bottom of the feet. Today, the medical student and the mother learned about hand, foot and mouth disease, which is a generally benign illness caused by Coxsackie virus. As ER explained later, “I got a good look at his tonsils, and didn't see any exudate suggesting strep throat, but I never thought to look a little closer look at his palate.” The next time she likely will.
PC, a second-year resident, said, “This patient has not responded to the usual treatment.” The night before she had admitted the 63-year-old man with respiratory distress. PO, the faculty member on the “In-patient Family Practice Service,” examined the patient and agreed with PC's observations. The patient had a long history of asthma and was being treated with steroids, nebulizer treatments and antibiotics for a presumed asthma attack precipitated by acute bronchitis. PO made the comment that he always makes when faced with a perplexing situation, “When in doubt, ask the patient!” When the two physicians interviewed the man together, he described how this episode was different from previous asthma attacks, which usually began rather suddenly. His feet had begun swelling several weeks prior, and he noticed slowly increasing dyspnea on exertion. On physical examination he was found to have jugular venous distention, soft crackles in the lung bases (along with a lot of wheezing and rhonchi) and rather marked peripheral edema. The diagnosis was amended to include mild congestive heart failure. The resident adjusted the orders and added furosemide and fluid restriction. Within a few hours the patient felt much better. PO was reminded again that practicing medicine is a lot easier when we remember to go to the patients for clues about how to treat them.
At our noon conference on Wednesdays, we have Journal Club where one of the residents reviews a recent article of his or her choosing. This week, JH, a third-year resident, led a lively discussion about the treatment of nausea and vomiting during pregnancy. JH has a personal interest in the topic because she's about 10 weeks pregnant with her second child and is sick most of the time. After describing the usual behavioral therapies (small frequent meals, dry crackers at the bedside), she gave a thorough review of medications and vitamins used to alleviate these symptoms, including the risks and benefits when used in early pregnancy. JH admitted having tried nearly every one of these remedies, and reported that none of them had helped her. The combination of long work hours, having a two-year-old son at home and a difficult pregnancy was taking its toll. Despite it all, JH is doing a wonderful job, and she is optimistic about the future. “I know that if I can make it through two or three more weeks, I will begin to feel a lot better,” she said. Being pregnant during residency is not rare—in fact, three out of the five women in JH's group have had a baby during the three-year residency program. It's an ongoing challenge for family practice residency programs to support these women through pregnancy and maternity leave and to encourage breastfeeding.
What help can a gerontologist be in a gynecology clinic? As part of our innovative faculty development program, each faculty member devotes four weeks to a “mini residency” in a field of their choosing. KS chose women's health and worked alongside the three family practice residents who were assigned to the gynecology rotation. This morning, KS saw a 63-year-old woman who had urine retention four weeks after a vaginal hysterectomy. As a rule, gerontologists suspect medications to be the cause of acute problems, so KS asked to see all of the patient's medication bottles. Along with medications for high blood pressure and arthritis, she had hydroxyzine and per-phenazine, which she had gotten from a psychiatric clinic. Knowing that hydroxyzine and per-phenazine can cause urine retention, KS called the patient's psychiatrist who was able to substitute less anti-cholinergic drugs (alprazolam and risperidone). KS was able to emphasize to the residents the value of being a “family physician”—even in a subspecialty clinic.
“Tell me about Noonan's syndrome,” said JR, a third-year resident who was seeing patients in the family practice center. KS, the faculty member assigned to the clinic this morning, was stumped. “I know it's a genetic disorder,” she said a little sheepishly, “but that's about all I can remember.” KS has been a faculty member for almost eight years, and she's used to being quizzed by residents and enjoys the animated discussions that often follow. “Let's look it up,” she suggested. JR pulled out the literature describing Noonan's syndrome that the mother of the 10-year-old boy he had just examined brought with her. KS had to chuckle. Once again, she thought about how doctors can learn more from their patients than from all of the textbooks in the clinic library. It was refreshing to have a parent who was so knowledgeable about her child's condition. Noonan's syndrome, JR and KS learned, is caused by a defective gene on chromosome 12. The most common features are short stature, webbed neck, congenital heart disease and a characteristic facies. About 25 percent of persons with Noonan's syndrome have moderate mental retardation. Usually the syndrome occurs randomly, but it can occur in families (Nelson: Textbook of pediatrics, 15th ed. Philadelphia: Saunders, 1996).
TA felt somewhat a sense of accomplishment as she toured the office of a new practicing physician. RA finished his residency program in June followed by board examinations in July. He was now hosting a reception to celebrate the start of his new career. While admiring the beautifully decorated office, which included three examination rooms, a fully equipped procedure room and elegant office area, TA thought back to when RA was a first-year resident feeling anxious about his first night on call. Now seeing him so enthusiastic about his future, it was nearly impossible to remember him three years earlier. One of the most rewarding aspects of academic medicine is to see new physicians grow in knowledge, experience and self-confidence. TA smiled as she watched RA in his new environment surrounded by well wishers. He was finally embarking on a career that he'd first envisioned more than 11 years ago. Always a hard worker, she knew that RA would rise to meet the new challenges that all physicians face, and that he would be a tremendous asset to the community.
Kathy Soch, M.D., is a clinical instructor with the Corpus Christi Family Residency Program, affiliated with the University of Texas Health Science Center in San Antonio. This community-based program, which employs nine full-time faculty and 36 residents, primarily serves low-income, uninsured patients.
Copyright © 2001 by the American Academy of Family Physicians.
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