Diary from a Week in Practice

Am Fam Physician. 2001 Nov 15;64(10):1700-1705.

Monday

A 78-year-old man who was a long-time patient of HBK's presented to JDF with weakness and shortness of breath. The physical examination revealed a pale, diaphoretic patient with bibasilar crackles, pitting edema, hypotension and bradycardia. ECG suggested posterior myocardial infarction. The admitting physician, KT, was summoned and plans were made to transfer the patient to the emergency department. Oxygen and an IV were initiated. The patient refused aspirin therapy despite the absence of contraindications to the drug. He seemed to understand the importance of aspirin therapy, but insisted that he was never, ever to take aspirin according to HBK's instructions. The man was on maintenance warfarin because of atrial fibrillation. Finally, KT and the patient's family members were able to coax him into taking the recommended dosage of aspirin just before his departure for the hospital. HBK was told about his patient's loyalty. He decided that, in the future, he would add to his patient instructions—“unless it's an emergency and another health care professional tells you to!”

Tuesday

It was PRP's birthday and the physicians were preparing to leave for her birthday luncheon. JDF was summoned to the last examination room for a blood pressure recheck. A 62-year-old woman with a history of end-stage COPD, hypertension, congestive heart failure, type 1 diabetes, ischemic heart disease, morbid obesity, chronic pain syndrome, hypothyroidism and depression was waiting. Yesterday, an epidural spinal injection had not been administered because her blood pressure was “too low.” Certainly, this is a rare occurrence for a patient with these medical problems. She had been asked to bring her medications to today's visit. She unloaded four gallon-size plastic zipper bags full of prescription medications. Apparently, every time she had been discharged from the local hospital, she kept every medication she had been given there and then continued taking them at home. She did not realize that many of the prescriptions were for medications she was already taking and had been rewritten for use at the hospital. This had gone unnoticed because she had not brought her medications to her office visits. Fortunately, JDF was able to reduce her medications to only one bag, avoiding potential self-medicating errors. JDF left for the birthday luncheon relieved and reassured that the patient knew more about what medications and how much of them she was taking.

Wednesday

Over time, family physicians who serve local populations accumulate information that can offer insight into medical situations that might otherwise be difficult to obtain or never come to light. This morning, a man in his 40s presented unannounced through our emergency entrance. He appeared pale and sweaty. He was not a registered patient at our facility but was accompanied by his mother who RHS immediately recognized. This triggered a recall of the man's father (a contemporary of RHS) who had premature coronary artery disease. Oxygen therapy, IV access and cardiac monitoring were established. An ECG was performed while morphine was prepared, and 365 mg of aspirin and sublingual nitroglycerine were administered. By the time the morphine was infused and the ECG was available, the patient's pain, color and diaphoresis were much improved. An ECG confirmed significant ST segment elevations. The patient was transported by ambulance to the nearest hospital. He remained stable, and myocardial infarction was ruled out. Subsequent cardiac catheterization revealed no significant coronary artery disease. RHS concluded this was indeed a coronary event, and appropriate follow up was indicated. RHS's knowledge of the patient's family history may well have interrupted a myocardial infarction in progress.

Thursday

A new patient presented to PRP with a migraine headache. She reported having had classic migraines for 20 years. She had previously been seen by several primary care physicians and by a neurologist. Treatment with over-the-counter medications had failed. She had never received a beta blocker, probably because of a history of mild asthma. She said that butorphanol had worked best but, even then, her headaches lasted three to four days. Without treatment, she was routinely debilitated for up to one week each month. She was clearly distressed. A few weeks earlier, CS and JF had attended a conference about a “new” treatment for migraine: instill 0.25 mL of 4 percent lidocaine in the nose with a dropper or tuberculin syringe. They had discussed this treatment over lunch. PRP decided to try it on this patient. A few minutes after the lidocaine was administered, she sat up with an incredulous look and said, “I can't believe this! My headache is gone. And I don't feel groggy, nauseated or drugged up!” PRP was amazed, but warned the patient that her headache might recur. However, when PRP called to check on the patient that evening, she was still headache free. It has been three weeks today since the patient first presented. She has had no recurrence of her migraine, and is doing well on a mild dose of propranolol with no exacerbation of her asthma.

Friday

We received a call from one of our regular patients. She had been seen three weeks earlier by JDF for her annual physical examination. At the age of 59, she had never undergone a routine flexible sigmoidoscopy screening despite many recommendations. This year she changed her mind. Last week, AJ performed the flexible sigmoidoscopy, and a large mass was discovered. Colonoscopy confirmed a benign tubovillous adenoma. Fortunately, persistence paid off. The patient's telephone call to thank us was the best kind we could get.

Saturday/Sunday

In family practice, you never know what is going to come in the back door or the front door. As is typical for a Saturday, we had a fair number of “walk-ins” mixed with our scheduled patients. Things were busy, but were running efficiently with only a few patients in the waiting room. RKT was standing in the hall reviewing a chart when he heard a loud crashing noise and screaming coming from the front office. Running to the front, RKT saw that one wall of the waiting room has been replaced with the front of a car! Fortunately, no one was injured. The driver explained that he intended to back out of his parking space, but the car was actually in drive. As the car jumped the curb, he panicked and stepped hard on what he thought was the brake pedal but instead was the accelerator. Realizing how lucky we were that no one was injured, the driver, patients and staff had a good laugh about our new “drive-thru window.”

Robert H. Shackelford, M.D. is associate medical director of and one of five physicians at Mount Olive Family Practice in Mount Olive, North Carolina. Dr. Shackelford and his colleagues, which include three physician's assistants and one nurse practitioner, provide all types of care (except obstetrics) to patients of all ages in their rural community.


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