Diary from a Week in Practice



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Am Fam Physician. 2001 Dec 1;64(11):1833-1834.

Monday

Pharmacologic agents receive FDA approval for specific indications, but this does not necessarily limit their use for other problems. JOH recognizes this but was still surprised when a teenage patient who came to the coach asked for clonidine for sleep problems. As an antihypertensive, drowsiness is a common side effect of clonidine. The patient had been prescribed 0.2 mg of clonidine, five tablets at bedtime for sleep, and she had been taking it for five years. The patient had a missed period and positive pregnancy test, which warranted against the use of a Category C drug, even if its use had been indicated. Additionally, she had been taking a Category C selective serotonin reuptake inhibitor for the past five years. JOH was concerned about abruptly withdrawing a drug that this patient had apparently tolerated and even done well on for five years. He learned that clonidine has several off-label uses for treating psychiatric disorders, including mania, schizophrenia, anxiety, attention-deficit/hyperactivity disorder, opioid withdrawal, and sleep disturbance. In the final analysis, JOH decided to taper the patient off clonidine and substitute a Category B antidepressant and Category B anxiolytic for sleep. The patient was referred to the obstetric clinic for follow-up and encouraged to see her physician for her psychiatric issues. The encounter was a learning experience for all involved.

Tuesday

A female resident and JOH entered an examination room at the coach to perform a culture. The triage nurse indicated that the patient had penile discharge and dysuria. As the resident waved a urethral swab in the patient's direction, the patient looked furtively at her and queried, “What you gonna' do?” Her explanation led to raised eyebrows, head shaking, and staccato hand motions from the patient. What he really was complaining about was a painful, burning rash on the scrotum. The resident learned a powerful lesson—take a history before doing anything else, even when the chart information seems to be thorough. The rash was erythematous, well demarcated, and macular. JOH reasoned that the pain likely excluded a fungal etiology and was more consistent with a bacterial infection. A similar type of rash described in a journal quiz, which JOH showed to the resident, made the point even more tangible. The patient was treated with an antibacterial ointment and was relieved that the urethral culture was not needed that day.

Wednesday

The decision to place a loved one in assisted living or a nursing home is never easy. JOH faced that task today. The patient, who had taught school until retirement age, had been self-sufficient all of her adult life. She was experiencing some loss of recent memory, and paranoia had begun to insinuate itself into her thought processes. The patient was accompanied by a friend who was a former student and whose devotion to the patient seemed to know no bounds. Medications had definitely slowed the progression of her deteriorating mental function, and she still had a sharp recall for distant events. She described growing up with a father who frequently physically abused her. The thought of a parent kicking or hitting a child was repugnant to JOH, understanding the physical and emotional vulnerability of children. Such aberrations can easily lead to permanent damage, which was evident in the patient's description of her brother who was similarly abused by his father. His reaction was to run away from home at 11 years of age and wander the country for the rest of his life. The patient, however, attended college and became a productive member of society, passing her wisdom and empathy on to others. When the visit ended, JOH had a much greater appreciation of his patient and of the resilience of the human spirit. She was not ready to leave her own home at this time, but the seed had been planted.

Thursday

JOH does not ask a lot of personal questions when treating patients, but sometimes explanations are volunteered. Today, he saw a patient who was living in a homeless shelter and was seeking rehabilitation. Fortunately, the patient discovered the coach. The man's visible shaking and furtive glances attested to the hold that alcohol had on his body. He brought his bedroll and personal belongings with him into the examination room. Living on the streets had dealt some blows to his health—infected sores on the buttocks and 4+ ankle edema. JOH surmised the edema was secondary to protein deprivation, constant walking, and alcoholic hepatitis. Ascites was not found. JOH temporized with a diuretic and antibiotic, and encouraged the patient to follow through with the social worker's recommendation to begin the alcohol withdrawal process. The patient had the desire, and now he had the support, too.

Friday

JOH read the chart of the next patient waiting to be seen, and it first appeared that the patient could be treated in the waiting area with a discussion, brief examination, and medication. But things do not always pan out as expected. The patient was middle-aged with diabetes and complained of sores on his fingers. He had been without medication for five months and his blood sugar level was 288. The finger lesions were superficial and not infected. Once asked, the patient complained of having diarrheal stools for the past four months, a foot ulcer, pruritic extremities, dizziness, and depression following his father's death. JOH has accepted that every problem can be addressed, but not every problem can be solved because of the limited resources available on the coach. Fortunately, JOH was able to refer the patient to a physician who was just starting his practice and was willing to follow up with his problems. Medications including glipizide, sertraline, metronidazole, and loperamide were prescribed, as well as lindane lotion for scabies and dressings applied for foot and finger ulcers. Follow-up was stressed, and the patient appeared to be genuinely interested in his health by the end of the visit. While the death of a parent causes sorrow, it can also be the occasion when people realize their own mortality and gain the resolve to turn their lives around.

Saturday/Sunday

Living on the streets is not easy, even for the strongest of men. It is especially hard for women when they have physical disabilities added to the mix. Today, JOH encountered a female patient with severe osteoarthritis of both knees, chronic obstructive lung disease, and a major depressive disorder. This combination of disorders does not bode well for her, although she has been homeless for many months. Addressing her needs one at a time, the family practice resident and JOH still felt helpless about her primary problem—homelessness. Her family was in a city 400 miles away, and she had no means of support. Clearly, she had few options. The tears streaming down her face spoke not so much to the physical pain but to the pain she carries in her heart. Even other patients in the coach commiserated with her plight. One of them told her about a program that provided nightly shelter in one of the downtown motels for people without a roof over their head. The information was graciously received and with a quiet “thank you” she left the coach. There truly is camaraderie among those with similar plights.

After years in private family practice and academia, John O'Handley, M.D., is medical director of the Mount Carmel Outreach Program in Columbus, Ohio. The program provides free medical care to uninsured and homeless patients throughout the city in a mobile coach clinic. Dr. O'Handley continues to see private patients two mornings a week.



Copyright © 2001 by the American Academy of Family Physicians.
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