Diary from a Week in Practice



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Am Fam Physician. 2002 Feb 1;65(3):412-413.

Monday

Obtaining a sexual history is usually the last item on the agenda during a physical examination. JOH, who trained in the early 1970s, never had the importance of obtaining a sexual history impressed on him. However, after almost 30 years in practice, it has become much easier to ask the right questions.

With the advent of drugs to improve erectile dysfunction (ED), the general population of males also seems more open to discussions about this problem. Humor on late-night television associated with the topic has also made men less reluctant to discuss the issue with their physicians. One of JOH's patients, a vibrant octogenarian retiree, came in for a general physical examination. A year earlier, he had asked for a prescription to “help his sex life” because he had recently remarried, one year after being widowed. JOH broached the topic at the end of today's examination, asking whether the patient needed refills. “Oh, no. I'm getting along just fine,” was his reply. He had gotten a “jump start,” as he put it, and was not in need of the drug now. JOH learned that ED did not have to be a permanent condition requiring pharmacotherapy.

Tuesday

A patient who had presented a month ago with pruritus returned to the mobile clinic today. He greeted JOH with the same complaint. Previously, the patient had been given lindane lotion and diphenhydramine for a presumptive diagnosis of scabies, but he had experienced only temporary relief of the symptoms. He had a questionable history of hepatitis, which had prompted an evaluation of liver enzyme levels. They were all normal except for moderately elevated alanine aminotransferase levels. No lesions were evident, but the patient related seeing “welts” appear at various times on different parts of his body, often in response to eating certain foods. The differential diagnoses included chronic hepatitis, idiopathic urticaria, uremia, polycythemia, thyroid disease, and malignancy, among others. The appropriate blood chemistries were drawn. The patient was treated with an antihistamine, an H2 blocker, and prednisone. When the patient left the mobile clinic today, JOH was still unsure of the diagnosis but was hopeful that a treatable cause of the pruritus would eventually be found.

Wednesday

A patient who came to the mobile clinic today caused JOH some unease when she manifested a jovial affect while complaining of intense pain with the slightest touch of the skin. “La belle indifference” did not fit with the pain that was localized to the right upper arm, anterior chest wall, right trapezius, and right posterior neck. The symptoms had been simmering for a year, but flared up when she was carrying a heavy backpack over her right shoulder one week earlier. The woman had sought relief at a local emergency department, but was dismissed after being examined, having a radiograph (with normal results), and given pain medication and reassurance.

When JOH examined the patient, her strength and reflexes were intact, no skin rash was visible, and there was certainly no joint misalignment. The dysesthesia with light touch that she reported along with associated mild edema of the hand made JOH suspect reflex sympathetic dystrophy, also known as complex regional pain syndrome type I. JOH knew that early mobilization and physical therapy modalities such as heat and massage were crucial in breaking the pain cycle. JOH encouraged the physical therapy modalities, assured the patient of the integrity of her joints, and instructed her about the source of her symptoms. Her upbeat attitude would likely be a positive influence in her ultimately gaining pain relief.

Thursday

Today, a first-year medical student was doing her community service hours with JOH. After becoming oriented to the mobile clinic, she went to see a patient who complained of a rash and itching scalp. When the student finished taking the patient's history, she presented the patient to JOH. It did not require much examining for JOH to see the source of the problems, which were crawling on the patient's long, brown hair. The body rash was the result of multiple bites from body lice. The patient was instructed about the use of appropriate medications, and was immediately sent back to the shelter where the staff was alerted to the patient's need to follow up with the treatment instructions.

JOH later learned that the triage nurse had removed several lice from the patient's hair before sending him to the mobile clinic. With such an obvious diagnosis, JOH requested that the triage nurses limit the number of locations to which they send patients with lice and institute treatment as soon as possible.

Friday

The patient came to the mobile clinic complaining of a swollen finger. Multiple diagnoses came to mind as JOH read the chart but, when he examined the patient, he saw a very swollen and obviously painful paronychia. A third-year student was working today, and JOH wanted her to learn how to treat such an infection. After preparing the finger for surgery, JOH unsheathed a no. 11 blade and asked the student to aim the stream of methyl fluoride from about two feet directly above the area of loculated pus. This allows anesthesia of the area long enough to introduce the blade into the abscessed area for drainage. The quicker the procedure can be performed, the better it is for the patient. The stream was cooling the area well enough, but not freezing it. JOH instructed the student to increase the height of the anesthesia bottle, and white frost quickly appeared. The swelling was incised and drainage was easily accomplished. When the patient left the clinic, he was appreciative and much more comfortable than when he arrived.

Saturday/Sunday

The patient was a small 62-year-old woman who spoke in Spanish through an adept interpreter about her shoulder and neck pain. The pain had been present for two years, but in the past two months it had become more severe. Despite a life of hard work in Mexico, the woman had not sustained injury to the area, and she had not recently done anything to aggravate it. The differential diagnoses included osteoarthritis of the shoulders, degenerative joint and disc disease of the neck, and polymyalgia rheumatica. Atypical chest pain with a cardiac etiology was also entertained, but was less likely because the pain was not aggravated by activity. JOH began examining the shoulders, which had some crepitus in each joint. Pain was present with elevation of both arms. The reflexes and strength were good bilaterally, and there was no sign of radiculopathy with neck extension and pressure to the top of the head. The woman's age and symptoms were right for polymyalgia rheumatica, and a sedimentation rate and complete blood count would help support the diagnosis.

After years spent 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 on a mobile coach clinic. Dr. O'Handley continues to see private patients two mornings a week.



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