Diary from a Week in Practice



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Am Fam Physician. 2002 Mar 15;65(6):1066-1068.

Monday

A 59-year-old woman came into the office today with pain in her left foot along with some leg and knee discomfort that has been ongoing for about two months. There was no history of injury, but the patient was moderately overweight. She had previously been seen by a physician and a physician assistant, and she was treated for metatarsalgia. She was returning for a follow-up visit because her symptoms persisted. The physical examination showed no significant changes. Her foot was tender over the middle metatarsal, but there was no swelling, heat, or redness of the foot. Despite the knee pain, no abnormality was noted, and a radiograph of the knee appeared normal. The PA consulted RHS who recommended a radiograph of the foot, which revealed a fracture of the shaft of the middle metatarsal with significant callous formation but no bone union. With the use of a post-op shoe and decreased weight bearing, healing and pain relief were complete in six weeks. When evaluating foot pain in post-menopausal women, stress fracture should be included in the differential diagnoses.

Tuesday

NE made one of her frequent visits to the office this morning. She is a 75-year-old woman who is moderately developmentally delayed with a significant dysarthric speech impediment. NE has never married, and her mother was her guardian until the mother died, at which time NE's brother became her guardian. Some years ago when she was employed part-time in domestic work, her employer became interested in getting NE established as a responsible party. With the aid of RHS and the Department of Social Services, this was accomplished. Soon after, NE began adult education classes with much enthusiasm and pride. Although she has no major medical problems, the support, reassurance, and friendship of our medical and office staffs are necessary to helping NE remain an independent and functioning member of society.

Wednesday

This morning, PRP examined a 19-year-old woman whose primary symptom was a mildly itching rash. PRP thought the rash looked like one she had seen during her pediatric rotation about three years earlier. She had not seen a case since then but thought this rash looked like pityriasis rosea. She consulted with RHS who examined the patient and agreed with the diagnosis. The patient had no suspicious sexual history, but RHS reminded PRP that, while pityriasis rosea is certainly common in young adults, secondary syphilis should be considered in the differential diagnosis. As the patient was leaving, she remarked that her new boss thought the rash was pityriasis rosea as well. PRP was curious, and asked about the patient's employment. She learned that the woman was a receptionist at a local pediatrician's office!

Thursday

This morning, PRP saw an 18-year-old patient who presented with a rash that did not itch. This rash, too, had a familiar look, and PRP was fairly confident that it was another case of pityriasis. She thought it was quite unusual not to see a single case of a disease for almost three years, and then see two cases in such a short period of time! She consulted RKT about this case. RKT admitted that he was not certain what the rash was, but thought that it was not pityriasis rosea. The patient was given a mild topical steroid to apply to the rash.

One week later, the patient returned with the rash having worsened but still not itching. PRP now could clearly see a “Christmas-tree” pattern across the trunk, a pattern that is typically associated with pityriasis. PRP learned that second opinions can be helpful, but it is important to trust her own instincts.

Friday

A female patient in her mid 40s presented to PRP with persistent body aching, especially in the back and legs. She had a low-grade fever, and casually mentioned that a rash had appeared on her lower abdomen and thighs in the past few days. Physical examination was initially unremarkable—ears, throat, lungs, and heart all looked and sounded good. The patient did not experience tenderness with palpation of any muscle groups. No masses or pain with palpation of the abdomen were present. However, a reddish-purple macular rash with lesions about 3 to 8 mm in diameter was scattered across the abdomen and upper thighs. PRP, who is relatively new to the practice of medicine, tends to ask for a second opinion on dermatology findings that she has not seen before. Today, RHS (with 50 plus years of experience) was in the office. He briefly examined the patient and, after seeing the rash, asked “Any sore throat?” The patient replied that she had a mild sore throat, which she had not previously mentioned. PRP was planning to get a complete blood count, and RHS instructed her to add a strep test even though the rash was not typical for scarlatina. “A strep test?” thought PRP. But it was ordered, and PRP was shocked to find it positive with a white cell count of 16,000. The patient responded well to treatment. PRP remains in awe of RHS's ability to just “know” things like this. It goes to show the difference between practicing three years versus 50!

Saturday/Sunday

RHS received a page from a telephone number in Italy. JK, one of HBK's sons, was in Italy to participate in an all-star high school basketball tournament accompanied by his two older brothers and mother. One of the brothers was on the telephone reporting that during practice JK had collided with another player and suffered a dislocated patella. The older brothers are premedical students and certified emergency medical technicians. His mother is a certified family practice nurse practitioner. RHS gave instructions to the brother, and he relayed them to the mother who, without great difficulty, reduced the dislocation. The plan was to follow-up at a local hospital for a post-reduction radiograph.

Unfortunately, JK could not participate in the tournament, but the family plans to complete their post-tournament tour of Italy.

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

Address correspondence to R.H. Shackelford, M.D., Mount Olive Family Medicine Center, 238 Smith Chapel Rd., Mount Olive, NC 28365 (e-mail rshackelford@nc.rr.co). Reprints are not available from the author.


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