Diary from a Week in Practice



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Am Fam Physician. 2002 May 15;65(10):2031-2033.

Monday

Charles, a 70-year-old man, came in today for a routine follow-up visit for congestive heart failure (CHF). At age 45, he had an acute myocardial infarction and was treated in the standard manner of that day—rest, analgesia, nitrates, and anticoagulants. He made an uneventful recovery and returned to work. He continued to have moderate angina and was referred to a tertiary care medical center for evaluation. This occurred in the early days of coronary artery angiography and coronary artery bypass grafting (CABG). At that time, the primary indication for CABG was angina not controlled by medical treatment. When Charles was studied, he was found to have significant three-vessel coronary artery disease (CAD) and was not considered a candidate for CABG. His symptoms were fairly well controlled with beta blockers and nitrates, and he was later prescribed statin drugs for hyperlipidemia. Currently, he is active, works full time in his own business, is a happy gardener, and a doting grandfather. This example should remind us, in the current milieu of highly aggressive interventional cardiology, that medical therapy for CHF was, and can still be, an effective treatment in combination with surgical intervention or alone in many patients with CHF.

Tuesday

RHS was both tricked and helped by his age and experience when asked to see a patient who had been vomiting about every 30 minutes since 5 a.m. this morning. An initial survey of the chart revealed a birth date of 07/23/00, which the long-time occupant of the 20th century perceived as 07/23/1900. Actually, the patient was 18 months old, with a 07/23/2000 birth date. The child vomited again as RHS entered the examination room. She was awake and alert but very still in her mother's arms. The initial history and physical examination were unremarkable except for a placid, quiet, and unresisting child. The mother commented that her daughter's behavior was uncharacteristic of previous visits to the physician. Because of his long experience, RHS was wary of the “quiet child.” So prompted, he completed a detailed history and physical examination and found no other abnormalities. This allowed him to diagnose nonspecific gastroenteritis and render positive assurance to the very anxious mother. Oral fluids and antiemetic suppositories, if needed, should result in an uneventful recovery in about 36 hours. Beware the “quiet child!”

Wednesday

Yesterday was PRP's day off, and AMS was just finishing with a patient she was seeing for the first time, although the patient was well established with PRP and JDF. Ms. James said, “I'm going to tell you what I told them about you up front.” AMS looked inquisitively at Ms. James as she described her conversation with the front-office staff. She had asked to see one of her regular medical professionals. When told that AMS was the only one available, Ms. James said, “I don't care to see that one. These two know me already. They've seen me when I've been at my best and at my worst. I've no interest in seeing someone who doesn't understand me and isn't going to listen to me.” She concluded, saying to AMS, “But you've been real nice.” AMS thanked Ms. James and was pleased to have made a good impression. It is important for every patient to feel comfortable with their health care professional and to have the choice of who they see. Of course, that is not always possible. AMS recommended that Ms. James come back tomorrow for a blood pressure recheck (it was markedly higher than usual). “Okay, but…” she paused. “That's okay,” AMS replied, “PRP will be here tomorrow.”

Thursday

Valerie, an 80-year-old woman, was seen in the office today by RHS for a follow-up of multiple problems, including COPD, pulmonary hypertension, right ventricular hypertrophy with secondary ventricular dysrhythmias, atopic dermatitis, and type 2 diabetes. For RHS, this visit recalled a day some 30 years earlier when Valerie came to the office with a primary symptom of chest pain. The initial electrocardiogram (ECG) showed only minor T-wave changes. In the midst of making disposition decisions, RHS dashed to an urgent house call one block from the office. As he finished the house call, he received a “may-day” call to return to the office, where he found a nurse and an emergency medical technician performing cardiopulmonary resuscitation on Valerie, who was unresponsive. An ECG strip from our recently acquired monitor/defibrillator showed fine ventricular fibrillation. External direct-current shock was administered, and in a brief time normal sinus rhythm was restored. Valerie was responsive and alert. In the hospital, acute myocardial infarction was ruled out, and an uneventful recovery occurred. Postdischarge, she was closely followed on a regular basis. Other medical problems have developed but, as of today, no myocardial infarction has been diagnosed. Following patients over extended life spans is a magnificent learning experience.

Friday

JDF was taking care of some day-to-day tasks when she noted a coworker who seemed not to be feeling well. Heather, who is 29 years of age and in good health except for recent problems with sinus congestion and “sinus headache,” said that she had not “felt quite right” since taking the first dose of prednisone for the sinus problems. She was immediately checked by JDF. Her blood pressure (BP) was 160/110, and fasting glucose was 156. She had not taken any over-the-counter or prescription sympathomimetics, nor did she have a history of risk factors for hypertension or type 2 diabetes. It was decided that she had an adverse reaction to the steroid, and it was discontinued after the initial dose. Over the next several days, Heather's BP was persistently elevated, and shortness of breath, headache, and chest pain ensued. A combination of beta blocker, calcium channel blocker, and diuretic was required to control her BP. Labs were all unremarkable. Today, ECG, stress cardiolyte, and renal ultrasound are pending. Her blood sugar has normalized, and her headache has resolved. However, she continues on multiple medications for unexplained hypertension. This situation reminds us that sometimes treatment of a straightforward problem with a common medication in an uncomplicated patient may not always be straightforward, common, or uncomplicated.

Saturday/Sunday

RHS attended the funeral of one of the three grandmothers mentioned in “Diary from a Week in Practice” in the January 15 issue of American Family Physician. Elizabeth was born before 1920 and “inherited” with the practice in 1949 when she was pregnant for the first time. She delivered twice in the 1950s. She remained a patient until her death, three weeks after she experienced a hemispheric stroke. Over the course of 52 years, the natural history of multiple disorders was documented in her records: generalized anxiety disorder, fibromyositis, coronary artery disease, hypertension, deep venous thrombosis, degenerative joint disease, postmenopausal endometrial carcinoma (cured by hysterectomy), and probably chronic fatigue syndrome before it was defined as a specific entity. Eventually, she had a gradual onset of atherosclerotic cardiovascular and cerebrovascular disease, which was the basis of her terminal illness. Much valuable experience was gained while diagnosing and arranging treatments for these problems. During the time that Elizabeth was a patient, her extended family were patients in the practice. Let's hope that today's mobile society and our emphasis on technology will not rob the current generation of family physicians of this enriching experience.

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, who include 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 Road, Mount Olive, NC 28365 (e-mail rshackelford@nc.rr.com). Reprints are not available from the author.

In order to preserve patient confidentiality, the patients' names and identifying characteristics have been changed in each scenario.


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