Diary from a Week in Practice



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Am Fam Physician. 2002 Nov 15;66(10):1863-1864.

Monday

Recently, a 17-year-old man came into the office. He had pain in his right anterior chest as a result of an altercation several days earlier. X-rays of his shoulder, chest, and ribs were negative. He had no difficulty swallowing, but further history revealed that at the time of the incident he had some difficulty breathing and brachial plexus palsy that lasted several hours. When HBK examined him, he discovered a bruit over his right subclavian vein. HBK did not think this was a simple venous hum. It did not change with position, and there was no diastolic component. The murmur radiated up into his right neck, and there was tenderness of his right sternoclavicular joint. A computed tomographic (CT) angiography and a CT scan revealed that he did have a posterior and inferior dislocation of his right clavicle at the sternoclavicular joint, with some compression of his right subclavian vein. In sports medicine, sternoclavicular dislocation is uncommon, but it can be life-threatening. Symptoms include dysphasia and vascular problems in the upper extremities. In an emergency situation, when respiratory symptoms are present, reduction should be attempted as soon as possible—even on the playing field. Those of us who do sports medicine for local athletic teams should always have an awareness of this potential life-threatening injury.

Tuesday

Seventy-five-year-old James presented for follow-up of his significant hypertensive heart disease. His wife, Florence, was also in the office. She had brought their five-year-old granddaughter, who was the child of their youngest son, for a pre-kindergarten physical. This family's presence reminded RHS of a Christmas Eve and an early Christmas morning many years ago when he attended Florence at home for a delivery. RHS had arrived late on Christmas Eve, and the labor had continued into the early hours of Christmas morning. The other children were “snug in their beds,” and James, Florence, and RHS watched and waited as the labor progressed. About 2 a.m., James went quietly to a chest of drawers and brought out the simple gifts of a tenant farmer for his small children, placing them on the hearth. The warmth and tenderness of this scene remains a poignant reminder to RHS of the true meaning of Christmas as well as a treasured example of “the doctor-patient relationship.”

Wednesday

One of the real advantages of family practice is the continuous care and availability of follow-up for patients. Two incidents today provided excellent evidence of this advantage. An 80-year-old woman had been seen in the practice six days earlier. At that time, she was afebrile with a cough and mild chest discomfort, and she had been treated symptomatically for pain and cough. Review of the chart revealed that the previous physician had also suggested that a chest x-ray might be indicated if symptoms persisted. The patient was asked to come in if her condition did not resolve. X-rays taken today revealed a left upper lobe pneumonia (she was still afebrile). A second patient had been seen three weeks earlier for foot pain. He had been treated for plantar fasciitis, again with the admonition that he should return to the office if problems persisted. After a short period of improvement, the pain increased. He returned today, and a foot x-ray revealed a stress fracture of the third metatarsal. Each incident illustrates the advantage of promoting patient trust, easy access, a common medical record, and respect for your colleagues in family practice.

Thursday

Penny, a 60-year-old woman, was seen by RHS for a wellness examination today. Her last examination was four years earlier, and before this she had been seen on an annual or biannual basis. Since her last examination, she had retired as a public school teacher and had become a grandmother times three. Apart from being treated for mild hypothyroidism and moderate hypertension, she had enjoyed good health. She was happy to be retired and was enjoying assisting with the care of her grandchildren. When questioned about her health, she said she was doing well but was having “a little low abdominal pressure” when her bladder was distended. She had noticed some low abdominal hardness at those times. On examination, a 10-cm left-sided pelvic mass was found. Ultrasound and computed tomo-graphic scans revealed this to be a “cystic mass, probably ovarian in origin.” This was the second newly postmenopausal patient seen by RHS this season whose last wellness examination was four years earlier and who now had a significant ovarian tumor.

Friday

Helen, an 83-year-old patient, was in the office today for a wellness examination. She was being monitored by RHS for hypertension and osteoarthritis. Her daughter, visiting from California, had prompted this examination. This visit recalled some of RHS' earliest encounters with this family. Before the days of effective drug therapy for hypertension, Helen's husband had been diagnosed with severe hypertension. In the middle of the night, RHS was called to their home, a small farmhouse a few miles out of town. On arrival, he found the patient with extremely high blood pressure and all the signs of a major intra-cerebral catastrophe. Forty plus years ago, we had no effective intervention to offer this patient. He was given moderate sedation, and RHS remained in attendance until the patient expired before dawn. Although there was nothing “to be done” for this patient, these hours of watchful waiting helped form a bond between this family and RHS that has endured these many years.

Saturday/Sunday

The month of October presented us with a wonderful opportunity. TSD, a senior family medicine resident, spent four days a week with us, learning and teaching. One afternoon, RKT was seeing Ms. Ellsworth for a colposcopy. CSJ had performed Ms. Ellsworth's annual examination. The Papanicolaou smear revealed high-grade squamous intraepithe-lial lesions, and the reflex human papillomavirus test was positive. Ms. Ellsworth asked that CSJ be present, to help her relax and stay calm during the procedure. This was an excellent opportunity for CSJ to review the colposcopy procedure. As the attending physician, RKT asked if TSD could perform the colposcopy and if a young nurse could observe. Ms. Ellsworth agreed. She said she was happy to help in the teaching process. During the procedure, RKT and TSD were able to share techniques and CSJ had the opportunity to review and get an update on the procedure. The nurse learned more about the procedure as well, allowing her to provide patients with reassurance and an explanation of what to expect from a colposcopy. This month we were reminded to take advantage of teaching opportunities and to involve our patients in the process of medical education in private practice settings.

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 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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