Diary from a Week in Practice
Am Fam Physician. 2000 Jan 15;61(2):351-353.
One of JRH's pleasures outside of the office is basketball. Gone are the days when he participated in this most noble of athletic endeavors. Nowadays, JRH takes great joy in watching his daughter's basketball team take on all the local teams and win its share of the contests. So it was with a sense of urgency today that JRH saw a member of this team who complained of sore throat, fever and cough. Deep in the recesses of her mouth appeared two large, irritated, pustular tonsils—and today was game day. The young girl was reluctant to take a shot of penicillin, but she was urged to comply by her mother and JRH. Finally, after poignant discussion, she acquiesced. Later that night in a pivotal match-up, she starred in her role as three-point specialist and tallied 17 points—her highest output of the season. JRH surmised that her shot was on.
The drug resistance of head lice seems to be increasing in the United States. Parents today seem to be interested in topical therapies, avoiding the possibility of systemic side effects. Some experts now say that topical occlusive therapies may be the most effective and least-used treatment for head lice (Worcester S. Scratching out louse infestations in schools. Fam Pract News 1999;29:51). Many recommend petroleum jelly, but WLL has found that his patients (and their parents) report that it is difficult to remove from the hair. An easier option is styling gel. WLL instructs his patients to copiously apply the gel to dry hair and leave it on all night under a shower cap. The next morning, the gel can be shampooed out of the hair. The parent should then apply a hair conditioner and use a nit-removing comb to remove all nits. This anecdotal therapy seems effective. It's easier than petroleum jelly and much less expensive than many topical medications.
All of us have an ample allotment of diabetic patients in our practices. Perhaps no specialty is better suited than family medicine to bring health care to patients with diabetes. Their needs demand a breadth of training that family practice is uniquely positioned to deliver. Today JRH visited with one of his teenage patients with diabetes who had been taking insulin shots for several years. The topic of the day became injection technique and the rotation of sites for injection. JRH had noted the “extra fat” on her abdomen and mentioned that the shots would produce this reaction if the sites were not rotated. In typical fashion, she responded with the ingenious denial: “Oh, I like it that way, 'cause all my friends think I have abs.” Nonplussed, JRH gave her a chart showing how to rotate her shots and kept his fingers crossed.
When it comes to the problem of obesity in his patient population, JTL often hears the same response from his patients: “I know what I gotta do, doc.” Assuming the role of motivational speaker, JTL has recently tried a new strategy. “If I were in your shoes right now (i.e., 40 or more lb overweight), I would consider that I had a potentially fatal illness, and I would take any measures, however radical or drastic, to modify my lifestyle to achieve a cure.” JTL then recommends changes in work schedule, times and composition of meals, and exercise routine, and makes a referral to one of the more comprehensive, nutritionally sound weight loss programs in the area. JTL also recommends the use of a reliable scale because any measurable weight loss can serve as much-needed positive reinforcement. Today, in response to this last suggestion, one sharp-witted patient replied, “Gee, doc, I've got a scale, but I'm pretty sure it's broken…it's been stuck on 217 lb.” When faced with a fatal illness, it helps to have a sense of humor.
As part of our calling to family practice, we like to encourage our patients to be planters as well as reapers of the harvest that grows in each community. Today, when a 30-something member of the practice mentioned that she would like to have a copy of her echocardiogram, JRH was happy to oblige. The story, as it unfolded, concerned her desire to donate blood as she had done several times in the past. On her most recent trip to the bloodmobile, she was rejected because of a history of mitral valve prolapse. She reminded JRH of the recent test that noted no sign of mitral valve prolapse or regurgitation. She was requesting a copy of her report for proof of her “qualification.” JRH has since learned that local blood donation branches are free to add additional restrictions to the national list of conditions that disqualify potential donors. Today, however, one donor was added, and her community will be the richer for it.
Today, CAG received a special note of thanks and an interesting article from a patient. This elderly gentleman was the sole caretaker for his 82-year-old wife (for whom CAG also provided medical care), and the previous eight months had been very difficult because of the wife's progressing Alzheimer's disease and three hospitalizations for pneumonia, gastrointestinal bleeding and a hip fracture. CAG was aware that the patient's wife had been an active Catholic before the dementia had worsened and that her husband was Jewish but for many years had taken little interest in spiritual issues. This had changed during his wife's illnesses. The article attached to the patient's note was titled “Faith is Powerful Medicine.” His note simply read, “Thanks for your interest, compassion and prayers.”
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