Diary from a Week in Practice
Am Fam Physician. 2000 Apr 1;61(7):2028-2030.
In this part of the country, we see our share of kidney stones. While most patients proceed to the local hospital emergency department, a fair number still show up at our office. Until just recently, JRH had been in the practice of getting a urinalysis and a kidney, ureter and bladder check to support findings of the history and physical examination before giving a narcotic injection. Today, however, a colleague, Dr. Linda King, shared with him that she uses intravenous Toradol to treat the pain. Not only does this therapy have great effectiveness for pain relief, but it also has the advantage of not altering a patient's consciousness or ability to perform necessary skill functions. In fact, JRH was able to see the effectiveness of this approach first-hand today as Dr. King treated a patient who was having his first kidney stone. It's always nice to have one more option in one's bag of tricks!
Breast complaints are frequently encountered in private practice. While most patient encounters center around the issue of malignant versus nonmalignant lumps, a few other problems arise in the puberty years. Today, a young lad of 14 years came in complaining of pain in his right breast. In fact, the pain was right at the nipple. Palpation confirmed the tenderness that he spoke of, but on inspection JRH saw subtle ecchymosis. “How did you get this?” “Oh,” the young boy said, “it was a nipple twister!” Apparently, the young crowd he “hangs with” draws attention to this aspect of emerging sexual maturity by a rather awkward practice of grabbing and twisting. After reassuring the boy and parent, JRH uttered a few words in favor of honoring our bodies (and encouraging others to do the same), hoping that this was, at least in this case, a teachable moment.
WLL has had success in using “pulsed” azithromycin therapy in patients with cystic acne who are not responding to (or tolerating) topical regimens, systemic tetracycline or minocycline, and who did not want to try Accutane. A growing number of case reports and controlled studies confirm this approach. A recent report in Prescriber's Letter (November, 1999;6(11):62) states that “pulsed” azithromycin works “… about as well as minocycline … and is sometimes better tolerated.” Azithromycin, because of its longer half-life, does not have to be taken daily. Published regimens include (1) an initial Z-pack followed by azithromycin in a dosage of 250 mg two to three times a week and (2) a Z-pack on the first and 15th of each month. For premenstrual acne, a single Z-pack can be given with each cycle. So far, no one has demonstrated bacterial resistance with these regimens; however, azithromycin is not cheap. The least expensive price WLL has found in our area is about $5 per tablet.
WLL's patients with allergy symptoms who have a positive skin test or serum IgE elevation after exposure to dust mites normally must resort to environmental interventions, along with standard antiallergy treatments. His age-old advice, to wash bed linens in water that is at least 130° F, now has a new wrinkle. A medical researcher at the University of Sydney, in Australia, Euan R. Tovey, Ph.D., has reported an easy solution to the washing problem: rinsing the bed clothes in a eucalyptus oil solution that can kill 97 percent of the bugs. Dr. Tovey suggests using this recipe: First, mix 30 mL of liquid dishwashing detergent with 120 mL of eucalyptus oil in a 10- to 12-oz glass of water. The solution should remain opaque for at least 10 minutes. If it separates, try another dishwashing detergent product. When you find the right solution, mix 100 mL of eucalyptus oil and 25 mL of the detergent. Fill the washing machine with the bed clothes and warm water. Add the oil-detergent mixture and allow the bedding to soak for 30 minutes, then launder as usual. This process can be done every two to three months for blankets and large bedding items, and weekly for sheets. An added benefit is that the bedding has a fresh scent.
Today, a 63-year-old woman presented as a new patient to CAG, complaining of a two-month history of spotty vaginal bleeding and mild pelvic cramps. The patient was well overdue for an annual evaluation and was concerned about cancer. She had not been sexually active since her divorce about five years ago and was postmenopausal. On examination, her cervix appeared to be inflamed, and there was a small polypoid mass at the os. Long forceps were used to grasp the “polyp,” and it unraveled into a string. When questioned, the patient remarked, “Oh yeah, that's my IUD. But don't take it out, it's been there a long time and might hurt coming out.” When asked when it was placed, she replied “either 1966 or 1967.” There followed a discussion about the risk of long-term IUD retention, and CAG's recommendation to remove a foreign body that was the likely source of her infection. She seemed impressed by the fact that her IUD was older than her doctor, and finally agreed to its removal. Removal was not difficult, and the IUD was identified as a Lippes' loop by JRH (who is older than the patient's IUD). Antibiotics were prescribed, and an appointment was scheduled for a follow-up evaluation. CAG commented afterward that a family doctor never knows what he or she might find each day—maybe even a fragment of medical history.
CAG had an opportunity to immediately return a favor recently. After rupturing the membranes of a multiparous patient whose labor had stalled at 4 cm, he headed to the office for the afternoon. About two hours later, CAG received a page from the hospital letting him know that his patient's delivery was imminent. Although our office is less than a mile away from the hospital and although he arrived in the birth suite only five minutes after the call, the baby was already out. A colleague who had been in the room next door with her patient had assisted in the delivery. CAG thanked her and said, “I owe you one” as she returned to her patient, and he awaited the placenta. A few minutes later, CAG was doing paper work in the nursing station when this same colleague sent a nurse asking him for help. Her patient was having deep and prolonged decelerations and needed an immediate cesarean section. The doctor on nursery call had not responded to the pages, and they needed to move quickly. CAG joined them in the operating room and received a baby girl with a tight nuchal cord who did well with minimal resuscitation. Although this procedure delayed his return to the office, CAG enjoyed being able to repay a favor so quickly. As he drove back to the office, he smiled, remembering JRH's common admonition that “what goes around, comes around.”
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