Diary from a Week in Practice
Am Fam Physician. 2000 May 15;61(10):3010-3011.
A young woman recently visited WLL in the office. The patient was covered from head to toe in an amazing rash. Itchy pustules coated even the soles of her feet and the palms of her hands. She was obviously miserable. The rash had been present for less than 36 hours and looked like a massive contact dermatitis. No mucosal involvement, blebs or bullae were apparent, and the patient gave no history of any recent use of external or internal agents that might explain the rash. There were no systemic symptoms—just a lot of itching—without jaundice. Like WLL's residency director at Duke University School of Medicine, Terry Kane, M.D., used to say, “If you can't figure it out, go back and retake a history.” On further questioning, the patient revealed that she had just switched from her regular multivitamin to “a natural vitamin,” she said, “you know, one with added ginkgo.” Bingo. WLL remembered reading a recent article on a rare problem with gingko—it can at times be contaminated with a poison ivy–like substance. Stopping the “natural” medicine, along with a prescription for corticosteroids, antihistamines and topical agents, cleared the rash in just a few days' time.
The many ancillary services in a community can be a family physician's best friend, as CAG discovered recently. The four-year-old son of one of CAG's maternity care patients had come along for many prenatal visits and had been friendly and outgoing. He had also had a recent well-child evaluation with our nurse practitioner. Through the course of these visits, we had not noticed any speech problems. However, during a routine speech evaluation for preschool, a nurse noticed that the child had some hoarseness and that his speech was sometimes unclear. He was referred to the center for speech and language and later to an otolaryngologist. Laryngeal polyps were found and treated, and he was also diagnosed with oral motor and articulation defects. His mother has noticed improvement in his speech with speech therapy twice weekly, and she and CAG have been thankful for the attentive nurse who made the initial discovery on routine screening.
With the constant introduction of so many drugs these days, it is a continual dilemma for the family physician to know just when to change a patient's regimen and when to try the newest alternatives. Today left JRH second-guessing himself. Only a month earlier, he had written a prescription for cilostazol (Pletal) in hopes of helping a patient's intermittent claudication. The same patient returned today, relating a history of swelling of the lips and throat, for which he had visited an ENT subspecialist. The patient even brought the office note of that visit with him, which offered the opinion that angioneurotic edema had occurred and that cilostazol was the cause. And so JRH went back to the drawing board, sacrificing twice-daily dosing of cilostazol for three-times-daily dosing of another drug, but exposing his patient to a shorter list of potential side effects. JRH recalled the adage learned in his residency at Duke: “Be not the first by whom the new is tried, nor the last to lay the old aside.”
Autism is among those diagnoses WLL hates to make. There is so little effective therapy to offer for patients with this condition. When few therapies are available for a chronic condition, many patients will seek help in support groups. One of WLL's mothers in the practice stays connected to a large network of parents of autistic children via the Internet. A reasonable Web site to explore for more information is www.autism.com, which is a compilation of links to a range of information about autism.
Two packages came in the mail today. JRH had been waiting six weeks for this delivery. Finally, after 23 years in the profession, a long-time dream was about to come true: JRH had bought a skeleton. One box was the stand; the other contained the bare bones. Often JRH had wished to have a skeleton around—sometimes for the educational value, other times for the ambiance. But it wasn't until he took a course on prolotherapy, under Dr. Jeffrey Patterson at the University of Wisconsin, that the need to study anatomy again became more urgent. So, after assembling the pieces, JRH stepped back to admire his new acquisition, beaming with delight as he did so. Where will the skeleton be stored? Why, in the closet, of course.
Sometimes, the role of the family physician is simply to stop and think. This morning, JTL was preparing to discharge a patient whose care he had assumed from another physician. The patient was a 75-year-old woman (a non-smoker) who had presented with hoarseness and a chest mass. She had undergone abundant diagnostic testing, including mediastinoscopy and wedge resection, to rule out lung carcinoma. When the tissue biopsy revealed evidence of mycobacteria (positive acid-fast bacilli [AFB] staining, granulomatous process), she was placed in isolation and started on four-drug therapy. JTL visited with the patient, now wearing a protective mask, who told him that her entire church and neighborhood were undergoing purified protein derivative (PPD) testing in the light of this finding of active tuberculosis. JTL then noted that this patient's PPD test, performed at the start of hospital stay, had been negative (along with her family's tests). He then called the laboratory processing her sputum AFB stains and discovered that three of three AFB smears had shown negative results. Furthermore, the initial positive AFB tissue specimen had not been sent for tissue culture. After consulting with an infectious disease subspecialist, JTL was able to reassure this patient that she was not contagious (although a small possibility of noncontagious tuberculoma remained).
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