Diary from a Week in Practice
Am Fam Physician. 2001 Dec 15;64(12):1960-1961.
“Why are you ordering a lipid profile?” asked KS, the faculty member on call in the Family Practice Center. She and a second-year resident, SO, were discussing the work-up of an 82-year-old woman who was in excellent health aside from mild hypertension. SO replied, “I order cholesterol levels on just about everybody.” KS reminded him that a screening that is indicated for patients in one age group may not be appropriate for another. KS acknowledged that routine lipid screening in the elderly is controversial and that organizations differ in their recommendations.” For example, screening low-risk seniors for primary prevention is not specifically addressed by the most recent National Cholesterol Education Program (Executive Summary of the Third Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults [Adult Treatment Panel III] JAMA 2001; 285:2486–97). When guidelines vary for a preventive service, the best approach is to review the recommendations of various organizations and discuss options with the patient. All authorities agree on the value of regular exercise and a healthy diet for persons of all ages. But in the elderly, quality of life can be more important than quantity of life—and enjoying a meal without worrying about its fat and cholesterol content can be one of the great pleasures in life for many people!
“The best part of practicing medicine,” JW thoughtfully said, “is when you unexpectedly learn to appreciate a different point of view.” Two days earlier, one of his patients had vaginally delivered a baby girl. The infant had experienced some mild respiratory distress but was recovering and would require several days of hospitalization. The mother, who was an avid supporter of breastfeeding, had continued to breastfeed her two-year-old son throughout her second pregnancy. JW had not discouraged the practice but thought to himself that the mother might regret her decision to continue breastfeeding the older child when the baby was born. As it turned out, doctor and mother were glad that she was actively breastfeeding. She produced a large amount of milk and was easily able to pump an abundant supply for the hospitalized infant. JW reminded himself that in many countries, women breast-feed their children for several years. “It worked out better than I had imagined,” he admitted to his patient as he made afternoon hospital rounds in the nursery.
Every Wednesday afternoon, KS meets with three third-year medical students for the geriatrics portion of their family practice clerkship. The session begins with an hour-long discussion followed by rounds at a nursing home. KS emphasizes to medical students the importance of reading and studying every day. “Last night while reading about common musculoskeletal problems in the elderly, I was able to diagnose my own medical problem,” she announced. The students exchanged puzzled looks and appeared a little worried until KS explained that she had periodically experienced numbness in her right second finger. She attributed it to carpal tunnel syndrome but, after developing numbness in her anterior thigh, began to fear a more serious problem. It was not until KS came across a description of meralgia paresthetica that she made the correct self-diagnosis. Meralgia paresthetica, also known as lateral femoral cutaneous nerve entrapment, commonly presents with pain, burning, and numbness in the anterolateral thigh. Treatment is symptomatic, and the condition usually resolves after several weeks to months (Snider RK. Essentials of muscu-loskeletal care. American Academy of Orthopaedic Surgeons, American Academy of Pediatrics. Rosemont, Ill.: American Academy of Orthopaedic Surgeons, 1997).
Morning report begins promptly at 7:30 a.m. every weekday. The meeting is attended by residents on call from the previous night, residents assigned to the various in-patient services, and several faculty members. BG, a first-year resident, presented her first case, a 26-year-old man with diabetic ketoacidosis (DKA). The gravely ill man arrived in the emergency room during the middle of the night. His blood glucose level was 724 with a pH of 7.02. “This patient kept me up all night,” said BG, “but it was amazing how he responded to therapy.” BG described how she bolused the patient with two liters of saline and 10 units of insulin, followed by continued vigorous hydration and an insulin drip. Because of severe acidosis (pH less than 7.1), she added bicarbonate to the first two liters. After this initial treatment, the glucose and electrolytes were measured every one to two hours, and the fluids were adjusted accordingly. BB, the faculty on the intensive care unit service, led the group through a detailed discussion of the management of DKA. He congratulated BG on her overall management of the patient, who was already considerably improved. “Next time, maybe I will be calm enough to grab some sleep between the every-two-hour-calls from the lab,” she remarked.
KN, a third-year resident, finished examining a nine-month-old child who was happily playing. “He was so cranky last night,” explained his mother. “He has had a lot of drainage from his nose, and he seemed to pull at his right ear on and off.” KN assured the mother that other than some purulent nasal drainage, the physical examination, which included a close look at both tympanic membranes, was completely normal. The child had been sick for two days, but was afebrile and eating normally. KN had recently heard a lecture on the management of sinusitis and acute otitis media in children, and he felt confident in diagnosing the child with a viral upper respiratory infection and in treating him with decongestants and acetaminophen rather than antibiotics. He advised the mother to call if the child's congestion persisted for more than one week or if his symptoms worsened. The mother was relieved that her infant did not need antibiotics because of the diarrhea he had developed when previously treated for an ear infection with amoxicillin.
Sometimes, the hardest thing to do when caring for a very sick patient is to leave things alone. TA was pleased to see that the patient, an 86-year-old woman who had been admitted with a large, left lower-lobe pneumonia, was sitting in a chair eating breakfast and looked remarkably better. After examining her, TA returned to the nursing station to review the hospital chart. She was surprised to see that the resident on the case had changed the antibiotic during rounds earlier that morning. TA paged the resident who explained that he was concerned about the patient's persistently high white blood cell count and her chest radiograph, which looked the same as it had on admission three days earlier even though the blood and sputum cultures were negative. He agreed with TA that clinically the woman looked much better. After further consideration, the resident returned to change the orders back to the original antibiotic. The next day the patient continued to improve and the results from her lab work looked better as well. Once again, the physician was reminded to treat the patient—not the results of the lab work!
Copyright © 2001 by the American Academy of Family Physicians.
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