Page 16 - Volume 69, Number 4
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The Power of the Home Visit
By Cheryl Farmer, MD
Home visits of necessity, take place before or after hospital rounds and office hours and can as a result, make the usual long day for a Primary Care physician even longer. If you are in Primary Care, you should not automatically dismiss the thought of ever making a home visit. These visits can be surprisingly powerful, both diagnostically and therapeutically! Let me offer some cases in point.
The Case of the Swollen Leg
A new patient came to my office with complaints of persistent edema in her right lower extremity. She had it for some time. Her lungs were slightly wheezy from underlying COPD, but her heart and abdominal exam were normal. There were no enlarged inguinal nodes to obstruct venous return, or abnormal findings in the legs other than unilateral edema. Her labs including CBC, renal and liver parameters and normal serum proteins were unremarkable. A venous duplex was negative for deep venous thrombosis (DVT).
As time passed, the degree of edema in this leg waxed and waned, but never resolved. Over the next few visits I ordered a cardiac echo, abdominal/pelvic ultrasound and CT scan of the abdomen and pelvis. All results were normal. Puzzled, I finally reassured her that although I was unable to explain why this was happening, at least we had ruled out anything serious. This seemed to satisfy her, but it did not satisfy me!
Several years later this patient was hospitalized for pneumonia. When the time came for discharge she was still quite debilitated. She lived alone and had no family, and few friends for support. Rather than requiring her to expend the considerable effort it would take to come in to the office for a follow up appointment, I offered to make a home visit. When I walked into her home for her first follow up visit, I noticed immediately that she was sitting with her left leg on the bed and her right leg hanging over the edge of the bed in a dependent position. “Do you sit like this very often,” I asked? “All of the time,” she responded. The enigma was finally solved!
The Case of the Guilty Pleasures
Another woman, elderly, with severe COPD on home
oxygen, had recurrent episodes of congestive heart
failure despite my best efforts to adjust her medications.
Her worried husband confided that she was not
following my recommendations. Specifically, she was not
wearing her oxygen as directed and was eating salty
foods. “Please don’t tell her I said anything“, he
whispered, “She would be furious!” As it happened, they
lived not far off my usual route home. I told him not to be
surprised if I paid them a home visit one day. One
evening I decided to drop in. The husband met me at the
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Boston City Hospital, Winter 1967-68 - Part I By Richard E. Burney, MD
In 1967 third year students at Harvard Medical School began the year with a 3-month “Introduction to the Clinic” in which they acquired all the necessary skills to “go onto the wards” and take care of patients during their “Principal Clinical Year,” a 12 month long stretch of continuous patient care responsibilities that began in December and continued through November of the fourth year. The term, “wards,” was used accurately, because patients were often cared for: large, open wards with 20-30 beds.
On the morning of Monday, December 4, 1967, I along with 5 classmates, reported to Boston City Hospital to start the PCY with three months of Internal Medicine. Medicine patients on the Harvard Service at BCH were housed in a 3-story pavilion, the Peabody building, one of several 19th century buildings connected by tunnels or covered walkways that constituted the hospital. The two wards were long, rectangular rooms with tall, poorly insulated windows on both sides and a large fireplace at the far end. Beds lined the walls under the windows.
At the near end was a small nurse’s station and supply room, and one private patient room. The male ward, Peabody 1, was on the ground floor; the female ward, Peabody 2, was on the second floor; above that, on the third floor, were primitive sleeping areas for students and house officers, a conference room, and a laboratory where house staff and students performed blood and urine testing (there was also a central clinical lab that could do electrolytes, liver function tests, and blood gases if needed).
There were no elective admissions to Peabody; all the patients came through the emergency ward. A house officer or student “picked up” the patient on arrival to the ward and began the work-up and treatment. The main differences between the house officers and the third year students were that students were responsible for fewer patients and took call every third night; the house officers took most of the admissions and were covered by a “night float,” who picked up admissions overnight and did necessary lab tests, giving colleagues respite from their 36-on, 12-off work schedule.
Working up a patient meant doing the history and physical, writing the orders (which the intern or resident would review), and doing the basic laboratory tests, spinning the hematocrit, doing the white blood cell count and differential with a microscope and hand-held counter, and a urinalysis. The important decision-making was of course in the hands of the intern and assistant resident, not the student, but students acted as the primary caregiver for their patients as much as possible. An attending physician, called a “visit,” would make
16 Washtenaw County Medical Society BULLETIN OCTOBER / NOVEMBER / DECEMBER 2017

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