Rick Ricer | PubMed Health

PubMed2003

The abnormal fontanel.

The diagnosis of an abnormal fontanel requires an understanding of the wide variation of normal. At birth, an infant has six fontanels. The anterior fontanel is the largest and most important for clinical evaluation. The average size of the anterior fontanel is 2.1 cm, and the median time of closure is 13.8 months. The most common causes of a large anterior fontanel or delayed fontanel closure are achondroplasia, hypothyroidism, Down syndrome, increased intracranial pressure, and rickets. A bulging anterior fontanel can be a result of increased intracranial pressure or intracranial and extracranial tumors, and a sunken fontanel usually is a sign of dehydration. A physical examination helps the physician determine which imaging modality, such as plain films, ultrasonography, computed tomographic scan, or magnetic resonance imaging, to use for diagnosis.

Humans↗

PubMedDate not supplied

How respected family physicians manage difficult patient encounters.

BACKGROUND: Nearly all family physicians have patients that engender a sense of frustration or dislike, often described as "difficult." Most research in this area focuses on describing these patients and their physicians, not management or coping. OBJECTIVE: To describe how respected family physicians identify, manage, and cope with difficult patient encounters. METHODS: Qualitative semi-structured interview study. Participant physicians described as "excellent" were recommended by medical school family medicine faculty around the county. Interview questions included "describe the patient you least like seeing," and "how do you keep sane but still assure adequate care for the patient?" Interviews were analyzed using the editing method, looking for common categories and themes. RESULTS: 102 physicians were interviewed. Physicians described both patient behaviors (stay sick and demanding) as well as medical problems (multiple, chronic pain, drug seeking, psychiatric) that they found frustrating. Difficult encounters occurred when these patient behaviors and medical problems clashed with physicians' personal and practice traits. Their management strategies to return the encounter to success incorporated collaboration, appropriate use of power and empathy. CONCLUSIONS: We propose a model where clashes between patient behaviors and physicians' traits turn a successful encounter of collaboration, appropriate use of power and empathy into a difficult encounter of opposition, misuse of power and compassion fatigue. Management strategies used by our participants aim to return success to the encounter and may serve as a guide for practicing physicians and for future research.

Adult↗