Diary from a Week in Practice
Am Fam Physician. 2001 Oct 1;64(7):1178-1179.
The outreach program has a motor coach equipped with examination rooms, a pharmacy, a radiography unit, a basic lab and a patient education area that travels to homeless shelters where medical students and family practice residents do clinical rotations. A man who was homeless returned to the coach for treatment of an infected abrasion on his left leg. Treatment was given, but JOH noted that the patient's attitude and demeanor were polar opposites of what he exhibited at a visit four months earlier. At that time, the patient sought medical attention for crushing chest pain. An ECG revealed ST-segment elevation, and he was taken by ambulance to the emergency department. A subsequent work-up did not reveal cardiac injury, and his symptoms were assessed as resulting from gastroesophageal reflux disease. He was no longer experiencing chest pain. The dramatic episode appeared to have turned the patient's life around and played a part in his positive attitude. He was in the process of leaving the shelter and finding a home. From his experience he reported having learned a valuable lesson—that other people do care about his well being.
Today, JOH saw a female patient for follow-up care after she had been treated in the emergency department by one of the residents. An acute episode of vertigo and nausea had precipitated the initial medical care. The work-up in the emergency department included a CT scan of the head, ECG, carotid duplex and blood studies. The history and physical examination were consistent with an inner ear problem. The patient was unsure about the etiology of the episode, and she feared the worst. Her anxiety level was high as reflected in an elevated blood pressure level. Reassurance about the diagnosis of vestibular neuronitis and an explanation of the clinical course and treatment went a long way in allaying her jangled nerves. The patient seemed much more at ease when she left. About one-half hour later, the carotid duplex report arrived and revealed a 60 to 85 percent stenosis of the left internal carotid artery. JOH doubted that this was the cause of the patient's true vertigo, but he informed her by telephone about the finding and recommended a consultation with a vascular surgeon.
Things are not always as they seem. Today, a tall, thin, unkempt man came to the mobile clinic after being taken to the homeless shelter by police. His complaint was, “I can't walk.” He knew the date, where he was and how he'd gotten there, but he couldn't remember further back than five years when he'd suffered a blow to the head. Along with the memory loss, he had missing teeth and poor hygiene, but his vital signs were stable and he did not appear acutely ill. JOH further asked what the man wanted and he replied, “To go to the hospital because I can't walk.” Clearly, he could walk and did so along the length of the coach. After a history and examination, a social service referral seemed appropriate along with possible urgent mental health services. Although our diagnostic labs are limited, a finger stick glucose measurement was available and requested. A glucose level reading of 554 came back. The problem was solved because now there was a reason for the patient to be hospitalized although not all of the medical questions were answered yet. This patient could not have been given an oral hypoglycemic and asked to follow up at the clinic. Now he could be further evaluated and cared for in an environment where a variety of services would be available to him. It was a start to healing.
One of JOH's favorite patients returned to the office today for a follow-up visit. The patient has diabetes, hypertension and back pain. The back pain is the result of multiple etiologies, but primarily degenerative changes in the lumbar spine. Surgery had never been an option until one month earlier when the patient presented with an initial episode of gross hematuria. The CT scan of the kidneys showed a large obstructing calculus of the left ureter, and the urologist disintegrated the stone using lithotripsy. The patient's back pain became much more tolerable. While the procedure didn't resolve the degenerative aspects of the back problem, the left-sided aspect of the pain was much improved. JOH had a basic lesson reinforced while treating this patient—do not assume that a longstanding diagnosis eliminates the need to investigate other etiologies, especially when exacerbation of pain occurs. Patients may not always be aware of subtle differences in pain. Physicians must not let familiarity dull their diagnostic senses in the search for alternative causes of illness.
Today, a large apartment complex was the site of the mobile clinic. Patients of all ages came for medical care, physicals, immunizations and reassurance. An older Somalian woman wearing a bright Hijab (outer garment) presented with pain in her lower back and shoulder, headache, heartburn and nosebleeds. JOH gathered the history through an adept interpreter, but the process was slow and tedious. Each of the woman's symptoms was addressed, and she was examined from head to foot. The back pain was degenerative and did not involve radiculopathy. The shoulder pain was an overuse syndrome that resulted in bursitis, and the headaches were muscle-contraction type. The heartburn was from gastroesophageal reflux disease, and the nosebleeds were from an irritated area in Kiesselbach's plexus. Medication, reassurance and home treatment modalities were recommended along with appropriate follow-up treatment. The interpreter then informed me that the patient's eldest son was in a refugee camp in Kenya and this was a cause of great concern for her. Many of her symptoms now made more sense. A heavy burden placed on an already overtaxed human being was brought to light. JOH felt the inadequacy of medicine to cure all ills but understood the power of listening and consoling.
Today culminated a week of outreach workers going door to door to assess the medical needs of an underserved refugee community. JOH, along with volunteer physicians and nurse practitioners, saw anyone in need of medical care. Physical examinations revealed various medical problems including anemia, diabetes, rashes and impacted cerumen. Earwax is not exciting or serious, but occasionally can cause hearing loss or obstruct the view of an infected tympanic membrane. When trying to view a blocked membrane, JOH had wished he had three hands until he learned to have the patient pull the external ear up and back using the oppositional hand. This allows for a direct view into the canal and frees the physicians' hands to hold the light and manipulate the ear curette. When a headlight is not available, this technique makes ear canal cleaning much easier. As we prepared to depart the area at the end of the day, a mother arrived with her young child who had fallen and was inconsolable. Evaluation was needed, and the day continued a while longer.
Copyright © 2001 by the American Academy of Family Physicians.
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