Diary from a Week in Practice
Am Fam Physician. 2002 Dec 1;66(11):2083-2084.
The homeless man complained of numbness and tingling in the index and middle fingers of his left hand. He had struck his palm with a tire iron a few days earlier, and he had come to the mobile clinic for evaluation. MC, the family practice resident, learned the true reason for the patient's visit when he noticed a mass on the volar aspect of the proximal digit of the left index finger. It had been present for 30 years, beginning at the age of 12, when a piece of metal imbedded itself in his finger. Any grasping action irritated it, and the patient wanted it removed. Using the mobile clinic's C-arm fluoroscopy unit, JOH confirmed the foreign body with a radiograph. It was a 2-cm oval calcified mass imbedded in the fat pad. It appeared superficial to any vital structures, and the dissection that followed a digital block, while tedious, was successful in locating and extracting the mass. Three interrupted sutures closed the incision. The patient was grateful for the surgery. When JOH mentioned sending the specimen to pathology, the patient shot back, “Doc, I want that for myself. I'm going to make a ring out of it.”
Today, a grown man was crying his heart out. It was not because of the blisters that covered his feet, but because of the pain in his heart. His story flowed like a river—years of drug and alcohol abuse, failed relationships, a hatred of others who he felt looked down on him for being homeless, and rage and guilt that made him feel that life was no longer worth living. The podiatrist tended to his feet; JOH and a first-year medical student tended to the more painful part. Did he have any support systems—family, friends, faith in a higher power? At this point, the man had only the latter. It is at times like this that medical science can appear ineffectual. What is needed is human-to-human contact, verbalizing hope, encouraging the weakest spark within the man to burn and warm his spirit. Crisis intervention came, a silent prayer was offered, and the broken man went out into the night with the thoughts and hopes of everyone on the mobile clinic following him.
The proverbial last patient of the day arrived with multiple complaints—dysuria, urinary frequency, vaginal discharge, generalized pruritus, seizures, crying spells, sleep problems, and hot flushes, to name a few. At age 24, she had a total hysterectomy for cervical cancer, and she had been out of her estrogen for two months. Now 29 and a single parent raising a family of four in a homeless shelter, she was experiencing depression. The seizures had been the result of taking “bad drugs,” and a urinalysis provided the answers for the dysuria and urinary frequency. JOH was ready to postpone the pelvic examination for another day, but his hunger pangs were bearable, and there were no other pressing appointments. The mobile clinic's microscope is not state-of-the-art, but it was clear enough to see the hyperactive flagellated trichomonads scurrying around the field. The patient was informed that the source of her discharge was treatable and not life-threatening. An antibiotic was prescribed for the cystitis, a selective serotonin reuptake inhibitor for the depression, metronidazole (Flagyl) for the vaginitis, and conjugated estrogen for the hot flushes. JOH would follow up on her medical problems in two weeks. But for now, he breathed a sigh of relief that he had not failed to do an important examination.
The articulate, well-groomed man had arrived from Florida a few weeks earlier. College educated and with a master's degree, he had lost two well-paying jobs because of alcohol abuse and had been on the streets for the past seven years. Work in the resort areas of Florida had provided some income, but not enough for both housing and food, and he had sacrificed the former for the latter. The man expressed concern about his episodic hypertension. JOH wondered how he was able to tell that his blood pressure was high until he was told about the two sphygmomanometers that he carried in his backpack. His blood pressure on the mobile clinic was normal, and JOH was reluctant to treat episodic hypertension, but the patient's knowledge and demeanor encouraged JOH to evaluate possible etiologies and arrange for rapid follow-up. There were still questions as he left the mobile clinic. How does someone from such a background survive for seven years on the streets? How does one avoid depression in such a situation? Are people so prejudiced as to deny a recovering alcoholic the opportunity to earn a living that would provide a roof over his head? The answers would not come today, but the questions will remain until the reasons are found.
One of the unwritten truisms of medicine is that the length of time required to elicit a true history is directly proportional to the reluctance of the patient to divulge embarrassing information. JOH suspected something along those lines when the young Hispanic man requested a male rather than a female interpreter for his encounter on the mobile clinic. The complaint was swelling of the foreskin. Examination showed diffuse swelling of only the ventral aspect of the foreskin, with no redness, heat, or pain. The differential diagnosis included an allergic reaction to something, and the patient was questioned at length regarding possible allergies. After several minutes, when the list was nearing its end and we seemed to be going nowhere, the patient asked if oral sex could have caused such a reaction. The truth was starting to appear. JOH did not believe that to be the inciting cause, but he asked about the circumstances surrounding the event. When the patient stated that “it happened in a park” near some foliage, the diagnosis became clearer. A plant dermatitis seemed the most likely cause of the swelling, and the patient was treated appropriately. Allowing patients sufficient time and opportunity to express themselves may help reveal the diagnosis.
Although the number of applicants to medical schools has been declining in recent years, the quality of those choosing a career in medicine seems to be holding steady or even increasing. Today, JOH spent some time at a predominantly Hispanic clinic talking with one of the Spanish-speaking interpreters about his plans for medical school. The son of a missionary, RR had learned Spanish during four years in Honduras as a youngster. The experience had colored his subsequent life. After dropping out of college and working for several years, he returned to complete his degree and fulfilled all of his pre-medical requirements. He had served as a translator during the past year in a hospital and clinic setting, and this had turned him on to medicine as a career. He was now planning to take the MCAT and later to apply to medical school. His background would be invaluable, and he has the communication skills so necessary to the profession. His mastery of Spanish will be an added bonus, which will allow him access to the most rapidly growing minority in America. JOH, who also chose medicine later in life, encouraged RR to pursue his dream and not waver in his resolve.
In order to preserve patient confidentiality, the patients' names and identifying characteristics have been changed in each scenario.
Copyright © 2002 by the American Academy of Family Physicians.
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