Diary from a Week in Practice
Am Fam Physician. 2003 Sep 15;68(6):1071-1072.
Differential diagnoses are influenced to a certain extent by our cultural experience. So, when physicians encounter patients from other cultures, it may be necessary to broaden the differential. The elderly Somali woman, a refugee in this country for two years, was complaining of a long history of numbness and paresthesias in her left foot. Through the interpreter, JOH questioned her at length about possible contributing factors, all of which were negative. Alcohol and nicotine were not possible causes. The examination revealed motor and sensory function intact in the foot, as well as strong pulses. The medical student, CC, asked her to lift the skirt of her hijab to get a better look at her leg and noticed a foot-long scar on the shin. “How did you get that?” JOH asked. “The lion bit me there,” was her answer. “So then what happened?” JOH asked. “I prayed to God, and he gave me the courage to pick up a rock and hit the lion and he ran away,” she replied. The extent of the injury could be the cause of the nerve damage, and this was explained to the patient. She was happy with the explanation and said that she would pray for JOH to heal his other patients. He also added to his differential for a neuropathy—lion bite!
After 30 years in medicine, there are still new experiences almost every day. JOH was looking over some laboratory test results when a third-year family practice resident, RH, approached him, asking if he had ever seen a patient with lindane (Kwell) toxicity. After being diagnosed with scabies, the resident's new patient, a young man, had been given lindane, but instead of using it once, he had applied it three times, leaving it on for over eight hours each time. He had developed seizure-like activity, vomiting, and lethargy. He went back to the physician who had prescribed it. This time, he was given lorazepam and sent home. He continued to have involuntary head movements and lethargy, and he came now as a new patient to our office. The history was certainly consistent with the diagnosis, but JOH had to admit to the resident that he had never encountered a similar reaction. Subsequent hospitalization and neurologic consultation revealed a normal electroencephalogram, but a positive urine toxicology screen for cannabis, alcohol, and benzodiazepines. The latter was from the prescribed lorazepam, but the neurologist believed that the combination of lindane with alcohol and marijuana could well have precipitated the neurologic symptoms.
Why do some people seem to escape the physiologic ravages of alcohol, while others succumb quickly to cirrhosis, bleeding varices, pancreatitis, cardiomyopathy, and dementia? Donald, a frequent visitor to the mobile clinic, has not yet tasted the bitter fruits of his addiction. Certainly, he has experienced the social and psychologic effects—homelessness, family rejection, incarceration, poverty—but these have not been strong enough to separate him from “his friend.” Although relatively young, with an engaging smile and gentle mien, he will eventually suffer the ravages of his habit. For a time, JOH had hope. Donald had a girlfriend and a roof over his head. But, these evaporated as quickly as ice in a glass. He was back on the streets among his cronies, and high on ethanol at 10:00 in the morning. He had a favor to ask—would JOH write him a note to prevent a judge from throwing him in jail for failure to pay a fine? It was a small request, and he “felt bad for asking.” Will the fact that he felt some sort of bond with JOH be the spark to ignite his recovery? Or, will he have to wait for his body to tell him, “I've had enough”?
Falling through the cracks happens every day in the homeless community, but it is still frustrating. A particularly upsetting “falling” was discovered today when a homeless patient returned to the mobile clinic. Two weeks earlier, he had been seen for a painful red eye. A fluorescein stain revealed a dendritic corneal ulcer, and JOH suspected a herpetic infection. Immediate referral to an ophthalmologist kind enough to see him confirmed the diagnosis. Eye drops and oral medication were prescribed, but the patient did not tell the treating physician that he was homeless and had no money to purchase the medications, which cost approximately $100. When the patient brought the prescriptions to the shelter, the social worker there suggested that he have them filled at a community referral office, which provides emergency medicine to those in need. The answer there was “no,” but this was never relayed to the social worker at the shelter or to JOH. Meanwhile, the patient did not pursue it. He missed an appointment with the eye doctor yesterday, and he returned to the mobile clinic today. JOH was able to order the medications from the hospital pharmacy and get the patient started on them, but had to heave a sigh of frustration at the obstacles placed in the way of care.
Sometimes histories from patients are difficult to believe, but they must serve as the basis of our treatments. An engaging, homeless single mother of four children was in her seventh month of pregnancy. She had had no prenatal care, but the amazing part of her story was that she had had a tubal ligation at six weeks' gestation, after the results of two serum pregnancy tests were negative. Such an occurrence was a first for JOH, and he tried to fathom how a test as accurate as a serum human chorionic gonadotropin could produce two false-negative readings. To say that this pregnancy had been a surprise to the patient was an understatement. However, she came to the mobile clinic not for her pregnancy, but because of a four-day history of cough and shortness of breath. Although afebrile, she had wheezes and rhonchi in the left lung field, and she smoked a pack of cigarettes a day. Her cough was loose and persistent. JOH debated in his mind about the use of antibiotics in this case. If she hadn't smoked, hadn't been homeless, hadn't had such a productive cough or shortness of breath, he could have watched and waited. But, those criteria tipped the scale in favor of antimicrobial therapy. JOH added a warning about the harm of cigarettes, but he wondered if it would be heeded by someone whose life had seen its share of sorrow.
At times, a physician can feel powerless. The 19-year-old Ethiopian woman did not speak English. In fact, she could not speak at all, because she had been deaf since birth. The young woman's mother explained that she was not sleeping well at night, she could not chew her food, and her foot was painful. These problems JOH could address. An examination of the mouth revealed molars that had broken off at the gum line. The ball of the left foot had a large corn on it. Dental referral could help the chewing problem, paring the corn would provide relief of the foot pain, and a trial of diphenhydramine might assist her sleep. But, the main disability (her deafness) was another matter, and it influenced every other aspect of her life. Case management could link her with an audiologist, and a course for sign language would benefit the young woman, but after 19 years of lacking resources, it would be a long process to reverse the patterns now so ingrained.
After years spent in private family practice and academia, John O'Handley, M.D., is medical director of the Mount Carmel Outreach Program in Columbus, Ohio. The program provides free medical care to uninsured and homeless patients throughout the city on a mobile coach clinic. Dr. O'Handley continues to see private patients two mornings a week.
Address correspondence to John O'Handley, M.D., 1335 Dublin Rd., Suite 110E, Columbus, OH 43215 (e-mail: firstname.lastname@example.org).
In order to preserve patient confidentiality, the patients' names and identifying characteristics have been changed in each scenario.
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