Diary from a Week in Practice
Am Fam Physician. 2004 Feb 1;69(3):517-518.
Today was especially busy on the mobile clinic. Perhaps the rain prevented other activities, but it seemed as if everyone in the homeless shelter had some medical complaint. One particular patient reported four months of right upper quadrant pain. A gastroenterologist had performed a complete work-up, including an abdominal computed tomographic scan, but this had revealed nothing except abnormal liver function tests. A cholecystectomy had been done seven years earlier. The patient had no fever or sign of infection. The abdominal examination revealed diffuse right upper quadrant tenderness, and the patient was desperate for some relief. “If I had a knife, I'd open my stomach up.” He had been to several emergency rooms without resolution. The patient was well aware of the policy of the mobile clinic not to administer narcotics, and JOH did not believe he was drug seeking. JOH encouraged the man to continue working with the gastroenterologist, and gave him a tricyclic antidepressant for his chronic pain and difficulty sleeping. He still felt puzzled, however, by the apparent severity of the symptoms and the paucity of objective findings. When it rains, it pours.
“Doc, my gene pool needs chlorine.” This comment brought a smile to JOH's face, but he felt like quoting Shakespeare back to the large man sitting before him: “The fault … lies not in our stars, but in ourselves.” The middle-aged patient had come to the mobile clinic with uncontrollable hypertension and type 2 diabetes. Despite the use of four antihypertensive medications prescribed by a previous doctor, the man's diastolic pressure was 110 mm Hg. His weight was well over 250 lb on a medium frame, but he was working on this and had succeeded in bringing it below 300 lb. In the past six months, however, he also had developed panic attacks. JOH posed the problem to KF, a medical student, who promptly replied, “Begin a beta blocker and an SSRI (selective serotonin reuptake inhibitor).” It was not chlorine, but other compounds that were to blame, and with continued weight loss, the patient might be able to reduce his dependence on all of those chemicals.
Solutions to difficult patient problems sometimes turn out to be more like “Catch-22s.” The young patient animatedly told of her recent onset of headaches, vertigo, nausea, facial numbness, crying spells, anhedonia, and fatigue. Seven months earlier, she had seen a psychiatrist, who had diagnosed depression and started her on a selective serotonin reuptake inhibitor. The side effects had been more than she could tolerate, but her psychiatrist had simply recommended smaller doses of the same medicine. When the side effects persisted, she left the care of the psychiatrist, hoping to handle the situation on her own. JOH found no consistent pattern to the symptoms, but eventually the patient confided that her spouse had been physically and verbally abusive to her. JOH asked her about going to a women's shelter. She had looked into that, she said, but they could only provide shelter for two weeks, and then she and her child would be on their own. JOH asked if there were friends or relatives with whom she could stay, but she knew of none. These problems were not going to be solved in one visit. Another antidepressant was started, and close follow-up was planned. She may be forced to leave her home if the situation escalates, but for now, nothing in this patient's future is certain.
It is rare for JOH to encounter a deaf person in the homeless shelter. The streets are dangerous enough for those with all of their senses, but for those lacking this most vital of faculties, they can be even more so. Jerry's face was open, smiling and, because reading lips was his only means of comprehending the spoken word, attentive. He had lived for many years in a hostile environment with his dignity intact. The reasons for his visit to the mobile clinic were of a surgical nature: he had two nevi that he wanted removed, and he also asked to have a hygroma on his face drained. JOH had an eager medical student with him that day, and he saw an opportunity for the student to get some surgical experience. The first site attempted was on the face. After sterilizing the 3-cm area, the medical student anesthetized a small wheal in the dependent part of the sac and introduced an 18-gauge needle. Despite several attempts at removing the fluid with a 12-mg syringe, he had no success until the needle was slowly withdrawn, at which point 5 mg of black fluid was aspirated into the syringe. The nevi were excised with a no. 15 blade and a hyfrecator, and Jerry returned to the shelter relieved of three of the burdens that he had brought with him. In addition, he had contributed to the education of a fledgling physician.
He was a bull of a man. Just released from the penitentiary, Richard was transitioning into society through a shelter. He came to the mobile clinic because of epistaxis, which was clearly related to his hypertension (his diastolic pressure level was 110 mm Hg). JOH prescribed hydrochlorothiazide, but made the mistake of telling him that it was a “water pill.” “But I need a blood pressure pill,” the patient insisted. Trying to backtrack by explaining the physiologic action of the medication was not an option at this point. Richard's halting speech attested to the dearth of education he had, and trying to connect the action of a “water pill” to stopping nose bleeds was an exercise in futility. Richard was polite but adamant. JOH realized that he was losing ground, and he prescribed long-acting nifedipine. This was a “real blood pressure pill.” Richard was smiling and grateful that the doctor had finally understood him.
A loud crash was heard in the residents' work area while JOH was seeing patients in the Family Practice Center. CS, a resident, turned from his computer terminal to see the second-year resident SK lying face up on the ground. Respirations and pulse were normal, with a blood pressure level of 110/65 mm Hg. SK quickly came to, but was unable to sit up because of lightheadedness. A blood glucose level and pulse oximetry also showed nothing abnormal. The evaluations done in the emergency room included electrolytes and orthostatic blood pressure readings, which provided no diagnostic answer. After the administration of 2 L of fluids intravenously, SK was sent home to ponder his fate. Because this was the second such episode in three months of syncope, he consulted his hometown cardiologist, whose previous work-up had not been elucidating. Now, however, an abnormal tilt-table test (the first one had been normal) confirmed the diagnosis of vasovagal syncope. SK has now returned to work full-time, armed with the knowledge of the cause of his syncope. Fluid loading and stress reduction were the components of his therapy. Whoever said a resident's life was easy?
Copyright © 2004 by the American Academy of Family Physicians.
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