Diary from a Week in Practice
Am Fam Physician. 2002 Jun 1;65(11):2256-2257.
The man had a gentle smile and visage that belied his advanced age. He had come to the mobile clinic tonight for the relief of nasal congestion and cough and because he could not afford to buy the antihypertensive medication prescribed for him by another physician. JOH listened intently as the man's story unfolded, somewhat awed because the patient did not fit the stereotype of a homeless person—but then who does? After earning a degree from a music conservatory, he had a long career as a jazz musician, touring Europe for about 30 years. He had formed a recording company, which had been sold, but he had no money left now. He was originally from California and was hoping to return there soon. JOH checked the medication list for major psychotropic agents, but it appeared that none had ever been prescribed for this man. Most remarkably, the patient had not started smoking or drinking alcohol until he was 52 years of age. These behaviors had led to most of his current health problems and, for the past year and a half, homelessness. JOH was able to solve the immediate concerns, and he was hopeful that the patient's present circumstances would provide an even more powerful experience to add to his already full life.
Many members of the large Somali immigrant population in Columbus lack health insurance and, consequently, seek medical care on the mobile clinic. The Somali culture is rich, and the people are generous and happy, despite sometimes difficult living conditions. A mother and her teenaged daughter were being seen for abdominal pain that had persisted for some time. On physical examination, each had numerous scars over the upper abdomen that were about 1 cm in diameter. The wounds had been made with a red-hot stick or the head of a rivet, which purportedly could drive out pain. The residual scars were a testimony to the extreme measures people will take to alleviate pain. The mother had a somewhat uncomfortable look on her face as she explained the practice. JOH had seen this practice before but had not really understood it. The mother admitted that while the burns initially eased the abdominal pain, it always came back rather quickly. The gate theory of pain explains the mechanism of relief. The mother and daughter were willing to use a histamine H2 blocker for symptom relief of peptic ulcer disease, and JOH hopes that they will not resort to such painful remedies in the future.
The triage nurse almost had to beg the small, slow-moving woman to see the doctor on the mobile clinic. She finally agreed. Her chief symptom of fatigue had been present since adolescence but was becoming more of a problem for her. The woman, who was now 48 years old, attributed the fatigue to “always having been anemic.” JOH noted her pale appearance despite her African-American descent. The conjunctiva was almost translucent. Heart murmur and tachycardia were absent. Blood pressure was 80/60 mm Hg, and pulse was slow at 50 beats per minute. Trace ankle edema was present, but the lungs were clear. The woman denied melena and had not had a period for three years following a hysterectomy. She refused a blood draw from her arm, but agreed to a finger-stick hemoglobin. The result of 11.5 g per dL surprised JOH, but then he looked at the patient's neck and it hit him like a ton of bricks! A large, smooth goiter jumped into his line of sight. The skin color, fatigue, slow pulse, low blood pressure, and goiter all pointed to hypothyroidism. JOH would now have to use his best powers of persuasion to obtain her consent for a blood draw for thyroid-stimulating hormone testing. This patient had been pulled from the brink, thanks to a persistent and caring nurse.
The book and movie A Beautiful Mind recount the life of John Nash, a Nobel laureate with schizophrenia. Nash's story serves to correct the general public's misunderstanding and fears about mental illness. It also shows the ability of the mind to rise above what too often is considered a societal death sentence. Today JOH reflected on that while talking with a 30-year-old homeless man with schizophrenia. His long, dirty hair and worn clothing were typical of a homeless person with mental illness. The man's family had rejected him, and he had lost his disability benefits as a result of irresponsible behavior. For three months, he had been unable to afford risperidone, but he was able to keep the voices at bay by reading books. He had considerable insight into his illness and seemed to be high functioning and handling life the best that he possibly could. JOH asked the young man who his favorite authors were, and his immediate and first response was Dostoevsky. The classics were his favorites. He boasted that he had a special aptitude for reading, and it took him to a world far from the streets. His medical symptom today was a prolonged cough, which was treated as a viral bronchitis. His mental condition could be managed by referral to the city's indigent mental health clinic.
We can all learn from children. Today JOH met a four-year-old boy who was a refugee from Liberia. He came for a preschool examination. When asked if he missed his native country, the boy replied, “No, because of all the shooting.” JOH was amazed by the boy's response, because it showed remarkable understanding and sensitivity for a child his age. The examination was uneventful. However, during the course of the examination, we realized that the young boy did not recognize the letters of the alphabet. When asked to identify letters, he spontaneously traced their shapes on the palm of his hand. We learned from him a method to perform vision testing on children who do not yet know the alphabet.
The problems of life that can result in homelessness can also complicate the provision of medical care. A middle-aged woman came to the mobile clinic today with neck pain radiating into her shoulder and arm. Two years earlier while living in another city, she underwent an anterior cervical laminectomy by a neurosurgeon. He had warned her about the possibility of a recurrence of a herniated nucleus pulposus, and the history and physical examination that JOH performed were consistent with that diagnosis. JOH's personal experience with a similar diagnosis had sensitized him to the pain. A referral to the original neurosurgeon seemed appropriate, but the patient explained that she had recently left that city to distance herself from an abusive relationship. She was fearful for her safety if she were to return there. This concern was a valid reason to avoid sending the patient back, but it did make the subsequent referral more problematic. Transferring records and establishing care with a new neurosurgeon would take more time, but it could be accomplished.
Copyright © 2002 by the American Academy of Family Physicians.
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