Diary from a Week in Practice
Am Fam Physician. 2003 Apr 1;67(7):1477-1478.
The towering young man squeezed himself onto the mobile coach and into the clinic examination room. The medical student took a detailed history and physical examination, but she was unsure of the diagnosis or plan. Living in the woods along the Scioto River during one of the coldest nights of the year, the homeless youth left off socks and shoes, relying solely on the insulating effect of his sleeping bag. This proved to be inadequate, and he now had erythematous blistered toes that signaled frostbite. Fortunately, there was no sign of gangrene, and movement of the toes was intact. He would probably keep all of his toes, but the damage done could leave its stigma for years to come. JOH detected an accent in his speech and asked the young man where he had acquired it. Twelve years in England with his grandfather had left its imprint. When his father brought him to the States, conflict with his stepmother eventually led to his leaving home and to a series of odd jobs, none of which paid the rent. JOH glanced at the medication list, looking for neuroleptics that might help explain the patient's current circumstances. Seeing none, he attended to the feet and orchestrated follow-up with the appropriate caregivers. As he left the mobile clinic, the staff said a silent prayer for this gentle giant's health and safety.
He looked a lot like Santa Claus with his white beard and rotund shape, but his story did not fit the image. Loss of employment as a truck driver had led to his present homeless condition. He was trying to keep his blood pressure under control to satisfy the requirements of his trucker's license, but lack of funds for medication had forced him to seek help on the mobile clinic. JOH inquired about his family, and the story that followed took him aback. The man was the father of many children by three different wives. Three of the children were living abroad, and the rest were addicted to illicit substances and refused him any help. A nomadic lifestyle may have been part of his problem, or possibly the result of it. As a race car driver, he had toured the United States and Europe, but he was now past the age of working in that arena. He seemed to have an innate confidence, and there was no sign of him feeling beaten down by circumstances. One could only imagine the gusto with which he approached life in his early days. JOH traded quips with him and provided the needed medication for his blood pressure. As he left the mobile clinic, the man greeted each of the staff with a twinkle in his eye. JOH looked out the window to see if a sleigh was waiting for him.
Today, MR saw a 13-year-old girl with a history of stomachaches. Her physical findings were normal, but she was underweight for her height. MR questioned her about school and family environment. She was very open and told the story of living with an aunt before her father brought her to live with him and his girlfriend. She was happy living with her aunt and did not want to leave. Her father worked in the evenings, and because his girlfriend didn't like her, the teenager stayed in her room. Whenever the girlfriend left the house, she sneaked downstairs to grab something to eat—usually potato chips. The school nurse was aware of this situation, as was children's services, who took her to a protective environment for a weekend because of physical abuse concerns. The child and MR talked to the nurse, who said she would contact children's services about what follow-up had been arranged. (The child said she was told that children's services would make a home visit, but so far this had not occurred.) An appointment for a complete evaluation and treatment for this child was made at one of the Children's Hospital clinics. Although the patient was open and apparently truthful, her history of events may be just the tip of the iceberg.
The big-boned, strapping, soft-spoken man sat quietly in the examination room as JOH pieced together his story. Three weeks out of prison with a history of human immunodeficiency virus (HIV) infection and depression, he had come to the shelter to avoid the bitter cold and to try to get his life back. He had been out of his HIV and psychotropic medication ever since his release and was now wondering if he had been better off incarcerated, where at least his medical needs could be met. He had a case worker who was attempting to connect him with his previous doctor, but for some reason (perhaps because of his lack of money), he was not successful. The situation was not hopeless. Several of the medications were available from the mobile clinic. But, the plight in which the patient found himself was a sad commentary on the fragmented health care system in this country. It is truly distressing that prison is viewed as a desirable option to maintain one's health.
It is easy to take for granted the medical knowledge of patients. With the proliferation of accessible information on the Internet and in periodicals, the physician may assume that patients have a greater understanding of disease processes than they actually do. The young Hispanic mother presented with right upper quadrant abdominal pain of several weeks' duration. The pain came and went but was worse with eating. JOH suspected cholelithiasis, and the translator conveyed the probable diagnosis to the patient. When she wanted to know what caused gallstones, JOH did his best with such concepts as stasis, female hormone levels, and genetics, but he was sure that a lot was lost in the translation. The inquisitive patient still had a face that expressed doubt. “I was told that gallstones were caused by anger and unhappiness,” she confided through the translator. JOH reassured her emphatically that these were not the cause of such a malady—they may cause those feelings by their effect on a person, but gallstones are no more caused by “evil humors” than maggots are caused by decaying meat. The smile that came to her face indicated the understanding she now had.
A disease that cannot be detected by any laboratory test is easy to dismiss as a “nondisease” if one looks at a person in a purely mechanistic manner. Fibromyalgia is such a disease. One of the patients seen today presented with pain in every part of her body. Her face perfectly reflected the distress that she was experiencing. She had been to the emergency department the evening before and had been given a prescription for pain medication. JOH was unsure what more he could do for her except to listen to her story and offer understanding. The diagnosis had been made nine years earlier, and the patient had been able to control the symptoms with analgesics, antidepressants, and acceptance. But she was now in a homeless shelter, sleeping fitfully on a cot, and her stress level was “off the charts.” Was it any wonder that every fiber of her frame was rebelling with pain? Perhaps a note to the shelter to allow her more rest, perhaps a heating pad to soothe and warm her muscles, perhaps a change in analgesics would allay the disease she was feeling. JOH knew he could not cure her today, but he did what he could to soften the harsh reality of a debilitating condition.
In order to preserve patient confidentiality, the patients' names and identifying characteristics have been changed in each scenario.
Copyright © 2003 by the American Academy of Family Physicians.
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