From a Week in Practice
Am Fam Physician. 2005 Dec 1;72(11):2212-2214.
Seeing a few cases of an uncommon malignancy in patients can easily increase the index of suspicion when other patients present in a similar manner. Reuben is a middle-age, homeless man who came in looking for help. For two months, he had noticed food “sticking in my throat.” I normally do not become too excited about such a complaint. Reuben told the medical student working with me that the symptoms were getting worse, that he was a 45-plus pack-year smoker, and that alcohol was his drug of choice. In addition, he did not plan to alter his habits “no matter what.” In 80 percent of patients with oropharyngeal dysphagia, the cause is neuromuscular disease. The other 20 percent are caused by an obstructing mass that in most instances is malignant. That solids and liquids affected him equally made me lean more in the direction of a mechanical obstruction. At any rate, I would not rest well until someone could examine his throat. Our social worker was able to link him to the Physicians Free Clinic in a month. It wasn’t ideal, but it would have to do. Thank goodness for the caring physicians who volunteer their time and skills for people like Reuben.
Hand infections can be difficult to treat. Louis had noticed a “pimple” over his right index metacarpophalangeal joint a few days earlier and proceeded to self-treat with his own needle (as many homeless patients do). The result was a raging cellulitis over the dorsum of the hand with abscess formation. The area was fluctuant, red, and warm. I instructed our nurse practitioner to open the area with a number 11 blade. After the skin was cleaned and prepped, ethyl fluoride was used to freeze the area, and a stab wound was made. Much to my chagrin, no pus was forthcoming. It wasn’t until the patient was anesthetized with lidocaine (Xylocaine) and a hemostat broke up the loculations that the pus flowed freely. An iodoform gauze drain was left in, and Louis, now much relieved, was instructed to follow up the next day at another of our clinic sites. The drain remained, but there was still a moderate amount of pus that was extruded with pressure over the dorsum of the hand. Louis returned the next day to another clinic; the gauze wick was removed, and more pus was drained. Because of the slow resolution of the cellulitis, I changed the oral antibiotics to a broad spectrum fluoroquinolone, hoping that would resolve the problem. Louis was a good sport about chasing the mobile clinic around town, and bus passes provided him with transportation. Several weeks later, he returned to the mobile clinic with a much improved hand. I was happy with the outcome and relieved that a serious problem had been resolved without resorting to emergency department visits.
Sorting out the possible causes of dizziness or lightheadedness is rarely simple. The real problem is not a differential diagnosis but rather understanding what exactly the patient is trying to say. James, a large elderly man, had been hospitalized recently with a complete work-up including magnetic resonance imaging of the brain, the results of which turned out to be normal. He had seen several physicians in the past for his symptoms. He assured me it was not a spinning sensation, and thus, not true vertigo. His job required him to be on his feet all day, and he was finding himself falling to one side or the other. His blood pressure was well controlled. Results of the usual tests—Romberg’s, cranial nerve examination, gait, and extraocular eye movements—were all fine. Tandem walking was unsteady, but this was more because of his size than a neurologic deficit. I was scratching my head trying to help him, but finally asked when he had started his present antihypertensive medications. “About two years ago,” was the reply. “And your symptoms began about one and a half years ago?” I queried. “That’s correct.” I recommended he slowly taper one of the medicines he had been taking for his blood pressure, and have his symptoms evaluated after a week or two. I did follow up on some of the blood tests he had in the hospital to see if there were any surprises, but hoped that the medication changes would have an effect on this enigma.
The triage nurses were trying to close the clinic, which was already running overtime, but could not turn away a young woman after listening to her story. Rosa’s legs looked as though they had been put in a wasps’ nest for days. The bites had become infected, and she had 4+ pitting edema to midcalf. But they weren’t wasp stings. Rosa had walked through the Mexican mountains for four days and three nights to reach the Mexico/U.S. border, only to be turned back by the patrol guards, who returned her to her town. The bites could have been mosquitoes, flies, bees, or any number of insects. Her determination to join her brother in Columbus was stronger than the fear of failure, and after many hours on the road again, she arrived at her destination in need of medical assistance. An antibiotic would cure the folliculitis, and elevation and rest would reduce the edema, but there would be permanent scarring of her legs. Her life in this country might be better, but it is hard to tell. To me, Rosa is a symbol of the spirit of the countless poverty-stricken people searching for a dream, a dream that America symbolizes for everyone.
I have taken various objects out of children’s ears and noses, but what happened this morning was a first. Carmen was a cute four-year-old girl into her third week of coughing and low-grade fever. Her lungs were full of rhonchi, but she was aerating both lung fields well and clinically did not have pneumonia. As I was pondering whether to prescribe an antibiotic to cover a secondary bacterial infection, Carmen wandered over to the examining room sink. Before I realized anything was happening, her father said, “Oh my! Her finger is stuck.” Carmen was nonplussed and had a smile on her face as her middle finger was wedged into the swan-neck spigot above the sink. A vacuum seal was holding it in, and I was reluctant to pull with any force. A call to maintenance brought a swift response, and we put our heads together. We decided to crack open the faucet to try to break the seal. The result was an immediate change in Carmen’s disposition from pleasant to tearful. As the maintenance man began to disconnect the entire spigot, Carmen was able to pull out her finger, much to the relief of all concerned. The finger, mildly red and swollen, was iced, and Carmen was able to leave on a happy note and with a prescription for an antibiotic for her cough and fever. Needless to say, a screen was quickly placed on the end of the spigot to prevent any such episodes in the future.
Physicians are taught to screen for alcoholism. However, until a patient is ready to admit that he or she has a problem, confrontation rarely has the desired effect. The ability to dissemble is almost an inherent trait in the alcoholic, and denial is a way of life. So when Nick, who had come in for neck pain, confessed to me that he had a problem with alcohol, it was as if a dam had burst. For some reason, he had reached the point of admitting his dependence. The signs had been there all along—the difficult-to-treat hypertension, gastroesophageal reflux, borderline elevated liver enzymes, macrocytosis. Until now, Nick had never admitted alcohol had a hold on him. It may have been the thought of losing his job as a bus driver or that his girlfriend had left him. In any case, I pointed him in the direction of Alcoholics Anonymous. Nick has taken that first, most important step, and now just needs to continue his journey.
To preserve patient confidentiality, the patients’ names and identifying characteristics have been changed in each scenario. Any resemblance to actual persons is coincidental.
Copyright © 2005 by the American Academy of Family Physicians.
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