Yuriria

"Room 11, physical, patient nervous"

I never quite know what to expect when I receive the non-specific warning that a patient is nervous. And when she is a new patient, all I have to go on is the basic essentials: female, age 36. Could it be a life-long fear of doctors, fear of needles and pain, a fear of a bad diagnosis, or just the ever-present shame of one's own body exposed--to be expected from a woman seeing a male physician for the first time?

I have all of 15 seconds to ponder this, before presenting my best culturally correct greeting, Hello, Yuriria, buenas tardes, reaching to shake her hand as I test which language she will answer in. In her Spanish response, she obviously is from the Caribbean, the clipped end consonants being a dead give-away. But also, her light skin makes the Dominican Republic, with it's strong African heritage, less likely. Indeed she is from Havana, Cuba, the only child, born and raised in a middle class, educated family. Her wide smile and pleasant demeanor hides her nervousness for the first few seconds.

Yuriria, would you tell me about your medical history? She's actually been very healthy. She has one child age 9, and otherwise the only significant factor is her overweight. She distorts her face and averts her gaze as she describes how she weighed 134 pounds before coming to the US, but since arriving has gained some 70 pounds. She has tried, but has been unable to lose it. Working long hours in the factory-bakery, she doesn't have time to exercise, is always too tired when she arrives home.

Sensing that she is ashamed about her overweight, I decide to engage her in distracting conversation about Cuba while I do her exam. She accepts this ploy, and occasionally I intersperse the conversation with details about the normalcy of her exam. By the time I get to her pelvic exam, we are deep into a discussion of whether Cuba is really that bad and she is telling me about positive aspects of modern Cuban life, such as universal health care and free education. She had no idea before moving here how difficult it would be having to work 6 or 7 days a week in a factory while raising a young child. This was certainly not a part of her experience growing up somewhat consentida, or spoiled as the only girl in her family.

I tell her, Yuriria, you are really quite healthy. Your transition to the US has left you much more overweight than if you were living in Cuba ( you have not done something shameful!). But you can change your habits to protect against the danger of overeating, and under-exercising. Remember how you had to go shopping every day by foot, perhaps taking the tram, in Cuba? You had no car? There was not always enough food to go around, and never an excess?

With lab slip in hand, successfully dressed, Yuriria is obviously relieved. I am also relieved that I have been able to put her at ease and her shame has retreated. Whether I will be able to help her find a healthy lifestyle to restore her to her previous health, while caught in the vortex of underpaid, overworked factory job is not going to be easy. The cards are stacked against us.

Yaquelin's baby is growing up

Room 17: "Breast pain x 2 weeks"

Yaquelin and her little boy are waiting for me, she on the exam table, he sitting quietly on the chair, with new Spiderman shirt. After shaking hands ( always necessary in Mexico, even with children), she begins to describe the problem. Over the past few weeks her breasts are painful all the time. She's not missed a period and doesn't believe she is pregnant. I give her a moment to change quickly, and then verify that there are no unusual lumps. She does have a little fibrocystic change in both breasts, but it is symmetric and mild. There is one small nodule that feels like a cyst to me. It is round , smooth and a little tender to touch. At age 31, it's almost certainly a benign cyst.

Yaquelin goes onto say she's been tired lately, sleeping poorly. She looks a little tense, worried, so I ask her to expand on that. She's not been sleeping well, and is worried. She's worried about her daughter in Mexico. Daughter? Yes, she admits, maybe she was egoista, selfish, but she and her husband decided to leave their 1 year old daughter in the care of his parents, so that they could make it in the US. They send money, clothes, and talk on the phone frequently. But lately their daughter has been asking to come to the US to be with her parents. A tear appears as Yaquelin talks, looking downward. Continuing, she mentions that their daughter is developing too fast -- she already looks 14 and she's only 10. She's so worried that she can't sleep at night, and so now is drinking about 3 cups of coffee to get up and get to the factory at 5 am.

I explain to Yaque that the most common cause of breast pain in women, other than pregnancy and menstruation, is caffeine use. I think she is drinking more coffee to compensate for her lack of sleep. In turn, this is causing her breast pain. Breast cancer almost never presents as pain. This is the most important thing for her to know.

Secondly, I must tell her, not to discard her daughter's call for help. I suspect her daughter desperately needs the love and acceptance of her parents, and the window will soon close on the ability to reconnect and re-develop the maternal child bond. Soon her daughter will be fully developed, and will seek attention, care, acceptance, and love from any source she can get it. Unfortunately for many children abandoned in Mexico by their parents, this means sexual precocity, and early pregnancy. It's often a stormy relationship that lasts a short time.

I encourage Yaque to find a way to reunite with her daughter. I also give her some primrose oil capsules to reduce breast pain; also she will reduce her caffeine intake. We will recheck her progress in a month.

Concepcion's elbow pain

Concepcion is a short Mexican woman. By her darker, indigenous features I'd say she's from Michoacan. Her wine-colored uniform tells me she has just come her from work at the factory where she racks boxes of steel bars. Next to her is her teen age daughter, who helped her with any unanticipated staff who may not speak Spanish.

She is here today with pain in her left elbow. She hit the elbow against something 2 years ago and now it is painful. Her hand is becoming weak. She can no longer carry the 35 pound boxes of steel bars without dropping them. In fact, she did drop the box, and that is what prompted today's visit. But it is not just the left elbow, but it is also the right knee, which has the same burning pain, and the same shape of pain. By this I mean the same oval area just below the joint. They are the same pain for her.

From my cause-and-effect point of view, I ask her what she has been lifting. She has been lifting boxes, bending under the assembly line, kneeling, scrabbling around under the table getting parts...."everything" she explains. "Is it hard for you to lift a gallon of milk?" I ask. That's right, she can not longer lift it; it would slip out of her hand. "Has it been hurting since you hit the elbow 2 years ago?". No, in never hurt until now, she reveals.

I run my fingers over her forearm and elbow, looking for tender points, moving the joint. She's tender over an outcropping of bone called the lateral epicondyle, the little bump on the outside of the elbow. This is where a muscle starts that stabilizes and retracts the wrist. She has tennis elbow, not from tennis, but from lifting heavy boxes all day. I offer her an injection of medication. She agrees and I return in a couple of minutes with my little cocktail of local anesthetic, steroid, and nonsteroidal mediation; all told about 2 cc. I slowly inject the area, bathing the affected tendons in medication. I also give her a note for work restricting her lifting to no more than 15 pounds, and a brace to go around her forearm to reduce the tugging of the mucle anchored to that bone.

This is a simple straightforward case except for one detail. Why did Concepcion relate the pain to an impact 2 years ago rather than to the daily grind of her work? My observation is that a golpe or impact is considered to be a disturbance that can unleash illness to the same degree as a disturbance of hot and cold. Many immigrants will ask me, "Will that golpe on the head cause a brain tumor?" In this case, even though the fall or hit to her elbow was rather minor, and caused no pain for 2 years, it was the source of illness assumed by Concepcion.

Ice water - chest pain

Manuel came in right after his wife this morning. Because of his complaint of chest pain, the nurse was on top of things and had an EKG done before I got in the room. It was normal. He was complaining of pain as motioned with his hand over his right chest, showing how the pain started just to the right of the sternum and radiated over the whole right side of the ribs, was worse with deep breaths, and accompanied by a little shortness of breath. It's been going on since last Tuesday, but he waited 6 days until today to come into see me.

Going back over the his story, Manuel described the day that the symptoms began. It was the day after Labor Day when suddenly the weather turned very hot and muggy, after a long spell of cool temperatures. It was very hot at work in the greenhouse. Someone offered him ice water to cool down. From the moment he took the first swallow of ice water, he began to feel the pain, and it has not relieved since it began.

We western physicans call this kind of pain "pleuritic", a sharp pain that increases with the depth of respiration. It almost always excludes serious sources of pain such as pneumonia and heart attack ( but not always!) Serious conditions such as a blood clot in the lung could be considered, but a vigorous man in his 40's without predisposing conditions, Manuel has a low probability of that. Much more likely is irritation of the muscles, ligaments of the chest wall, or even irritation of the sac like covering of the lungs. After all, this would not be unusual -- 2 other people had already been in with viral flu-like illnesses today with the same symptoms.

But what makes Manuel's description unique and so different from my other patient today, a computer network administrator, is the emphasis on change in temperature. In Manuel's world, the ancient world of hot and cold, illness is caused by a disruption of the balance cold and hot forces in the body. In his view, heating the body up unusually put Manuel at risk of illness, because any sudden cold impulse, whether it be ice water, ice cream, walking on a cold floor, or walking into air conditioning could disturb the balance, and set off illness.

I check Manuel's oxygen levels which are normal, and then send him off for a chest X-ray. I am going to treat him with ibuprofen for muscular and ligamentous pain, but how do I treat him in a way that makes sense to his traditional sense of hot and cold upended?

MRI's demanded

Seeing Kimberly’s name on the schedule brings tightness to my chest.  I know it’s going to be a confrontational, tense appointment.  Kimberly just called two days ago.  She has pain in 7 different body areas, and she wants MRI’s ordered on all of them.  She does not see why she should have to come in for this, as she is too busy, and frankly the co-pay is not worth it.  My message through the nurse: you must come in if you want to be evaluated for these problems.

 

I open the door.  Kimberly is smartly dressed, all business.  She has a page long list of her symptoms, and further questions.  She has pain in her shoulder, back, neck, abdomen, left side of her head, knee and wrists.  When asked to focus in on the main, or most pressing problem, she states, “All of them are equally important”.   When asked to go through the history of the complaints, she rolls her eyes, as if to say, “Here we go with this game again.”  I spend about 15 minutes going through her history.  In addition I notice that her blood pressure is quite high.  “Are you taking your blood pressure medication?” I ask.  Yes, but she changed it back to an old medication, and she really doesn’t believe it is that high.

 

Getting back to her physical exam, I examine each of the areas she is concerned about.  Although she has 10 – 15 minutes scheduled, I know there is no way this is going to take less than 30 minutes.  It’s better to put the time in now, I say to myself.  Her physical exam is really rather unremarkable.  It would be hard to list a single significant physical finding.   Once again I share with her my impression from my physical exam.  As I do so, I see her body language of defiance.   I ask her, “Do you believe anything I am telling you?”  “No,” is her reply.

 

Now is when I am going to have to be very direct and lay it on the line.  “Kimberly,  I believe that there can be a physician-patient relationship unless there is trust, and unless you are willing to follow my recommendations, or at least to discuss and manage our areas of disagreement.  But we have none of those.   There is no trust here and I am not willing to order tests just because you demand them.  I am not willing to continue as your doctor.   “That’s fine”, she responds, “ I was going to switch to another doctor if you did not order those tests.”  

 

I am relieved that I have been able to deal directly with Kimberly’s demands  and have been able to tell her what I am willing to do, and, in her case, not willing to do.  It is so easy for physicians to become burned out when they do not tell their truth about unreasonable expectations or demands.  In my early years of practice, I could not have dealt with Kimberly as directly, and I would carry around the stress, feel guilt and anger that would seep out on other innocent people.

A woman with headaches

Jackie is the epitome of youth -- young, beautiful, black and smart. She moved here to start her first job as a social worker. But tonight she complains of a daily headache for about 2 months. The headaches start behind her right eye, pound, and cause her to have to go to bed when she returns home. She had never had headaches before coming to Grand Rapids, and they are not present in her family. I asked some probing questions, caffeine? alcohol? cheese? medications?... all met negative response. Finally I asked, " do you eat or drink anything with artificial sweetenters?" "Well, yes, since I started my job, I have been drinking Crystal Light most of the day," she replied. Ah, this is the clue, I remarked to myself. Crystal Light contains aspartame, and a continuous intake of this could precipitate the new onset of migraine headaches. After a neurological exam, I prescribe Jackie some medication in case she continues to have headaches, but most importantly, she will stop drinking Crystal Light. Hopefully, her headaches will resolve without need for an extensive evaluation and multiple medications.

A wall of smoke

Joyce is 58, and as I walk in for her annual physical I am confronted by a wall of stale smoke as I enter the room. She doesn't have to tell me, she's started smoking again. It was just 2 months ago that she had completely stopped smoking. I had tried all the medications plus counseling, and now the new medication, Chantix. Chantix works by blocking the receptors in the brain that give people the pleasure from smoking. It's worked better than other devices or drugs I've used in the past. I thought we had finally won a 40 year battle with an addiction. But my heart sinks now, knowing that we have lost. Joyce tries to put a positive spin on the situation, "I haven't quit quitting", she says. But honestly, looking at her across the chasm that divides us, I see a 100# overweight woman with grey coarse skin, bags under her eyes, and stained with nicotine. I am struggling to maintain hope for Joyce. "You were right," she says, "it did make the cigarettes taste like cardboard. But it reminded me of those cigarettes from the late 60's, 'Lark' I think, that also tasted like that, and I really wanted one." I proceeded with Joyce's physical, ordered her mammogram and blood tests, and asked her to attend a free smoking cessation class. I don't believe she is ever going to stop, but I have to try. Sometimes I am surprised by who finds hope to break free from an addiction.

A resilient child

Simpson Claude Rodriguez seemed a peculiar name, as I picked up the chart for an immigration physical and flipped through the documentation. I opened the door and a smiling blonde woman and two boys awaited me. Both boys are very dark with African features. As I went through the documentation for immunization and tests, I asked the boy, "so how are you so lucky to have one English name, one French name, and one Spanish name?" He shrugged. His mother told the story. Simpson is Haitian. When he was four, he was being brought to the US to have an operation on his face by a missionary group. But before the group could get to the US, they were kidnapped by an armed gang in Haiti, and before Simpson could escape, he was shot. Fortunately the party escaped and was able to get to the US. After arriving here, the blonde woman and her husband decided to adopt Simpson, so now he is applying for residency. Simpson shows no signs of post-traumatic stress. He is calm, not fearful and plays like any other kid. His mother confirmed that he shows no signs of the trauma he survived before. I am always struck by how resilient children can be, given a stable and loving home.

Dry wells restored

I was dragging in the office today. All the children are back in school. It's the difficult chronic medical problems that seem to have no solution that confront me, and my energy is lacking. Taking a brief nap at lunch helps a little.

I pick up the first chart after lunch... a middle aged Asian woman, Mrs. Q. As I walk in, she looks puffy, and runny, but there is an intensity and a liveliness in her eyes too. "Thank you for saving my husband's life," -- it jumps out as if she had been holding it in for a long time. I did not expect that. Yes, I did work her husband in at the end of a Friday when the couple drove 3 hours back to Grand Rapids from the Upper Peninsula, him with chest pain, and instead of going to an emergency room like most people, they wanted to see me. His EKG showed an arrhythmia and possible ischemia(critical lack of oxygen that carries the threat of heart attack), but not a heart attack. I was able to get my good friend and cardiologist, Dr. M, to see him yet that afternoon. Within a couple of days in the hospital the mystery had been solved, a pacemaker inserted, heart attack averted, life normalized. "I was very pleased to help your husband, and I am glad he is better". I am thankful that there are still people for whom the relationship with their doctor is more important than an MRI. But mostly, I am thankful that my dry well is filled today by the celebration of a success and for life restored. It becomes energy that I can draw on for the rest of the day.

Why is brown ugly?

Maria says she is here today because of pain over her heart. It is like a rock on her chest, and it gets worse when she thinks about the pain in her life. She says, "Mis hijos me odian, " my children hate me because I abandoned them in Mexico. I have no one. I work hard but my body is failing as I work. I don't ask her to tell me why she abandoned them. I know. It was her husband who told her to come to the US, and he's not there anymore. Maybe he died, maybe he found another woman. Maybe he's an alcoholic. "I was left in a garbage dump by my parents," she goes on to report. "Another family found me when I was a few hours old. They never told me until one day I was yelling at Blanca she shouldn't be hitting that child, and she fumed back, 'you are not really a part of our family, so don't tell me what to do with my children. Your parents left you because you were ugly. Your eyes are brown and their eyes were colored'". "Why are brown eyes are ugly", I inquired? She said its just the way things are, but she said, " sometimes I dresses up and can look nice. I'm not really ugly, I don't think."
Maria's EKG is normal and I am going to have her get a stress test. I am suspicious it will not divulge the source of her pain.