I have a medical student rotating with me from MSU this month. The clinic provides a good environment for teaching due to the prevalence of persons with no medical care in the recent past, who at times have very advanced disease. Unfortunately for many students, they never actually see a patient who has not already been poked, prodded, imaged, irradiated and chemically profiled 100 times prior to their encounter with the patient.
Monday would provide a contrast of two persons who present with superficially similar symptoms, but have drastically different diagnosis and prognosis.
Luis is a 50 year old Cuban man with mild prostatic symptoms. He's fit, well groomed, humorous, and well muscled from physical work. He has not gained the American belly fat due to having immigrated recently. On exam he appears younger than his stated age. His prostate is mildly enlarged without a hind of nodularity or tumor. His PSA is normal. He has responded well to a medication designed to ease the mild slowing of urination caused by the pressure of his expanding prostate. He is reassured that his condition is mild, though progressive, and may need surgery in 5 -10 years.
Leister is a 55 year old Black man who has not seen a doctor in decades. As I enter the room he appears gaunt, wasted, and strangely unresponsive to my greeting...managing only a faint mumbling while looking into the distance. He complains of pain in his left flank, has no appetite, and has lost weight. He is urinating less, though it's not clear if that's do to his lack of eating and drinking. Pounding over his kidneys demonstrates tenderness over the left kidney only. The abdomen is thin and flat. There's no fat layer in his skin and his skin and hair are dull. The muscles are wasting away in his temples and face. His teeth are missing and the gums have turned white, suggesting a precancerous change. On rectal exam there is a large bulging prostate which is not hard or nodular.
Later that day a phone call from radiology confirms my suspicion: a calcified tumor in his bladder blocking the left urinary tube and causing back pressure to the left kidney. Advanced cancer until proven otherwise.
Tuesday, September 10, 2013
Saturday, September 7, 2013
Unlikely reunion
The name sat at the bottom of the schedule for the day: Akanyah Brown, I'll say for privacy. It's not a name that you can forget. But where had I known her? When? I looked through the computer data bases and finally found a reference to my name: a copy of an ER report sent to me in 2004. So I was right, I must have been her doctor a long time ago. But now she's on my schedule for "eye issues".
That word "issues" has crept into my list of meaningless overused words in the past decade. Issues.....what kind of issues? Redness? Pain? Visual blurring? It could be mild or it could be severe. The statement does nothing to help me know the severity of the problem.
The day went by a little slowly, but eventually 3:30 rolled around, and the assistant had brought her to an exam room. Eager to see if I recalled her, I walked quickly, tapped on the door, and opened. As our gazes met, there was instant recognition. But now at age 35 instead of 17, her face had filled out. She had gained a few pounds, but was still a smaller woman. She was still the soft spoken, woman with the quick smile, the lively but somehow resigned expression. I reached for her, not with a handshake but an open arm, and she also, embracing as if we had found a long lost relative. How did you find me, I asked? I didn't know you were here, she responded. It's just by accident.
She was here today because she had lost vision in her left eye four days ago. I examined her eye. It was red with hemorrhages about the sclera. The retina showed no evidence of bleeding or retinal detachment. She admitted the eye was painful and had gone blank overnight so she had awakened with the blindness. Could this be be acute open angle glaucoma? That could be threatening to her vision permanently.
I looked at my watch and saw it was 4:10. Friday afternoon. No insurance. Where am I going to find an ophthalmologist emergently on a Friday afternoon at 4:10? Who is going to be willing to see her?
Quickly I picked up the phone and called the largest ophthalmology group in the city and waited to clear the phone tree. Softly repeated messages regarding Botox injection, cosmetic surgery and laser surgery cycled over several times, letting me know of the high end clientele that were being courted. Finally I was directed to the on call physician. All of a sudden the speech became serious, intent. Yes, he did know exactly the seriousness of the situation. Can you get her to our East Beltline office before we close in 40 minutes? Without thinking I said yes. Then I realized, she has no transportation. A bus, a taxi all are going to take too long during rush hour on a Friday afternoon. They will never make it in time. My assistant, I thought. She lives on the northeast side. Could she possibly take the patient? I asked her the favor, could you please take Akanya? She didn't know what to say, she had work to get done before the end of the day. Please take her and we will get the other work done next week.
Twenty minutes later we got a call from my assistant. There was trouble about no form of payment. But my assistant Jenn had insisted they see the patient. She can bull dog a little when it 's necessary, thank God.
To be continued....
That word "issues" has crept into my list of meaningless overused words in the past decade. Issues.....what kind of issues? Redness? Pain? Visual blurring? It could be mild or it could be severe. The statement does nothing to help me know the severity of the problem.
The day went by a little slowly, but eventually 3:30 rolled around, and the assistant had brought her to an exam room. Eager to see if I recalled her, I walked quickly, tapped on the door, and opened. As our gazes met, there was instant recognition. But now at age 35 instead of 17, her face had filled out. She had gained a few pounds, but was still a smaller woman. She was still the soft spoken, woman with the quick smile, the lively but somehow resigned expression. I reached for her, not with a handshake but an open arm, and she also, embracing as if we had found a long lost relative. How did you find me, I asked? I didn't know you were here, she responded. It's just by accident.
She was here today because she had lost vision in her left eye four days ago. I examined her eye. It was red with hemorrhages about the sclera. The retina showed no evidence of bleeding or retinal detachment. She admitted the eye was painful and had gone blank overnight so she had awakened with the blindness. Could this be be acute open angle glaucoma? That could be threatening to her vision permanently.
I looked at my watch and saw it was 4:10. Friday afternoon. No insurance. Where am I going to find an ophthalmologist emergently on a Friday afternoon at 4:10? Who is going to be willing to see her?
Quickly I picked up the phone and called the largest ophthalmology group in the city and waited to clear the phone tree. Softly repeated messages regarding Botox injection, cosmetic surgery and laser surgery cycled over several times, letting me know of the high end clientele that were being courted. Finally I was directed to the on call physician. All of a sudden the speech became serious, intent. Yes, he did know exactly the seriousness of the situation. Can you get her to our East Beltline office before we close in 40 minutes? Without thinking I said yes. Then I realized, she has no transportation. A bus, a taxi all are going to take too long during rush hour on a Friday afternoon. They will never make it in time. My assistant, I thought. She lives on the northeast side. Could she possibly take the patient? I asked her the favor, could you please take Akanya? She didn't know what to say, she had work to get done before the end of the day. Please take her and we will get the other work done next week.
Twenty minutes later we got a call from my assistant. There was trouble about no form of payment. But my assistant Jenn had insisted they see the patient. She can bull dog a little when it 's necessary, thank God.
To be continued....