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....
Wednesday, November 5, 2008
Three men on Wednesday afternoon.
I. Hope
Ray, an 81 year old African American man is in today for a recheck of his hypertension. Actually, it is not an accident that he is here the day after the election. 4 months ago, when I was planning his return appointment, and the date fell on October 31st, I said, no, Ray, I want you to come in the day after the election so that I can hear how you react to Obama winning the election. Doctor, I just can’t really believe it could happen, he said. I just don’t think they is going to let it happen, he said, shaking his head. Ray, I said, I think he is going to win, and I want you to be here when he does.
Today, walking in with Mary, my nurse, Ray practically jumps me, holds out is long right arm with a big hand and pulls me in a giant bear hug, practically knocking my glasses off. “You were right, Doctor, you were right!, he says. Later, when I get in the room, I decide to let him unload his thoughts and feelings before proceeding to check his blood pressure.
There’s something I never told you, he says. Oh? Remember I told you I was in World War II? I fought in the negro regiments. We had separate regiments. The army didn’t trust us so they wouldn’t give us any ammunition. I was stationed in Germany and France and worked as an engineer, protecting equipment and delivering ammunition. They gave us guns to watch guard, but they wouldn’t trust us to have ammunition, so the guns were empty. We could transport ammunition, or guard it, but we couldn’t use any and we couldn’t be involved in combat.
Afterwards when I got home to Mississippi, I figured I’d get a job pickin’ tomatos. But when they started treating me like a 2nd class citizen, you see I just got done fighting for peoples rights over in Germany, you see I just couldn’t take that any more. So I boarded a bus for Berrien Springs, Michigan and paid $19 for the ticket. That was in 1948. I got to Berrien Spring hoping I could pick fruit – peaches, pears, apples, whatever. But then we heard in Berrien Springs that there was a factory that had openings in Elkhart. So I took the bus, me and my buddy, over to Elkhart. There was a Gerber baby food factory there. We went in, they gave us a slip and said, “Go downtown and have a medical exam and come back here”. So I went into town, had the exam, and came back to the factory again. And they said I was hired, just like that.
Later that year, after I got settled, I voted for the first time. Now all the negroes had to live in the black part of town, on the east side of the railroad tracks. There was a drugstore there, it was owned by a white man, but it was in the black part of town, and that was where we voted. We had to go in the side door and that’s where I voted for Harry Truman. That was 1948.
I wanted to listen more, but I needed to transition into the reason for the visit, so I stood up and took out the blood pressure cuff. The blood pressure was normal.
I never thought I’d see this day, Doctor, he repeated, as I wrote out another prescription. Neither did I, I said. Thank you for telling me you thought he could win, doctor. I’ll never for get that. And one more thing, he says, with a twinkle, “You said if I quit smoking I would likely live to reach 90.” You have as good a chance as anyone, I thought.
II. Despair.
Stan, age 60, is sitting in the chair, his eyes down to the ground. He barely looks at me as I enter. It’s been almost a year since Stan has been in, and I wonder what has happened. He looks even more obese than last time. His enormous belly hangs out over a large “Vietnam Vet” belt buckle. His neck, face, legs, all swollen, overflowing. All 362 pounds. Looking down at his lab results I see that his diabetes has become completely uncontrolled since his last visit. He must have stopped taking his medicine. What happened?, I ask. I didn’t want to commit suicide and I didn’t want to live, he answered. So you stopped treating yourself? Yes, he answers, looking at the floor.
Stan has been depressed, on antidepressants, but to little avail. He is a modern day leper. He is on the sex offender list and can not travel, can not get a job and can not volunteer. “I thought I would pass my retirement traveling and volunteering, he says, but I can’t do either. “Have you thought about escaping?, I offer. Yes, I’d like to get to Mexico, so I can get away from this list. It is like eternal damnation. I wish that other crimes would go on a list too, like murder, robbery. But no, it’s just us sex offenders. Stan’s offence was having some illegal pictures on his computer. Now, after losing everything in his life, his freedom, his job, his self-worth, there is little left. What do you have left?, I ask. I have one friend he says. We like to go out sometimes.
How could I possibly motivate him to take care of his health I wonder. “It reminds me of how criminals were treated in previous centuries, I offer. “Oh?”, he says. “Did you ever read Les Miserables”, I ask. “No.” I write out the title on a prescription pad. You can get it on tape at the library, I think you might like it.
“Stan, I think you blood sugar is very high and it is hurting you. You should consider taking insulin to give your pancreas a break. The high blood sugars are damaging your pancreas and blood vessels.” After thinking about it a minute, he says, no , I’m going to get back to taking my medicine again and then I’d like to see how I’m doing in a month”. So we schedule an appointment in a month.
III. Apathy.
Al, age 52, is in for a check of his heart failure. Al is more or less eating himself to death. His weight is now up to 375#. He sits in the exam room with his portable oxygen. His face picked, bleeding from his nervous habit. His thin hair, long, hangs over the collar of his plaid shirt. The same plaid shirt and jeans he wore the last time I saw him.
“How are you feeling?”, I ask. “I’m doing OK”, he says, noncommittally. We review his recent echocardiogram. The medication has reversed the swollen heart, which now beats almost normally, except for atrial fibrillation, the quivering beat of the atrium that means we must keep him on blood thinners.
“I’m on disability now” he says. What do you enjoy doing?” I ask. Not much, he says. “Just keep up the house”. “Any family or friends?” I ask. “No, not really”. Feeling stymied, I scribble his prescriptions, and make plans to have him back in another 6 months.
Ray, an 81 year old African American man is in today for a recheck of his hypertension. Actually, it is not an accident that he is here the day after the election. 4 months ago, when I was planning his return appointment, and the date fell on October 31st, I said, no, Ray, I want you to come in the day after the election so that I can hear how you react to Obama winning the election. Doctor, I just can’t really believe it could happen, he said. I just don’t think they is going to let it happen, he said, shaking his head. Ray, I said, I think he is going to win, and I want you to be here when he does.
Today, walking in with Mary, my nurse, Ray practically jumps me, holds out is long right arm with a big hand and pulls me in a giant bear hug, practically knocking my glasses off. “You were right, Doctor, you were right!, he says. Later, when I get in the room, I decide to let him unload his thoughts and feelings before proceeding to check his blood pressure.
There’s something I never told you, he says. Oh? Remember I told you I was in World War II? I fought in the negro regiments. We had separate regiments. The army didn’t trust us so they wouldn’t give us any ammunition. I was stationed in Germany and France and worked as an engineer, protecting equipment and delivering ammunition. They gave us guns to watch guard, but they wouldn’t trust us to have ammunition, so the guns were empty. We could transport ammunition, or guard it, but we couldn’t use any and we couldn’t be involved in combat.
Afterwards when I got home to Mississippi, I figured I’d get a job pickin’ tomatos. But when they started treating me like a 2nd class citizen, you see I just got done fighting for peoples rights over in Germany, you see I just couldn’t take that any more. So I boarded a bus for Berrien Springs, Michigan and paid $19 for the ticket. That was in 1948. I got to Berrien Spring hoping I could pick fruit – peaches, pears, apples, whatever. But then we heard in Berrien Springs that there was a factory that had openings in Elkhart. So I took the bus, me and my buddy, over to Elkhart. There was a Gerber baby food factory there. We went in, they gave us a slip and said, “Go downtown and have a medical exam and come back here”. So I went into town, had the exam, and came back to the factory again. And they said I was hired, just like that.
Later that year, after I got settled, I voted for the first time. Now all the negroes had to live in the black part of town, on the east side of the railroad tracks. There was a drugstore there, it was owned by a white man, but it was in the black part of town, and that was where we voted. We had to go in the side door and that’s where I voted for Harry Truman. That was 1948.
I wanted to listen more, but I needed to transition into the reason for the visit, so I stood up and took out the blood pressure cuff. The blood pressure was normal.
I never thought I’d see this day, Doctor, he repeated, as I wrote out another prescription. Neither did I, I said. Thank you for telling me you thought he could win, doctor. I’ll never for get that. And one more thing, he says, with a twinkle, “You said if I quit smoking I would likely live to reach 90.” You have as good a chance as anyone, I thought.
II. Despair.
Stan, age 60, is sitting in the chair, his eyes down to the ground. He barely looks at me as I enter. It’s been almost a year since Stan has been in, and I wonder what has happened. He looks even more obese than last time. His enormous belly hangs out over a large “Vietnam Vet” belt buckle. His neck, face, legs, all swollen, overflowing. All 362 pounds. Looking down at his lab results I see that his diabetes has become completely uncontrolled since his last visit. He must have stopped taking his medicine. What happened?, I ask. I didn’t want to commit suicide and I didn’t want to live, he answered. So you stopped treating yourself? Yes, he answers, looking at the floor.
Stan has been depressed, on antidepressants, but to little avail. He is a modern day leper. He is on the sex offender list and can not travel, can not get a job and can not volunteer. “I thought I would pass my retirement traveling and volunteering, he says, but I can’t do either. “Have you thought about escaping?, I offer. Yes, I’d like to get to Mexico, so I can get away from this list. It is like eternal damnation. I wish that other crimes would go on a list too, like murder, robbery. But no, it’s just us sex offenders. Stan’s offence was having some illegal pictures on his computer. Now, after losing everything in his life, his freedom, his job, his self-worth, there is little left. What do you have left?, I ask. I have one friend he says. We like to go out sometimes.
How could I possibly motivate him to take care of his health I wonder. “It reminds me of how criminals were treated in previous centuries, I offer. “Oh?”, he says. “Did you ever read Les Miserables”, I ask. “No.” I write out the title on a prescription pad. You can get it on tape at the library, I think you might like it.
“Stan, I think you blood sugar is very high and it is hurting you. You should consider taking insulin to give your pancreas a break. The high blood sugars are damaging your pancreas and blood vessels.” After thinking about it a minute, he says, no , I’m going to get back to taking my medicine again and then I’d like to see how I’m doing in a month”. So we schedule an appointment in a month.
III. Apathy.
Al, age 52, is in for a check of his heart failure. Al is more or less eating himself to death. His weight is now up to 375#. He sits in the exam room with his portable oxygen. His face picked, bleeding from his nervous habit. His thin hair, long, hangs over the collar of his plaid shirt. The same plaid shirt and jeans he wore the last time I saw him.
“How are you feeling?”, I ask. “I’m doing OK”, he says, noncommittally. We review his recent echocardiogram. The medication has reversed the swollen heart, which now beats almost normally, except for atrial fibrillation, the quivering beat of the atrium that means we must keep him on blood thinners.
“I’m on disability now” he says. What do you enjoy doing?” I ask. Not much, he says. “Just keep up the house”. “Any family or friends?” I ask. “No, not really”. Feeling stymied, I scribble his prescriptions, and make plans to have him back in another 6 months.
Friday, October 24, 2008
Looking for a cyst
Claudia is back and the pain is worse. She’s done everything I’ve asked but the problem is getting worse.
It was about a week ago when she showed up with her son, Christopher, complaining of pain under the left breast. I checked there area and it was a bit perplexing. There was tenderness, but I could not feel anything abnormal – no telltale bogginess to suggest a fluid collection. Yet my suspicion remained – there could be an abscess or cyst under there. But I don’t want to go in there with a scalpel without knowing what I’m going to find.
So I sent her to ultrasound. I was pleased to get a personal call from Dr. V., letting me know that there was a fluid collection, and that it was likely a sebaceous cyst. It was only 1 centimeter in size, so not extensive in size.
Now back in the exam room, I had Claudia get back on the exam table. Once again I felt for any telltale localizing signs to help me know where to cut. There was not much there to guide me. I got out the syringe with anesthetic and begain to inject a little of it. But this was destroying what little telltale signs there were. Then the area was cleansed with iodine, making ever larger circles with the brown colored swabs until the are was painted about 6 inches across. With scalpel in hand, I chose and area and began to cut into the skin. It did not feel like the right spot. The skin was too firm, too normal. I felt the skin again with my gloved hand, trying to detect the telltale flexibility in the skin. There, just a centimeter to the left, it was a little different. Again I took the scalpel and cut in, looking at her face to detect whether the anesthetic was working. No pus or liquid was detected. I cut alonger incision, now 1 -2 cm long and gradually began to dissect the skin to the side. Suddenly, the telltale white, cheesy liquid bubbled to the surface. I was in the cyst. Paydirt! ‘
Opening the incision a little more I began to explore the cyst cavity. Large amounts of purulent smelly marterial bagan to extrude and trickle down her left side. I pushed the curved hemostat into the wound, exploring it’s limits. The cyst extended along the muscular chest wall about 1 inch in each direction, forming a large flat cystic structure.
Then, taking the syringe, I injected saline solution to cleanse the wound until fragments of the cheesy material stopped rising to the surface. I then pushed a long piece of gauze into the wound, taking care to fill all the empty spaces. I trimmed it close to the opening of the wound.
Claudia looked exhausted and painful, but relieved. I gave her a prescription for an antibiotic, and asked her to return in a few days. Her husband will withdraw the drain little by little until I see her.
Wednesday, October 15, 2008
Dizzy, falling Chinese man.
Dizziness, room 16
I picked up the chart. This is the last one before lunch, I thought to myself. Maybe I'll get time for lunch today since things are going so smoothly this morning, a great relief from last Saturday's craziness.
It's a charming couple, Han, and his wife Phan, with the sparkling eyes. About 40 years old, he is from China and she from Cambodia. He's in for dizziness. Now I remember, last Friday he called me after falling in his front driveway. I must have tripped, he says. He had been feeling weak and dizzy for a couple of days, like he was drunk. His wife had kept him home because of not feeling well. I could see the small cut on his nose, and some bruising around the eyes. At the time I suggested he rest over the weekend and come into see me today.
I started his exam. Looking over his head and neck, I see mild bruising around the eyes, but none behind the ears to suggest a subdural hemorrage. His neck is flexible and has no pain with movement, good. Cardiac exam shows no evidence of an rhythm problem that could have caused him to faint. Skin is rather yellow. Is it just his Asian features? I compare him to his wife and to my own skin. Definitely yellow. This is worrisome given his history.
It was five years ago that Han came in with his wife worried. He was bleeding from the rectum. I had taken him into our surgical suite and performed an immediate unpreped sigmoidoscopy. A long flexible tube was inserted into his rectum, and by use of fiberoptics, it was immediately obvious - a huge necrotic tumor obstructing his rectum. I was so thankful that my colorectal surgery colleage, Dr. K. agreed to see him that same afternoon. He biopsied that tumor and it proved to be a rather advanced rectal cancer. Later Han underwent surgery and had the tumor removed, the colon temporarily re-routed to a pouch, and then on a second surgery, reconnected to the rectum and reconstructed. The chemotherapy was not pleasant either. But he's been back to a fairly normal life since then.
But now, with jaundice, I am worried about a tumor recurring in the liver. The colon, like almost all the digestive organs, have their own blood return circulation to the heart, through the liver. The liver cells filter and process all the substances coming in through the gut. But they also take the brunt of any cancer cells flipping off from a tumor, so they lodge in the liver and start growing a second tumor, a metastasis.
I can't dwell on the jaundice. I turn to Han's rectal exam. It's clear, and there is no blood. Atleast that's normal.
Now to the neurologic exam. Starting with the cranial nerves, I check his vision for double vision. Holding one finger up, I ask him to follow my finger in all directions. His eyes seem to track well most of the time. Are you seeing one or two fingers?, I ask. One and a half he replies. I crack up laughing and so does his wife. What does that mean? I mean I can see one finger, he corrects. I've heard of diplopia, seeing two fingers instead of one, which is caused by the eyes not tracking coordinately, but one and a half? That's new. Back to more serious stuff, I track his cerebellar function -- coordination and balance. When trying to move a finger back and forth from his nose to my finger, his movement is slow, but accurate. When holding his hands straight out in front of him, there is no unusual shaking -- asterixis-- to indicate liver failure.
His exam concluded, I sit down to talk things over. I'm concerned about how your brain is functioning and also your yellow skin color. Han says that Dr. K told him that if his cancer comes back, it will be in his liver. I'm going to check your liver and blood tests, and at the same time get a CAT scan of your abdomen to get a better look at your liver. I don't want you to go to work or to drive by yourself right now as your balance and reaction time is not normal. If we can't find anything in your abdomen to explain your symptoms, we may need to scan your brain also. It's a tense moment. Phan holds her husband close. We all know Han's life hangs in the balance.
I picked up the chart. This is the last one before lunch, I thought to myself. Maybe I'll get time for lunch today since things are going so smoothly this morning, a great relief from last Saturday's craziness.
It's a charming couple, Han, and his wife Phan, with the sparkling eyes. About 40 years old, he is from China and she from Cambodia. He's in for dizziness. Now I remember, last Friday he called me after falling in his front driveway. I must have tripped, he says. He had been feeling weak and dizzy for a couple of days, like he was drunk. His wife had kept him home because of not feeling well. I could see the small cut on his nose, and some bruising around the eyes. At the time I suggested he rest over the weekend and come into see me today.
I started his exam. Looking over his head and neck, I see mild bruising around the eyes, but none behind the ears to suggest a subdural hemorrage. His neck is flexible and has no pain with movement, good. Cardiac exam shows no evidence of an rhythm problem that could have caused him to faint. Skin is rather yellow. Is it just his Asian features? I compare him to his wife and to my own skin. Definitely yellow. This is worrisome given his history.
It was five years ago that Han came in with his wife worried. He was bleeding from the rectum. I had taken him into our surgical suite and performed an immediate unpreped sigmoidoscopy. A long flexible tube was inserted into his rectum, and by use of fiberoptics, it was immediately obvious - a huge necrotic tumor obstructing his rectum. I was so thankful that my colorectal surgery colleage, Dr. K. agreed to see him that same afternoon. He biopsied that tumor and it proved to be a rather advanced rectal cancer. Later Han underwent surgery and had the tumor removed, the colon temporarily re-routed to a pouch, and then on a second surgery, reconnected to the rectum and reconstructed. The chemotherapy was not pleasant either. But he's been back to a fairly normal life since then.
But now, with jaundice, I am worried about a tumor recurring in the liver. The colon, like almost all the digestive organs, have their own blood return circulation to the heart, through the liver. The liver cells filter and process all the substances coming in through the gut. But they also take the brunt of any cancer cells flipping off from a tumor, so they lodge in the liver and start growing a second tumor, a metastasis.
I can't dwell on the jaundice. I turn to Han's rectal exam. It's clear, and there is no blood. Atleast that's normal.
Now to the neurologic exam. Starting with the cranial nerves, I check his vision for double vision. Holding one finger up, I ask him to follow my finger in all directions. His eyes seem to track well most of the time. Are you seeing one or two fingers?, I ask. One and a half he replies. I crack up laughing and so does his wife. What does that mean? I mean I can see one finger, he corrects. I've heard of diplopia, seeing two fingers instead of one, which is caused by the eyes not tracking coordinately, but one and a half? That's new. Back to more serious stuff, I track his cerebellar function -- coordination and balance. When trying to move a finger back and forth from his nose to my finger, his movement is slow, but accurate. When holding his hands straight out in front of him, there is no unusual shaking -- asterixis-- to indicate liver failure.
His exam concluded, I sit down to talk things over. I'm concerned about how your brain is functioning and also your yellow skin color. Han says that Dr. K told him that if his cancer comes back, it will be in his liver. I'm going to check your liver and blood tests, and at the same time get a CAT scan of your abdomen to get a better look at your liver. I don't want you to go to work or to drive by yourself right now as your balance and reaction time is not normal. If we can't find anything in your abdomen to explain your symptoms, we may need to scan your brain also. It's a tense moment. Phan holds her husband close. We all know Han's life hangs in the balance.
Sunday, October 12, 2008
Jan's chest pain
I was working the morning urgent care clinic, rather annoyed at how tightly things had been scheduled. But there is nothing I can do about being 1-1/2 hours behind. I'm just going to have to deal with it.
In room 18, Jan, age 52, is sitting on the exam table. Her husband Evan sits attentively in the chair next to her. She is here because of chest pain. I'm on my guard knowing chest pain can present a number of traps for the primary care physician. A host of serious conditions can masquerade as commonplace muscular strains or joint problems. Now she has my full attention and any distraction I had about the overscheduling is gone.
Jan first noticed chest pain about 2 weeks ago. It's located just to the left of the breastbone and goes through to her shoulder blade. She thinks it's related to some painting and yard work she was doing a few months ago. In fact her husband, taking charge at this point, assures me that it is a very muscular kind of pain, and he is sure she does not have heart pain. Jan does have a history of heart disease, having received a stent two years ago. Just 6 months ago she was examined by Dr Q, the cardiologist, and found to have pristine arteries on cardiac catheterization. Evan makes clear, their son is arriving within the hour from basic training, and they are intent on seeing him.
There's not much remarkable on Jan's exam. Her chest wall is not tender anywhere. The shoulder exam doesn't reproduce the pain. The heart and lung exams are normal. The right leg shows some varicose veins, but I can't reproduce any tenderness with pressure over the calf. The only slight abnormality -- oxygen saturation at 95% -- a little low for a non smoker.
Every physician has been lectured about this type of patient-- it's engraved in our memories with the admonition, "do not miss a pulmonary embolism", a blood clot that has arisen from the legs and lodged in the arteries to the lungs from the heart. The story is perfect -- leg pain, chest pain, a little short of breath.
Jan, I think you need to go to the hospital, I say. Turning to her husband, who looks a little uncomfortable. I can see their plans melting away and hours of emergency room evaluation looming ahead. I know it's difficult to interrupt your plans, I explain, but a blood clot to the lungs would be extremely dangerous. It can result in sudden death. I can't agree with you going home or giving it time. Anything other than going directly to the hospital would be like playing Russian roulette. I don't like to pull out the "death" card frequently. It's the atom bomb of medical advice.
Jan accepted my recommendation, and the couple headed down to the hospital. I called report into the hospital, waiting to hear what would be found.
About 3 hours later, I received the call. You were right, Jan has multible pulmonary emboli. 3 in the right lung and 2 in the left lung. She is being admitted for treatment and monitoring. I'm thankful that my annoyance at the scheduling snafus did not result in a superficial encounter and a missed diagnosis.
In room 18, Jan, age 52, is sitting on the exam table. Her husband Evan sits attentively in the chair next to her. She is here because of chest pain. I'm on my guard knowing chest pain can present a number of traps for the primary care physician. A host of serious conditions can masquerade as commonplace muscular strains or joint problems. Now she has my full attention and any distraction I had about the overscheduling is gone.
Jan first noticed chest pain about 2 weeks ago. It's located just to the left of the breastbone and goes through to her shoulder blade. She thinks it's related to some painting and yard work she was doing a few months ago. In fact her husband, taking charge at this point, assures me that it is a very muscular kind of pain, and he is sure she does not have heart pain. Jan does have a history of heart disease, having received a stent two years ago. Just 6 months ago she was examined by Dr Q, the cardiologist, and found to have pristine arteries on cardiac catheterization. Evan makes clear, their son is arriving within the hour from basic training, and they are intent on seeing him.
There's not much remarkable on Jan's exam. Her chest wall is not tender anywhere. The shoulder exam doesn't reproduce the pain. The heart and lung exams are normal. The right leg shows some varicose veins, but I can't reproduce any tenderness with pressure over the calf. The only slight abnormality -- oxygen saturation at 95% -- a little low for a non smoker.
Every physician has been lectured about this type of patient-- it's engraved in our memories with the admonition, "do not miss a pulmonary embolism", a blood clot that has arisen from the legs and lodged in the arteries to the lungs from the heart. The story is perfect -- leg pain, chest pain, a little short of breath.
Jan, I think you need to go to the hospital, I say. Turning to her husband, who looks a little uncomfortable. I can see their plans melting away and hours of emergency room evaluation looming ahead. I know it's difficult to interrupt your plans, I explain, but a blood clot to the lungs would be extremely dangerous. It can result in sudden death. I can't agree with you going home or giving it time. Anything other than going directly to the hospital would be like playing Russian roulette. I don't like to pull out the "death" card frequently. It's the atom bomb of medical advice.
Jan accepted my recommendation, and the couple headed down to the hospital. I called report into the hospital, waiting to hear what would be found.
About 3 hours later, I received the call. You were right, Jan has multible pulmonary emboli. 3 in the right lung and 2 in the left lung. She is being admitted for treatment and monitoring. I'm thankful that my annoyance at the scheduling snafus did not result in a superficial encounter and a missed diagnosis.
Thursday, September 18, 2008
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.
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.
Wednesday, September 10, 2008
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.
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.
Monday, September 8, 2008
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.
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?
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?