Tuesday, November 20, 2012

All in a Day's Work

     Today, I saw a 10-year-old who couldn't breathe out of his nose.  He had blue-white nasal mucosa.  We did nasal irrigation, prescribed nasal spray for allergies, and tried to persuade his parents to let me help them quit smoking.
     Then, I took a 7.5 cm crusted, funny-shaped, rapidly growing basal cell cancer off a patient's neck-chest junction, and had to do a plastic surgery to cover the opening. Since it's the fourth skin cancer I've removed, and he has another large one above his left eyebrow, I know something serious is going on with his immune system, and have set out to find out what.
     Lab tests confirmed a case of West Nile virus in a patient whose left lung pneumonia looked unusual to me last week, and whose symptoms of fever, chills, night sweats and nausea seemed to signify a problem even more serious than penumonia.  Tests for Lyme disease, influenza, erlichiosis, HIV, and Eastern Equine virus were negative.  But West Nile titers were positive.  The patient doesn't have encephalitis, hepatitis, or nephritis, and therefore is better off recuperating at home with the treatments I gave her.  Rest, rest, rest, I said.  Meanwhile, I called her daughter to keep an eye out for complications, should they occur, and be prepared to take her to the hospital.
     A newly diagnosed twenty-something HIV patient is beginning to accept his need to take medication to keep his CD4 count and viral load down.  After telling him about his test results he fell into a deep depression.  The lymph nodes in his chest, revealed on a CT scan, were enormous.  He refused to see an Infectious Disease specialist, or even go to the Health Department.  Finally, he started the prescription for Atripla we gave him, and now the lymph nodes in his chest are going down.  He feels better, but asked--can he still have children?
     Another patient hasn't been able to sit down for three days.  Examining her with an anoscope, I saw a thrombosed internal hemorrhoid, and treated it.
     A young couple brought in their six-month-old baby, who has been coughing and running a fever of 101.8.  They had gone to the ER last night, but after waiting for eight hours without being seen, drove to my office this morning. The baby was cheerful, but a chest x-ray showed pneumonia.  "Oh, my God," the father said, then told me that a family member's baby died of pneumonia not long ago.  Undoing the notion that his baby was likely to die took a little time--then I used the opportunity to say all both parents and grandparents should quit smoking, as a way of improving the baby's health.
     A 40-year-old woman has been picking a scab off a nodule on the bridge of her nose, but it keeps coming back.  It was a sebaceous cyst to me--but might have been skin cancer, so I did surgery to remove it.
     A man with cellulitis of his leg came back to be checked after three rounds of IV antibiotics and an Unna boot wrap.  The original ulcer, caused by poor venous circulation, was getting better:  islands of normal tissue had sprung up in the center of the red speckled skinless area, which was the size of a half-dollar.  The cause:  he weighs more than 400 pounds, and the veins in his legs can't return fluid fast enough to his heart, so the fluid pools in the tissues, and seeps through the skin, causing breakdown of skin cells.  He's lost 40 pounds in three months, which I thought was great.
     A young woman with positive tests for a clotting disorder (antiphospholipid anitbodies) wanted to know if she could take birth control pills.  She refused my suggestion to get a Mirena IUD, because she's worried it will hurt.  But she agreed to Depo-Provera shots.  Estrogen-containing contraceptives might increase her risk of a blood clot, and are contraindicated.  If she gets pregnant, I said, it will be a high-risk pregnancy.
     A patient with hepatitis C can't stop using pain pills.  He doesn't want to have a liver biopsy.   Nor does he want interferon treatment--because he knows it will cause depression.  His liver enzymes are sky-high, suggesting damage of the liver at the cellular level.  He knows that hepatitis C is one of the biggest causes of liver cancer.  He quit drinking alcohol, for which I commended him, but refuses AA and NA.  "Don't yell at me, Doc," he says, in a self-berating way.  But I would never yell at a patient, never.
     A young man's asthma is suddenly worse.  He can't breathe without coughing.  His chest x-ray is normal, but his spirometry shows a breathing capacity at 50% of what it ought to be.  We ran some tests and treated him with antihistamines and inhalers.  He may need prednisone, but I have to figure out why he's having this problem.  I wonder if he might have been exposed to airborne toxins at home or work.
     A woman has a hole in the septum of her nose.  She swears she's never used cocaine, or snorted any drugs.  She doesn't use Neosynephrine nasal spray.  Maybe she has an abscess in the root of one of her lateral incisors, and it has eroded through her cartilage--this is not impossible, but would be very unusual.  Off to the dentist she goes.
     A patient with a malignant melanoma on her arm, came back for surgery of another site, where biopsy of a tiny freckle between her toes revealed an atypical nevus, or pre-melanoma.  Lucky you looked there, I told the nurse-practitioner.  An assistant held the toes apart so I could remove the lesion in the web space, a tricky maneuver that took just a few minutes. 
     A 375 pound patient wants to be referred for gastric bypass.  She has tried many dietary regimens, as well as pills to lose weight.  I agree that she needs a gastric bypass, since she now has diabetes, high blood pressure that persists even with three medications, back pain, knee arthritis, and high cholesterol.  But her insurance, Medicaid, won't cover the procedure--either that, or it pays so little no surgeons in the area will accept Medicaid patients for gastric bypass surgery.  "But they'll pay for me to have a heart attack, right?"  she asked in frustration.  "Right," I said.
     A young woman believes her partner is cheating on her.  "Did you ask him?" I wanted to know.  She said she did, and he denied it.  She wants to be tested for STD's, anyway.  I wonder if she's the one with another partner, but won't tell me for fear of being judged.  Almost no one ever tells me he or she is the one "cheating"--it's always the partner who's implicated.  If we could all accept that half the world cheats, and that it might even be "normal" to cheat, maybe I'd  get the straight story.  But that would mean overhauling religion, and it doesn't matter, anyway.  I ran assays on her for all seven testable STD's:  HIV, syphilis, chlamydia, gonorrhea, trichomonas, genital herpes, and human papillomavirus.
     Another patient's golf-ball sized abscess, angry and blistering, which we lanced last week, releasing copious amounts of foul, blue-cheese material, is now almost gone.  I gave the her daughter credit, because she has applied hot compresses to the area four times a day.  In three weeks I'll remove the little cyst that got the whole thing started.  Now I see a skin cancer near the abscess, and proceed to biopsy it.  The patient spent thirty years in the blazing sun as a migrant farm worker, and he skin is paying the price.
     Thank goodness for my wonderful staff, because without them I couldn't accomplish a third of what I do in a day.  The phone rings a hundred times a day, and they field the calls, scheduling appointments, copying records, making referrals.  They order supplies, sterilize equipment, set up surgeries, draw blood, do IV's
     Five patients needed physical exams, there were two Pap tests, three had arthritis, one had a fractured vertebra, one had heart failure from cardiomyopathy, and two had sinusitis.  We placed two Holter monitors, scheduled three stress tests, gave well-child immunizations, administered several B-12 shots, dressed a wound, took out stitches, did  ten x-rays and seven ultrasounds, and had telephone conferences with many more.  Dozens of faxes arrived with requests for signatures for home care orders or medication refills.  We made referrals for mammograms and colonoscopies.  I sent one patient to the ophthalmologist.  Last week, when the weather was cold, there were many joint and sciatic injections for arthritis, but none today.  I scheduled a patient for an endometrial biopsy.  When the last person left at 6:30, I had three stacks of charts to finish, and a pile of phone messages to answer.  Forty patients asked for our help, and we gave it.
     The only ICD-9 code I had to look up, because I have so many memorized, was West Nile virus: 066.40--but it's changing to A92.30 next year.
     I won't need it then.

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