Clinic Stories - March 21st

today was a fascinating day in the clinic. we broke alot of social/medical rules but hopefully no true physiological laws in our practice of medicine.

we received a call from a local DOH office with an urgent referral of a hypertensive woman with chest pain, 180/110 blood pressure. she had the pain for over a month but it was getting worse. the woman is undocumented, uninsured and refused to go to the hospital for fear of a crushing bill. we agreed to do an initial assessment of her with our handy EKG and sensitive palpatory skills so they sent her on her way to see us. about 20 minutes later we get a call telling us she doesn't have a car so she's walking over!!!! at this point our awesome receptionist volunteered to go pick her up and transport her the 2 miles to our clinic. when she arrived, she looked sad, tired and was toting two young children. a quick EKG revealed Q-waves in two inferior leads (not reassuring) with no ST changes and a regular rhythm (reassuring). blood pressure of about 160/100 (not reassuring). and on top of it all, she's allergic to aspirin! (not good). what a day. she got metoprolol PO and some clinidine to control her BP, a GI cocktail which actually helped her chest pain alot (reassuring), and a physical exam which revealed reproducible mucsle pain along her sternum (reassuring). at this point we recommended her to the ER but she refused to go so we agreed to draw her blood and send off a STAT Troponin-I while she waited. Once again our receptionist volunteered to take the blood to the lab and amazingly enough, it came back FAST - completely normal value (very reassuring). we are bringing this woman back tomorrow to ensure her blood pressure is controlled and will do strong risk reduction counseling to ensure she minimizes her future potential for more heart attacks. the EKG findings could have been her baseline but i suspect that at some point in the past she lost a bit of heart function. she's had high blood pressure since she was a child.

what are you going to do? what would a court of law say? looking back with hindsight, if she was having an acute MI or if something happens to her tonight, it ain't going to look good for us. but from my perspective, we are honoring her wishes, and doing a good job within her means. it's a risk i'm willing to take.

we also saw a woman with bad cellulitis of her right hand secondary to injecting Crank (speed). she missed her vein and caused a serious bacterial infection to happen. we treated with a shot of ceftriaxone in the butt and a return visit tomorrow but she is right on the edge of needing hospitalization and possible surgery on her hand. she's another one who was mortified by the idea of entering the hospital, but for different reasons - she doesn't want anyone to know she is using drugs or else she'll lose her job.

another gentlman came in, alcoholic but recently quit, with a sebacious cyst right on his adams apple. i had cut it open a few days ago and drained out the cyst but it was in too delicate a place to remove it completely, so he was just back for followup wound care. he is going to have to try to get himself an appointment with a surgeon at the public hospital to have it removed. i'll let y'all know what that journey is like in a few months because that is likely how long it will take him to resolve this fairly simple problem.

andru