A 55-yr-old woman tells me she was sitting in church on Sunday when she suddenly felt pain and "chills in my vagina". I'm not sure what she means, and she doesn't know either. All she knows is that her "pee smells bad". Ironically, she is wearing a gallon of cologne and the fumes are making me woozy. I quickly perform a pelvic exam before her cologne knocks me out completely, and there is nothing out of the ordinary. Her wet mount, KOH prep, urinalysis, and cervical swab for chlamydia & gonorrhea are all stone cold normal. Maybe having chills in your vagina is not such a terrible thing after all.
A waif-ish 32-yr-old woman comes in and spends 20 minutes complaining about frequent headaches that don't respond to ibuprofen. She is vague about her symptoms, and all the medications I mention (triptans, beta-blockers, neuroleptics) she thinks she's already tried without relief. She doesn't have medical records from her former neurologist. "I had percocet once," she says coyly, "and it was too strong." She asks for tylenol #3 (with codeine), "just until my medical records arrive." Against my better judgment, I give her a limited prescription for 10 tablets with no refills. Two hours later, she returns to clinic pouting, led by her grim-faced husband who is dressed in army fatigues and combat boots. Turns out she's been in & out of treatment for an addiction to prescription narcotics & benzos for the past 4 years, but none of this is in her medical chart. Needless to say, she'll be returning to treatment as soon as possible.
Sometimes I get a more satisfying case that makes up for the crazies, like the 10-yr-old girl with recurring muscle spasms in her left trapezius. She had been seen in February and given a trigger point injection which provided good relief for several months. She had full range of motion and normal strength in her shoulders & arms, but I was disturbed by a subtle asymmetry: her left shoulder was slightly higher than her right; and her left scapula was just a hair more prominent than the right. She had been told that this was due to "stress". I ordered a series of plain films which revealed mild scoliosis manifested by a teeny 11.9 degree levocurvature of her thoracic spine.
I wonder if I'll ever get used to having 20-minute appointment slots. It rarely ever seems like adequate time to spend with each patient, especially when it also encompasses the time it takes for the medical assistant to call the patient from the waiting room, take vital signs, and review allergies and medications. By the time the patient is ready to be seen, I'm lucky if there are 7 minutes left in the appointment slot. It only works if it's a relatively straightforward medical problem, or if the patient can give an awesomely concise synopsis: "I'm a 19-yr-old G0P0 with a history of chlamydia, continuing to have unprotected sex, here for evaluation of crampy low abdominal pain with unusual vaginal discharge, s/p an exploratory laparotomy for what turned out to be severe pelvic inflammatory disease with Fitz-Hugh-Curtis syndrome 3 months ago"...[I really did see that patient! But without the neat synopsis]
No comments:
Post a Comment