In fact the morning was weird,
With the patients who laughed and then teared,
With an upcoming divorce
An ambivalent course,
Afternoon? Not as bad as I feared.
I walked down the hill to the Care Initiatives Hospice meeting this morning and enjoyed the misting rain. I had forgotten the weekly face time was cancelled in favor of the ribbon cutting and open house in the evening.
The day got weird before noon. A youngish patient, taking many positive life styles steps away from self-destructive behaviors, had been awakened from a sound sleep at one Easter morning by severe abdominal pain. The situation became intolerable in a matter of hours, warranting a trip to the ER. The CT scan of the abdomen normal, morphine was administered (if you ask me, a bad choice in this patient) which helped for an hour, and the patient was sent home.
Having vomited everything for the last three days, with continuing pain, my first concern was fluid status. The tongue was dry, but the skin at the back of the hand didn’t tent up when pinched, and I estimated more than 5% and less than 10% dehydration. I found tenderness in the epigastrium, that part of the abdomen at the midline in the inverted V at the base of the breastbone, and no bowel sounds.
If I were still doing hospital work it would have been a slam-dunk admission. I could have sent the patient over to Saint Luke’s for lab and x-ray and ultrasound, and had the fluids poured into his veins while the results trickled in. When the diagnosis became apparent I could have called in the proper specialist if needed.
Things are the way they are. I called the hospitalist, gave the background, and sent the patient over. I’ll have to wait for a couple of days to have the mystery revealed.
Most of today’s patients quizzed me about my career plans. We went through a lot of Kleenex. One told me I couldn’t leave till after she died. Several said that they could wait for a year till I came back. Many asked for, and received, hugs.
Two patients came in for anxiety stemming from the John Morell plant closing.
Another came in bouncing and happy, with a main complaint of anxiety, because of an upcoming divorce from an abusive spouse. I prescribed buspirone, the mildest anti-anxiety agent we have, and noted that irony of hope and fear coming hand-in-hand in the face of a major change.
One, who weighs more than any two of our doctors, arrived with urinary frequency, sweating and cough productive of bloody sputum. The chest radiograph taxed the x-ray tube output and didn’t reveal much, and the urine showed no sign of infection. But there was a great deal of protein in the urine. I explained to the patient that I had never seen a case of pneumonia without proteinuria (a datum I don’t believe will be found in many textbooks). Then the patient revealed a series of infections over the last several months. So I asked about stress, of which there turned out to be a great deal.
But I sent that patient to the lung specialist, mostly out of fear. I had a bad experience with a lawsuit almost ten years ago and I have been irrationally conscientious about investigating bloody sputum ever since.
By comparison the afternoon was mostly tame, even reasonably paced.
At five I walked back down the hill to Care Initiatives Hospice, and ran into a lot of people I know. Some patients, relatives of patients, social friends, and people I’ve worked with.
No matter where I transition to in Sioux City, I’ll know plenty of people.