Day 1

The patient is a 16 year old girl, complaining of ‘crackling’ in her ear. No fever, no cold symptoms. The diagnosis was an easy one. Cerumen Impaction. Cerumen is ear wax and when it builds up and blocks the ear drum, the sound waves can’t reach the drum and you can’t hear as well. Your own voice might sound muffled, or amplified. The solution: Remove the ear wax by irrigation in the office. This is one of those diagnoses when the patient actually leaves the office feeling better than when they entered. Once the cerumen is out, the patient can hear and EUREKA! They feel so much better.

Day 2

The patient is a 92 year old fairly fit female residing in an assisted living facility. She recently lost her 96 yr old significant other and is depressed. She is not suicidal, but states she ‘has been there before’ so she is grateful things are not as bad as at times in her past. She has other losses as well..hearing loss, visual loss from macular degeneration, and ambulatory difficulties, but she does not yet require a walker. The solution: Increase the patient’s Venlafaxine dose to help with sleep, depression and apetite and consult the psychologist that comes into the facility to talk with the patient.

Day 3

The patient is a 55 year old patient seen at the free clinic which is closing in 2 months. She currently has no insurance and comes in with a blackish lesion on her left nipple for 4 weeks. She has a history of calcifications in her breast tisses. These can frequently be a sign of cancer so often need to be biopsied, or at the least, followed with serial mammograms. She did not have a biopsy in the past because the more suspicious calcifications were in her nipple and the surgeon would have had to remove the nipple to get the biopsy. She was lost to regular follow up and overdue for her mammogram. The lesion was 3mm and bluish-black with a domed top. Most likely a blue domed nevus or mole UNRELATED to her breast calcifications and not a sign of breast cancer. The solution: Reassured patient the spot is most likely benign (but keep an eye on it for change) and PLEASE get your mammogram! Since the clinic is closing in 2 months, she needs to do it soon.

Day 4

Another free clinic patient from Guyana. 60 year old with diabetes, high cholesterol, a significant tremor of hands and head and balding. Blood work from last month shows diabetes decently controlled with HgbA1C (an average of the previous 12 weeks blood sugars) at 7%. The closer to normal (less than 5.7%) the better with this number, and good sugar control is an A1C less than 7%, but given that she just moved to the US and had been out of medicines for awhile, not too shabby. Her tremor was much improved with the addition of a beta blocker blood pressure pill to her regimen last visit. (atenolol). She, of course, is most concerned with her hair loss. Her blood work ruled out more common causes of hair loss such as thyroid disease. Her best bet at this time would probably be OTC womens rogaine, but she cannot afford it, so she will keep pulling her long black hair from the front to the back and keep it in a pony tail that covers the spot. She is beautiful!

Day 5

The patient is a 76 year old morbidly obese female with multiple medical problems. She is on Coumadin, a blood thinner, for an irregular heart beat called atrial fibrillation. She lives alone, is on continuous oxygen for emphysema, and uses a walker to get around. She is estranged from several of her family members one of whom is 2 doors down from her in the office RIGHT NOW for follow up on his attention deficit disorder. He is her grandson. The patient is here for packing to be removed after a nosebleed (epistaxis) that landed her in the emergency room (ER) 3 days ago. She also has a wound in her abdominal fold crease that is bleeding. After removing the packing, the right nostril showed rebleeding. The wound was ugly looking, but not infected. It will be difficult to heal because of its location with constant ‘skin on skin’ moisture. The 23 yr old grandson does NOT want to accidentally run into his grandmother in the hallway or at check out. He is doing well on his vyvanse for ADHD, and his only sequela  from a concussion 4 weeks ago is a headache when he sneezes. The solutions: Grandma had to sit for 15 minutes with pressure on her right nostril until the bleeding was stopped, and she was told to hold her Coumadin dose that night. For the wound, a visiting nurse was going to go out to her home and apply a special dressing. (Another cure would be weight loss of 200#s—but this would take too long). As for the grandson, I renewed his prescription and delayed his check out by taking the time to pull his paper chart (we are electronic x 4 years) and find out when his last tetanus booster was. Indeed, to my surprise, he was due for a Tdap (this is the tetanus booster recommended for all adults that has pertussis, or whooping cough, in it). By the time he received his shot, Grandma was long gone. WHEW!D