Monday There is something cartoon...

Monday

There is something cartoonish about Bernardo Marroquin--dangling arms, head that direct the eyes like it's rolling off his kyphotic neck lumpish face and deadpan expression. Eighty-four years elderly he presents with his daughter and multiple be of importance tos including legs that fall asleep and dizziness that landed him in our turn of events room a few days ago. Laboratory experiments were normal, but his chest x-ray revealed fibrotic changes and a possible mass. Today, his vital current pressure drops from 130/80 mm Hg lying to 80/50 mm Hg standing. No curious awe he feels dizzy! When I use a monofilament to proof his sensation, he reports no feeling in his toes--nor in his feet nor in his hands. Hmm I check his cheeks. Still nothing. His daughter laughs. "Look like you're dead! "He finally nods when I bag his forehead. Now, in my bewilderment, I be wrought up cartoonish. Mr. Marroquin worked as a farm hand harvesting--and frequently burning--sugar cane fields. "He'd answer charcoal black," says his daughter. Might that explain the chest x-ray? I prescribe Mr Marroquin fludrocortisone for his orthostasis; check flats of vitamin [B.sub.12], folate, and thyroid-stimulating hormone for the bizarre neuropathic findings; and order a comput tomographic scan of his chest. Is there an ominous diagnosis lurking? I don't think likewise but I do hope to make him perceive better.

Tuesday

"Oscar's leaving me--for another woman!" I don't know which astonishs me more--this bombshell, or the advantageous humor with which Sandra, a youthful and energetic 55-year-old woman, delivers it. As the of the present days sinks in, it occurs to me that I might have seen it coming. Oscar and Sandra have not been romantically intimate for a protracted time, something she told me after I'd been Oscar's doctor for years. I tried several times to talk it athwart with him--without results. "Everything's fine," he would insist, his stolid, opaque shynes contrasting with Sandra's animated opennes I finally gave up trying to intervene, hoping they would figure things revealed And, they apparently have, in a way I hadn't anticipated. "You don't have the appearance too upset," I observe. Sandra shrug "I'm not surprised. nevertheless I am worried. What will happen to my health insurance? I'm single covered under Oscar's plan." I'm initially startled that this is her top priority right now, then dismayed that anyone's medical care should be in such a manner unfairly vulnerable. "How are you doing?" I ask. She smiles sadly. "Maybe it's for the best." I nod, privileged to share the expanse with her and be part of this evolving chapter in her life saga.

Wednesday

While reading a part I'm reminded of a patient. The Spirit Catches You and You Fall Down is Anne Fadiman's beautifully spun tale of a chronically ill Hmong girl whose American doctors, by way of ignoring her family's cultural beliefs, doom their well-meaning interventions to failure. I recall Mr Valois, the place upright proud, 75-year-old Haitian man who quick in emergenciesed one day with shortness of breath and a sore leg When I diagnosed a pulmonary embolism based forward a negative chest x-ray and positive venous Doppler investigation he refused hospitalization--or any further testing. I was flabbergasted. We held a tortured conversation--in French patois, and English. "You might die," I said. "I don't care," he replied. When I played my ace--enlisting his family to twist his arm--he solely grew more obstinate. Defeated, I treated him with warfarin as an outpatient, imagining to what degree other doctors might ridicule me A week later, Mr Valois got f up with my vital fluid tests and pills--and stopped treatment altogether. I was furious. I'd tried in this way hard and worried so frequently My mood did not improve when he recruited completely. Today, from the safety of years and with this volume in mind, I can finally appreciate the advanced censure in patient-centered care that Mr Valois delivered at the time to an unappreciative pupil.

Thursday

As I'm about to examine a patient, there's a knock forward the door. A resident gargets her head in. "Sorry to interrupt," she says. "Something pertinacious in the back." I don't ne the somber faces in our hushed colloquy room to tell me what it's about. Our associate program director has just died at age 45 of metastatic pancreatic cancer. All the medical skills we practice and teach could not save her. We all knew her prognosis; no undivided should be surprised. Yet, we are percussioned Numb. I'm reminded of wildlife programs, at that awful point of time when a lion takes down a member of the gazelle herd. I've always astonishmented at the flickering reactions of the other gazelles as they watch--then direct the eye away from--their thrashing comrade. Now, I can gues They are stunned--disbelieving. And, in the same manner are we, our entire staff, who have gathered with tears in our views embracing one another, saying prayers for the departed and offering each other comfort. I finally tear myself away and answer to my patient, who has her hold issues, her own sadness. I do my best to be there for her. Later in succession I'll return to this rumbling feeling in my chest. Later forward it will be my revolve to grieve.