Had a patient today who is an ex-con who just got out of prison a few months ago. Was a poly-substance abuser. Saw an order for a PPD. Doctor's note stated patient had chronic back pain, ordered Flexeril tid, Tylenol PRN (nothing else). Titers for Hep B and C are positive, but he is new to us, so, new bloods were ordered. Will be revisiting the clinic on one month after an abdominal sonogram (due to the Hep B and C) and CXR. Oh, and the provider is a resident, and all resident cases are reviewed by an attending in our clinic.
The patient refused the PPD, stating that he is no longer in jail living in closed quarters, and does not feel the need to have one. Spoke to him of the importance of why. Still refused. While asking the screening questions, patient stated he was diagnosed with Diabetes while in jail. Said he never took medications for it while incarcerated and he also said that he experienced hypoglycemia at least three times while in prison and described symptoms that sounded alot like peripheral neuropathy to me. He said he also has documents at home from prison that he can bring in to 'prove' his diagnosis. The resident is gone for the day, but I went to the attending that signed off and presented the information given to me by the patient and told her that I didn't see a note from the doctor stating that he was aware of this information.
The attending tells me that she doesn't believe that this patient has diabetes, because he would not have ever experienced hypoglycemia if he was not treated with any antidiabetic medications. I repeated what the patient shared with me and said that in spite of that, I think that he still needed to be evaluated for the possibility, especially if he is reporting that he is experiencing tingling and numbness of his extremities and the fact that he is claiming to have documented proof of his diagnosis. She started saying again how this can be something else, such as a tumor "or something". She checks the resident's note, sees that there was nothing documented (which it means to me that the man didn't ask his patient any questions, and also, that she, as the attending that signed off on the chart did not make sure that this student did actually assess properly). I said to her "Bottom line, what are we doing for this patient?" She does order a 2 hour post prandial glucose and A1c, but when I asked her if she would like to speak to the patient, she said "No, I am about to go home". I drew the A1c myself and instructed the patient on the importance of obtaining the other labs, abdominal sonogram and CXR. The patient still refused the PPD, but said to me "You were the only person who asked all of these questions and followed up. That man didn't ask me a thing...he just checked labs, made orders and that is all. At least someone cared." And, I rescheduled him for 3 weeks rather than a month so that he can be treated, if necessary, based on the labs and results of everything else.
My goodness, what are these medical students being taught?? The man was certainly open enough to share, and if I can come across this information with the screening that the nurse does, how is it that all of this information was missed??
Also, this may be a dumb question, but am I correct in thinking that just because this man was not treated for diabetes, even with oral medications, that he may still experience symptoms of hypoglycemia?
I know I tend to have a high index of suspicion, but this patient should also be offered AN HIV TEST!!!
Incarceration, hx of Hep B and C (maybe some IV drug abuse?), substance abuse with at least ETOH, who knows what his sexual hx has been like.
Got some risk factors goin' on.
Just thought I'd throw it out there...
Way to go for getting the hx, pagandeva. Funny what people tell you when they sense that you care about them... which this gentleman obviously felt you did.
Specializes in Community Health, Med-Surg, Home Health.
I know I tend to have a high index of suspicion, but this patient should also be offered AN HIV TEST!!!
Incarceration, hx of Hep B and C (maybe some IV drug abuse?), substance abuse with at least ETOH, who knows what his sexual hx has been like.
Got some risk factors goin' on.
Just thought I'd throw it out there...
Way to go for getting the hx, pagandeva. Funny what people tell you when they sense that you care about them... which this gentleman obviously felt you did.
I forgot to mention that...he did have an HIV test done-we have a test that tells the status in 20 minutes, and it was negative. If they take the swab test and it is positive, then, a blood draw is sent for the Western Blot. Thanks!
VivaRN
520 Posts
I know I tend to have a high index of suspicion, but this patient should also be offered AN HIV TEST!!!
Incarceration, hx of Hep B and C (maybe some IV drug abuse?), substance abuse with at least ETOH, who knows what his sexual hx has been like.
Got some risk factors goin' on.
Just thought I'd throw it out there...
Way to go for getting the hx, pagandeva. Funny what people tell you when they sense that you care about them... which this gentleman obviously felt you did.