I walk into the clinic at 7:45 this morning. The waiting room is full. It is already warm in the room as well. And muggy. I know that within a few hours it will be hot in this room, yet the people will continue waiting until they are seen. I left at 6pm Wednesday night. There were 250 patients registered to be seen. There were 5 of us working all day, with one or two others popping in when they could, to help out. When I left yesterday, I went home, walked down the street to have a beer and dinner, and had to just sit and watch the sunset to let my mind unwind.
But it is a new day, and I'm ready. I've set a goal to be more efficient today. I call the first patient to be seen. Mr. AN.
A man stands up. He looks no different than many in the room. Aged. He looks fifty plus, but looking at his date of birth, I see he is actually 40. We walk to the end of the corridor, and enter my exam room. I glance over his details.
Week # 48 of ARV (anti-retrovirals, aka HIV treatment). Doing well. His viral load was not detected 3 months ago, and his CD4 count is around 300. No other real medical issues that will have to be dealt with. I look over his clinic note from 3 months ago, and he's compliant with meds (as expected given his undetectable viral load, and decent CD4 count). I breathe a mini sigh of relief, first patient of the day will be out of my office in 5 minutes. I go through the standard questions. Have you been hospitalized? Have you been started on TB treatment? Have you missed any of your medicines? No, No, No. Is anything wrong? No. Perfect.
I look at his vital signs. No Problem.
I look at his weight. Problem.
We're using a simple bathroom scale, the kind that you may buy at Target, or any store. It's not all that accurate. But AN's weight is down 5 Kgs since his last visit. About 11 pounds. Where is the problem??
I worry about hyperlactateaemia. A complication of HIV treatment. Asymptomatic elevation of blood lactate levels. The only sign may be weight loss. Possibly some abdominal pain as well. He is feeling fine though. I can only really rule this out by doing a blood lactate level. I tick the box on the lab form.
I worry about TB. He doesn't have a cough, or fever, or night sweats. He had TB in the past, but that was years ago, and he's far out of the risk of IRIS. And he has a decent CD4. He shouldn't have TB. A chest xray would likely be pointless (but I'll get one anyway), and no chance of getting sputum because he isn't coughing.
I worry that maybe he's too embarrassed to admit to having chronic diarrhea. So I reword my questioning, but he's consistent. "Doctor, the caca is fine."
I worry that his liver has taken a hit from the HIV medications. But he tells me he has a good appetite. He's already denied abdominal pain. He hasn't been jaundiced.
I wonder if he has hyperthyroidism. But his heart rate is normal, and no other real stigmata of thyroid disease.
There is a problem. He has lost a significant amount of weight, and I can't forgo finding out why. I'll throw out some target screening labs, in addition to the lactate, I'll check his thyroid, his liver, his blood count as well as his renal function. Maybe he needs an ultrasound of his abdomen too?
We talk about these possibilities. I write up his note, and his lab forms, and his xray form.
"Doctor, I take my pills on an empty stomach."
"Well, that's fine," I say, "but luckily the pills you are taking can be taken on an empty stomach, or with food."
I go back to writing. As I'm writing, he grabs some papers out of his bag, and I recognize the familiar disability grant paperwork. And the light bulb goes off. I've made such a gross assumption, that I'm quite embarrassed
"Is there a reason you take your pills on an empty stomach?"
"Doctor, I'm not working, I don't have food."
Is it possible that the reason he's lost weight is because he doesn't have food. Is the simplest explanation the most likely?
I take the disability paperwork. All of a sudden I have a flashback to the resident clinic back home, and the sinking feeling of getting those fat envelopes in the mailbox when somebody wants disability, when in fact, there is no disability, but rather poverty and poor social circumstances. Today, I filled out 5 disability forms. For 5 people who all are unemployed, some supporting 3 kids, but none of them qualifying for disability. I didn't know what to do in these circumstances, so I filled out the forms, and told the patients that they wouldn't qualify. Perhaps I (grudgingly) filled out the forms to make me feel better, but knowing that they were only going to waste time and effort for these patients, as well as "the system."
After clinic, talked to the clinic attending, Dr K, and asked about what to do in these situations, when somebody wants disability, but won't quality... We talked about the breakdown in "the system" and what to do...
I see AN in 2 weeks.
