"Her main complaint is wrist pain. I know her blood pressure is sky high, but you always say to find out what the patient's agenda is. Her agenda is to stop her wrist from hurting."
That's what my intern told me as we both faced the computer screen. Her blood pressure--sky high, yes--was in bold numbers across the window displaying her medical record. I had worked with this intern for a while now so our discussion of this patient was easy and familiar.
"That is pretty high," I said.
"It is. But she didn't take her medications this morning. Didn't want to have to pee on the MARTA train. I mean urinate."
"She took them in the waiting room. I'll retake the blood pressure in a bit. I think I'm going to add some amlodipine."
I scrolled through the note he'd written and paused on the examination. Dragging the mouse, I highlighted where he'd written "1 to 2+ pitting edema" under the extremity examination. This was my nonverbal reminder of that common side effect seen with drugs in the same class as amlodipine--leg swelling.
"Oh. Yeah. That." My intern looked over at me and nodded.
"How bad is it? The swelling?" I asked.
"Not bad enough to stop us from controlling her blood pressure with amlodipine."
"What about a beta blocker?"
"That's a thought."
"Her wrist hurts pretty bad. That could be raising her pressure. That and the fact that she didn't take her diuretic this morning."
"So, yeah. I did the . . .uhh. . .what is it called? Finkelstein's maneuver? Yeah, it was positive. Big time."
My mind wandered for a bit. I recalled Deanna with her repetitive crochet motions whimpering to me about a tender wrist. Her medicine-nerd sister instructed her over the phone to fold her thumb into her palm and then flex her wrist toward the floor.
Ah hah! A positive Finkelstein's maneuver. Over the phone. Who's better than me?
"My sister once had this from crocheting all the time. Too much repetitive motion, you know?"
"Your sister that you told me about last week that made the scarves?"
We paused for a moment. Not quite long enough to be considered an awkward silence, though. More like a deferential one.
"Oh. And you know what? I diagnosed her with the Finkelstein maneuver by phone."
"Rock and roll."
"Yep." I closed one eye and remembered something. Snapping my finger I added, "You know what? I just thought of something. My brother, Will, had this, too. He's a veterinarian and he sutures a lot." I demonstrated the rhythmic motion of a surgeon's hands. "He was miserable."
"What'd you do?"
"The same thing you should do for this patient. That is, if you're right." I laughed at my own joke. He did, too.
I pointed at him and that was it for my affirmative. "Right wrist?" I asked.
"Nope. Left." He was typing into the computer and trying to get the last of the note in.
"Is she left-hand dominant?"
"Uhhh, hmmm. I don't think so. Well, actually I didn't ask."
I liked his honesty. "Okay. Why'd this happen? What's she do for a living or for a hobby?"
My intern looked back at me and twisted his mouth. "Actually, Dr. M.. . . I don't know that answer."
"Fair. You just want to be sure you aren't mistaking this for DeQuervain's tenosynovitis when it's really something else. My sister had this in her right hand--the one she held the needle in. My brother is a southpaw. We injected his left wrist. Both had a clear mechanism, though."
"I get what you're saying."
"So the question is--what's she been doing with that left hand to get her wrist hurting so bad?"
"I should have asked," he said quietly.
"You will next time," I replied with a big smile.
Because he will.
And so. We went to her room together and he introduced me to her. When he retook that blood pressure, it was a bit lower--at least no longer "sky high"--just like he'd predicted. She endorsed the same story of not wanting to urinate from her water pills while riding public transportation. Then she jumped straight into that wrist.
"Are you left-handed?"
"No'm. I'm a righty."
I nodded. I had her do the Finkelstein's maneuver once more.
"What have you been doing? This is usually something that people get in the hand they write with."
"Pardon?" I wasn't sure I understood.
"I got to lift my mama a lot during the day. To get her cleaned up. To sit her up to eat. And all that."
"My right wrist was hurting me so I ended up doing more with the other hand. I also be doing Mama's laundry. Folding clothes, all that."
That's what I said because this Grady elder was old enough to be the "Mama" she was talking about. Well into her golden years and fully deserving of an ottoman upon which to prop her feet and fuzzy slippers, too. Definitely not any heavy lifting.
"How old is your mama?"
"Wow. That's a blessing."
"Sho is. But Mama a big lady. It ain't easy."
Next we talked about injecting her wrist with steroid which she appreciated. We followed all of the proper steps and together we gave what we hoped would give her relief--a steroid injection. We talked about an additional antihypertensive and the visit was nearly done.
"Who helps you with your mama?" I asked.
"It's just you?"
"Naaaw. I'm one uh'fourteen. But they ain't no count."
"Maybe I can ask our social worker about respite options?" My intern was speaking to me and not the patient. But he was looking for ways to make her life easier.
Respite? I hadn't thought of that.
And as it turns out, it was more that just a good idea. It was a great idea. Our social worker helped our patient by arranging some respite care to assist her. And home health people to help her lift mama. She even arranged some transportation to get her to Grady Hospital so she wouldn't have to take the train.
She left with a big smile on her face. We took her blood pressure one last time and you know what? It was just about back to normal. It really was.
Instead of a blood pressure pill helping, the intern had found something else. Somebody to help her with lifting Mama. And a ride to Grady so she wouldn't have to fret over needing to empty her bladder. That brought her pressure down better than even amlodipine could.
After all that talking and teaching, what she needed was far less technical than I'd thought. For her wrist, for her blood pressure. For it all. She just needed some damn help. More than anything else.