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The Art of Medicine

The least of the concerns

Sweeney, Cameron Young MMS, PA-C

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Journal of the American Academy of Physician Assistants: July 2018 - Volume 31 - Issue 7 - p 58
doi: 10.1097/01.JAA.0000534988.84415.e8
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I expected the last appointment of the day to be a straightforward follow-up. Initially, we met her as the wife who accompanied the patient to his oncology visits. His cancer had been resected and he was on surveillance. When his memory rapidly worsened, the diagnosis was not brain metastasis but dementia. He had to close his medical practice, then battled depression when his identity as a physician was lost. Nevertheless, at our visits he was attentive and engaged.

A few months ago her primary care provider referred her for a benign hematology problem. We followed her on observation, and her laboratory checks were typically uncomplicated. I looked forward to escaping the office early for a change. Her review of systems was negative, and she said she was doing “Great!” We chatted amiably as I periodically refreshed my screen to see if her laboratory results were available. As I clicked through the chart, I commented on her elevated BP. She attributed it to my white coat but I noticed her fingers kneading the hem of her left sleeve.

I let silence linger until her words tumbled forth. “He still drives. At least with OnStar he shouldn't get lost,” she worried. “He doesn't remember to switch off the coffee pot or turn on the burglar alarm. He left the TV remote in the refrigerator. He forgot to close my car door, and the light stayed on until my battery died.” She sighed, “It's not his fault.” She seemed to resent the unrelenting role of caregiver. “I can't leave for more than a short time. When my tennis match went long, he went looking for me, then couldn't remember which house was ours. A neighbor brought him home and called me. It took hours to calm his agitation.” She fretted about the future. “He always handled everything, maintenance, finances. He's the smart one. I'm just a housewife.” She lamented, “I miss talking to him. He's my best friend. I don't have anyone else.” She agonized over all she had lost. “I'm not angry at God, but I lost my faith. What kind of a God allows your only child to die, then takes away your husband's memory? I don't go to church anymore.”

Over the years that I'd been caring for her husband, I never knew that they had lost a child. “So many people came when she passed away. On the 20th anniversary of her passing, we got out all the cards people sent. Everyone said such wonderful things.” Her voice became a whisper, “We sat together and cried.” She dabbed the corner of her eye with the tip of her pinkie. “I don't know why I told you all that.”

I wondered aloud if she had any outlet for her stress. “I walk on the treadmill almost every day.” She was fit and looked younger than her chronological age. I applauded her regular workouts.

I asked if she had the support of friends. “All the women I know talk about grandchildren, but we don't have any. I don't really belong, and I wish we had never moved here.”

I offered a referral to a counselor. “Talking makes it worse. I'm not going to a support group, either, so don't bring it up. I don't want to know what's coming. When it gets too bad, I don't know what I'll do, because I'm not going to change his diapers... I just can't do that.” She concluded lamely, “We have insurance.”

Would she consider an activity like yoga, belly breathing, creating art, or keeping a journal to ease her stress? I suggested drafting a letter to her husband or to the daughter she mourned to express her feelings, even if only on paper, even if the letter would never be sent. She gasped and forcefully shook her head.

I was concerned that her hypertension was inadequately controlled, but she insisted that her BP was “not high, usually just 150 over 80-something.” She preferred alternative therapies and was willing to entertain my suggestion of hibiscus tea that some research indicated could lower BP a few points. I also demonstrated a free app for guided meditations. We finally agreed that she would follow up with her primary care provider if the BP readings were consistently greater than 140/80 mm Hg.

She reminded me of a glass teakettle on the stove with blue gas flames that curled to warm the pot. Her emotions, at first tiny bubbles, barely visible, formed hesitantly along the base, slowly, singly percolating up the sides before they broke free in the riotous explosion of a full, rolling boil that rippled the water's surface.

I had incorrectly assumed that this appointment would require a simple review of laboratory results, and I'd be out the door in no time. As so often happens inside the examination room, the stated problem is sometimes the least of the concerns.

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