Norris Family News

Evolution of a Diagnosis

Recently I saw a 39 year old man as my last patient of the day. It had been a busy morning and my thoughts were drifting toward wrapping up. His complaint was swollen ankles. In the back of my head a bell was ringing very quietly....swollen ankles is not a complaint of relatively young men. But, I was ready to go home, so I ignored the bell for the moment.

He was a good looking guy, neatly dressed and groomed with a decorative big belt buckle and some discreet gold jewelry. He wore no expression in particular. He was very muscular with bulging veins showing over his tidy collar. He wedged off his pointed boots (alligator skin? I see them often) and showed me swollen ankles...the real thing. They had been that way several weeks. He thought in his manual labor he had been working in a field and maybe a spider bit him. This didn’t fit with what I was seeing, so I was curious to consider other possibilities. His head and neck exam were unremarkable; normal thyroid, lots of lean muscle, those bulging veins, remarkable dark skin and even darker lips. His heart exam was very remarkable with a fairly loud murmur. I have seen this fairly often also, in healthy active people without complaints, probably the remains of an untreated strep throat in childhood....rheumatic heart disease. That is a non-urgent finding that needs to be studied eventually, but a young man with his complaints (oh, yes, now he was mentioning some shortness of breath if he worked hard...) and a murmur raises red flags.

Since he now had an abnormal heart exam, I did an EKG for further clues as to what was going on with his heart. If he had a problem since childhood I would expect a reasonably normal EKG maybe with part of the heart enlarged from pumping with an abnormal valve for years. However, it was really worrisome, with signs that his heart may have had damage as from a heart attack, possibly still going on. Suddenly those bulging veins and dark lips didn’t seem so handsome and healthy anymore. This man was in trouble.

I suspect he knew something serious was going on. When I returned to the room to begin to negotiate the bad news and what needs to be done about it (with no insurance and no money), he eyed me gravely. I broached the subject as I usually do with sensitive topics..."I need to ask you some personal questions to help me understand what is going on with your body, and I need you to tell me everything. Have you used cocaine?" Yes, he had a history of cocaine and relapsed into it a few weeks ago. He even had some chest pain three weeks ago but he had a "cold" at the same time, and the pain went away with the cold. Still the same flat expression and cool reaction.

He probably had a heart attack 3 weeks ago when he returned to his cocaine habit, and has been experiencing right sided heart failure over these weeks, where the part of the heart that pushes blood forward into the lungs for more oxygen can’t keep up with its job. Blood backs up into the legs more than anywhere because of gravity, and the jugular veins because they are easy to fill up, low resistance. The murmur is probably because heart muscle attached to a valve is dead and so the valve is ineffective and leaking. The EKG shows that a lot of muscle is injured, dead or dying.

We sent him to the emergency room to start down a long road of getting his heart studied and his situation under control as best as possible. With no insurance and no money, this is doubly unpleasant, altho’ because in this country we have support and solutions for his situation I suspect he’ll get what he needs urgently. However, long term follow-up and medical care might be tricky, especially if he isn’t here legally. I’m sure the pressures of poverty and the unpleasant idea that he has already ruined his body and shortened his life will make drugs tempting in the future. Of course, he didn’t come to his follow-up appointment, but we hope to track him down and make sure he is OK. They don’t answer the phone.

People abuse cocaine and other drugs in high- as well as low-income situations. This is not a judgmental look at how hardened young men on the border deal with their poverty. All kinds of people do all kinds of crazy damaging things to their bodies, families, and marriages trying to make themselves feel better, with no regard for others and for what is right. There is a body of literature written by those who knew the Lord personally which tells us how to resist these awful temptations and cruel solutions, and how to live the way we were intended. Our family is praying this man can know what his Creator wants for him, and you can too.

--Erika