It was at the end of the day. Encounters like this one always happen at the end of the day. You’re tired, your staff is tired, and you’re behind schedule. Welcome to any day of the week at 4pm at a community health center.
I had scanned my schedule as I finished my note on the last patient. A new patient visit popped up. A women age 43 with an unfamiliar (for this particular clinic), Nordic-sounding name. Okay, I thought, maybe someone visiting here and not wanting to go to the emergency room. This was before there was an Urgent Care Center on almost every block. And it was always very difficult to get into a private practice for what is likely to be a one-time visit. The complaint written on the schedule was “teeth falling out.”
Oh. Or uh-oh. Or at least, hmmmmm. When I think of missing dentition in a relatively young person, I think homelessness/mental illness. Or meth. I dutifully checked Uptodate (www.uptodate.com) to see if I was missing something, like some rare auto-immune disorder. I wasn’t.
Sooo. I walked into the exam room ready for anything. I encountered a tall, blond women, gowned and sitting on the exam table, shuffling a lot of papers. Never a good sign. The part about the papers, I mean. I smiled and introduced myself and I asked why she was there. Sometimes, with our bilingual front desk staff, things can get lost in translation. For many of the staff, English is their second language and certain physical complaints can be hard to translate. It was a hopeful thought and I decided to stick with it until I heard otherwise.
“I was at the emergency room all night,” she said, as she thrust the papers towards me. She had a faint, Germanic-sounding accent. In fact, she slightly resembled the model Heidi Klum. “They said I had vasculitis.” She moved the hem of her exam robe to expose a reddish rash going down her thigh.
“Well, what did they give you?” I asked.
“It’s all there,” she responded with a touch of impatience. She tossed her blond hair, a habit from youth, I guessed, but her hair was straggly and dull, rendering the movement ineffective.
I explained that these reports often fail to contain the information that will be most helpful to me: a diagnosis, test results and medication prescribed. Often it is page after page of instructions and disclaimers with the important stuff hopelessly buried within, if present at all.
“They gave me this,” she said as she handed me a prescription bottle from her purse. “But I know it’s a steroid and I don’t want to take it.”
“Okay,” I said. “Have you had a bad reaction to steroids before?” It was relatively common to get palpitations, anxiety or insomnia while taking this kind of medication.
“No, it’s not that. I just prefer to do things naturally. I don’t like medication. And besides, the people at the ER didn’t help me with my main problem.”
“Which is?”
“My teeth are starting to fall out.”
Here we go, I thought. “Let’s start at the beginning, is that alright? I just want get your basic medical history. I positioned the computer so I could enter the information while we still talked face-to-face.
The history she gave me was totally unremarkable. According to her she was the picture of perfect health. She took no medication. Her teeth just started to become loose about 4 weeks ago. She made it a point to tell me she lived, not in the town the clinic was in, but one town over – a very upscale suburb. She also mentioned her two children who were excelling at the high school. One had just gotten into an Ivy League college, in fact.
She dug in her purse and I thought it was for her phone to show me a photo but she took out a laminated newspaper clipping with well-worm edges. “That’s me,” she said proudly. “I was a model in my country. “
“Very nice,” I murmured. It was indeed her, about 20 years ago, and she’d been beautiful. She was handsome, as they say, even now. “Let’s get started on the exam.” I suggested.
I couldn’t really tell what the rash was, but vasculitis seemed a long shot. I thought it was a simple, uninfected contact dermatitis, which could be treated with an OTC steroid cream. But now I went on to the part I was dreading, the oral exam. She complained of no pain when I palpated her jaw and cheekbones. She had no swelling or bruising. I did notice her complexion was a little rough and there was one unusual scab right in front of her ear. When she opened her mouth, it was clear she was missing a few of her back bottom molars, and when I shined a light inside, the top ones too. She wiggled a canine tooth for me like an excited kindergartener. The disconcerting sight gave me goosebumps.
“See, nurse, this is what I’m talking about.” I nodded and completed the rest of the exam. Other than her skin and teeth, nothing seemed amiss.
I excused myself and conferred with a colleague, who agreed that I had to do a tox screen.
“What’s weird is that she’s not asking for anything, no requests for opioids.” I mused.
When I went back in the exam room, I told her I was stumped. I recommended we start with some basic blood work. I told her we needed to do a urine test as well, to test for drugs.
“But I told you, I don’t even like medication. I certainly don’t take drugs.” She made a point of holding my gaze directly, her clear blue eyes telegraphing her sincerity.
“I understand,” I responded, “But please humor me. Use of methamphetamine is a major cause of teeth falling out. I would not be doing my job if we didn’t rule that out first “ I also wondered if they had done that at the ER. If so, I was sure that particular tidbit would not be included in the papers she handed me.
“I will call you with the results,” I told her.
“Don’t I need a follow-up appointment?” she asked, which kind of surprised me.
“Well, you can certainly make one if you wish, but until we get the results, I’m not sure how productive it will be. We may need to refer you to a specialist.”
I went on to the next patient and my medical assistant went in to draw blood and hand her a urine specimen cup.
My last patient was an 8 year old with strep throat. Easy peasy and she was a sweetheart to boot. I was about to sit down at my desk to finish charting when my medical assistant informed me my prior patient was still here because she couldn’t pee. She was drinking water when I entered the room. My patience was wearing a little thin. “Look,” I said, “We really need to do this test. We can’t continue to take care of you and get to the bottom of this if we don’t.” She regarded me coldly as she took the last swig from the bottle.
“Very well,” she retorted.
By the time I left that day, I had no idea if she submitted the specimen, but it turned out she had. The next morning the urine test was back. Positive for methamphetamines. I called several times, leaving discreet messages asking her to call me but she didn’t.
They informed me at the front desk that she had indeed made another appointment. She told them this time she wanted to see a doctor, “not a nurse!”, and she wanted a male doctor. I doubted that she’d show.
I was wrong. I guess her charms were lost on me. Because the doctor, even though I had told him about the tox screen, was driven to find out what was wrong with “this poor women”. He said she told him that she was taking her child’s Ritalin to concentrate and that’s why her tox screen was positive.
“But I asked her about medication. She denied taking any.”
“Well, I guess she didn’t feel comfortable with you,” my colleague suggested. And I guessed that old modeling photo still had a certain juju.
“And she hasn’t requested any opioids?” I could not help asking.
“Oh, no,” he responded. “She’s very anti-drug.”
It made me wonder why she came to the clinic in the first place. Was it for the attention? Was she mentally ill? A borderline personality disorder, maybe? But it wasn’t my problem anymore, and there were always more patients to see.
I did ask my colleague a few months later what progress he had made in her case.
“Oh, she just stopped coming.” He admitted sheepishly, and a little regretfully.
“And her teeth?”
“Kept falling out. I referred her to a dentist but not sure if she went. She was going through a divorce and there were insurance problems and money was tight.”
I began to question myself. Maybe I was getting too hard. Could it have been really advanced periodontal disease? Was it all from stress? But how and why did she know the exact thing to say that would explain away her positive urine screen?
About six months later, another colleague drew my attention to an article in the local paper. “Isn’t this that women with the teeth?” It was. Her bone structure prevailed even in the mug shot. Heidi Klum on a very bad day. She was found sleeping in her car in that exclusive suburb. Also found was her stash of methamphetamine. It was sad. I wondered if the children she told me about were real, and how they were faring in the midst of all this. I asked one of our social workers to look into it.
It continued to be a mystery to me. Was that first visit a cry for help? Or did she think stopping her teeth from falling out would prevent her life from falling apart?
©2017 by Eileen Healy Carlsen. All rights reserved.
