5 Dec 2012
On a day when the Pop Wuj mobile clinic was in a Mam-speaking community, Mateo was my last patient. I opened the door and called his name.
Mateo’s father Fidel walked up first. He looked to be in his later 40s, stood a little taller than me, with glasses and a friendly smile.
As Fidel moved to the side I saw Mateo walking up behind him. I knew from his chart that he was 16 so I was surprised to see that the top of his head barely reached my chest. He walked with a slight limp and one shoulder sat higher than the other. I motioned for him to come in. He passed me as he entered the room. Seeing him from behind revealed a large protuberance on the right side of his back.
We all sat down. I asked Mateo why he had come. He had a long list of complaints.
“No tengo ganas de comer.” I don’t feel like eating.
“I’m weary. Caminar me cuesta. Me cansa.” Walking costs me. Walking tires me.
“Sometimes I find it hard to breathe.”
“I have back pain.”
“I have stomach pain.”
Overwhelmed, I employed a technique you learn in med student 101. “What bothers you the most, Mateo?”
“Tengo una deformidad en mi espalda.” I have a deformity in my back. “And one leg is shorter than the other. When I walk I have a hard time. I feel tired all the time.”
His father jumped in in and told me that Mateo was born with a bone deformity, a horrible hunchback. A few years ago the family went to doctors in Guatemala City. “They did studies, took a lot of pictures. At the end they told us there was a surgery that could be done, in the US not here. But they said it could have left him an invalid. His mother and I decided against it. At least now he can walk.”
After a pause Fidel continued. “But now for the past few months he hasn’t been eating well. He’s also talked of pain in his chest and trouble breathing. We’re hoping there is something you can do.”
I suspected that Mateo, in the middle of his teenage years where looks are everything, was depressed and not eating. It was also clear that his deformity was exhausting him, his awkward bone structure tiring him while walking. And at 16 perhaps his bones were growing in such a way that impinged on his lungs.
When examining Mateo I first wanted to see how he walked. He stood up and took several steps around the room. His walk was actually quite functional despite the limp.
Next I had him sit back down and take off his shirt. I felt my breath still when I saw the skin tented over his distorted bones. Mateo’s spine was twisted in an exaggerated S-shape. It looked like his right scapula was overgrown, a pyramid that came to a point just to the right of his spine in his mid-thorax. A smaller prominence of bone was visible above his right abdomen as well.
When I asked Mateo to indicate where his back and stomach pain were, he pointed to where deformity met normal in both areas.
I listened to his lungs. They sounded normal. And they were surprisingly hearable, except directly beneath the top of the hunch.
Pushing down on various areas, I examined his stomach. The pushing did not bring on additional pain.
Asking Mateo and Fidel to wait, I excused myself to find a doctor. When I saw Aleema in the hallway I said, “I need a consult.” In other words, I don’t know what to do – please help me.
Since the family did not want surgery, the other option was to control his pain. Aleema advised me to prescribe a strong pain killer. She also told me to screen for depression. “If he screens positive, give the one thing that we have.”
Fluoxetine. Also known as Prozac. The only option in our pharmacy.
There are 9 possible symptoms of a major depressive episode. If you have 5/9 for two weeks you are having an episode and thus have major depressive disorder. If you have 3/9 for two years you have dysthymic disorder, a sort of mild depression that lasts all the time.
Mateo answered yes to 4/9: feeling depressed, want of energy, changes in appetite, and sleep disturbances. Given his overall situation, I prescribed the Prozac. And the strongest painkiller we had. “I would also like you to follow up with every mobile clinic.”
I went to help in the pharmacy and ended up filling medications for Mateo’s mother and vitamins for his little sister. The whole family had come to clinic that day.
All four walked up to the pharmacy door when I called. Mateo took the prescriptions for his family and put them in his bag. They walked away together, Fidel keeping slightly behind as if watching over everyone. And Mateo with one arm around his sister’s shoulders, the other holding his mother’s hand.