Two Mondays ago a patient came into the clinic with complaints of upper right abdominal pain that hurt most when he would take a deep breath in. He had this pain a week ago and it resolved with ibuprofen. Sunday night he became uncomfortable with feeling feverish and nauseous. Monday the pain itself returned and was unrelieved by ibuprofen. The pain radiates to his mid-back and up to his neck. He thought it might be worse with eating, but couldn't affirm it definitively. He is a non-smoker, non-drinker, full-time worker, morbidly obese uncontrolled diabetic on metformin and on blood pressure medications. He cannot afford health insurance and so wanted to keep costs as low as possible. Exam showed tenderness to touch mid-upper abdomen, the rest of the exam was unremarkable but it was difficult to assess some things due to size. My differential diagnosis list included gall stones, hepatitis or pancreatitis. My money was on gallstones and I strutted around telling everyone else it was so. I had labs ordered and sent him for an abdominal ultrasound. (I was so proud of my diagnosis!)
Well, the labs showed elevated liver enzymes, inflammatory markers, and elevated pancreatic enzymes. His ultrasound came back negative for gallstones. It put us back to the beginning with no diagnosis. The other providers at the clinic did not know what was wrong either. We decided to take the watchful waiting approach to see if this would resolve on its own as the patient could not afford even what we had already done.
The next day the patient called after spiking a 102* fever. He was sent to the emergency room. My preceptor kept in close communication with him. She text me last Wednesday to tell me "He has gallstones after all." He was admitted to the hospital due to its severity and the impact it was having on the pancreas and liver. (Admittedly, I was proud my original diagnosis was correct.)
I touched based with my preceptor today to find out how he was doing. He had to have his gallbladder removed. He continues to run fevers so they are concerned that he has pericarditis (inflammation of the heart, probably infectious causes). He is now under the care of a specialist and may need hospitalization.
It makes me sad that he ended up having this experience. The cost of labs, ultrasound, the office visit, the emergency room visit, the hospital stay, surgery, specialists=$$$. He didn't have insurance previously because he couldn't afford it. His job didn't provide it. Because he has a pre-existing condition his premiums would have been unreasonable. Guess what he really can't afford now?
And how many people are like him, walking around not taking appropriate care of their health because of cost? We all will lose to patients in this similar situation. He simply will not be able to pay his medical bills. He will probably make monthly payments of $50 until the hospital writes off the debt. Or he will need to file bankruptcy. Ultimately, it’s the whole population that will shoulder this debt. Had he had affordable insurance and was able to take care of his health under the supervision of a capable provider, maybe none of this would have happened to begin with.
With that, I encourage everyone without insurance to visit their state’s health care exchanges. Find out about the various plans, see if you qualify for subsidies. ENROLL and begin the process of taking care of your health.
