Do you ever have one of those days, when it seems like every patient is coming in for the same thing?  And that you’ll never remember the differences, when it comes to doing your dictations at the end of the day?

A few weeks ago, six of my appointments had as their chief concern “ear pain.”  But of course, in the end, no two ears were at all alike.  I love that, about being a primary care physician.

1. The night guard twins. C.R. is a 56-year-old second-grade teacher who is an avid runner, and spends every summer on missions with her church, to needy areas.  She is one-eighth Cherokee, with a whopping family history of diabetes.  Her right ear pain has been going on since her night guard broke, and her right TMJ joint is tender on exam.

L.D. is a 56-year-old human resources manager for a high-tech company.  She is originally from the Philippines.   She has a grown son she worries about a lot, ever since his father (her first husband) died of a drug overdose (which she told him was a stroke).  She has been happily partnered to a musician for many years, who plays with David Beck. She has just started using Invisalign to straighten her teeth and, therefore, has not been wearing her usual night guard.

2. The disbeliever. G.B. will be 95 at her next birthday.  She is only recently my patient, having moved here from Santa Cruz after her husband died.  Her health has declined a lot since his death, and she is now confined to a wheelchair due to a stroke and end-stage knee arthritis.  She also went suddenly deaf a few months ago, which has further isolated her.  But she remains cheerful and aware.  Her greatest distress right now is that a grandchild is getting married and the family has not invited her to the wedding (which will be in the wine country somewhere), probably because taking care of her there would be difficult.

As it happens, I take care of several members of her family, and the day she was upset at learning she wouldn’t be going to the wedding I was, by coincidence, seeing her daughter-in-law immediately after her.  Neither of them knew, of course, that the other was there.  It was probably ridiculous, but I felt compelled to orchestrate things elegantly — like in a comic English play — so they wouldn’t have to run into each other.

Today she has a superficial burning ear pain that extends up to her forehead and down to the jaw; a classic recurrence of the trigeminal neuralgia that plagued her years ago, but she doesn’t believe me, and thinks I’m missing an infection.  She takes my hands and puts them on her cheeks, which are as soft as velvet (and not at all abnormal, that I can see).  “See?” she asks, “isn’t that side of my face all swollen?”

3. Mental neuropathy. C.O. is an employee of my clinic: a long-time department manager  She has a hectic life working for us, and taking care of her unemployed husband, two grown children (both still at home) and her elderly disabled mother (who moved in with them a year ago).  She comes in with numbness more than pain (but it still ended up as a recorded chief concern of “ear pain”), running all along one jawline.  I vaguely remember this can be something awful, so I go look it up while she is getting undressed.  This is what I find on Medline:

Mental nerve neuropathy, also referred to as numb chin syndrome, is a rare, seemingly harmless symptom. It is more often associated with cancer, either as first symptom or during the outcome, than with benign diseases. In this review, we will focus on the numb chin syndrome presenting as an isolated neurological symptom. We report five patients with mental nerve neuropathy associated with metastatic disease (small cell lung cancer, prostatic cancer and breast cancer). In one patient, numb chin syndrome preceded the discovery of the disease, while, in the four others, it occurred as a sign of relapse or progression. Isolated mental nerve neuropathy, frequently associated with breast cancer and lymphoproliferative diseases, is generally thought to be the consequence of bone metastases or leptomeningeal seeding, but may also present without an obvious cause, most often secondary to the involvement of the mental nerve itself. Although various therapies may lead to the resolution of this symptom, median survival after diagnosis is generally less than 1 year. The appearance of a mental nerve neuropathy should never be considered as a ‘banal’ symptom and investigations to detect a possible cancer should be mandatory.

I try to arrange an enormous workup without unduly alarming her.

4. Is the ear connected to the kidney? O.M. is a second-generation Mexican-American tennis enthusiast who was diagnosed unexpectedly with kidney cancer in 2011.  Previously somewhat cavalier about her health, she now worries — understandably — that every new symptom is a recurrence.  Today she has muffled hearing on the right, and pulsatile tinnitus, along with some discomfort in the right jaw.  Her wife, who accompanies her, points out how swollen the right side of the face is (I agree, this time).  I have no idea what it all adds up to, and I send her to ENT, but I don’t forget to assure her first that I’m sure this isn’t a metastasis.

5. My ear, or yours? B.G. is a relatively new patient to me.  She is a retired teacher for developmentally-disabled children.  She has right ear pain and a fever she wasn’t aware of.  Her right eardrum is red and swollen, and I start my usual spiel about treatment of otitis, but she starts crying before I get very far.  The ear infection is a consequence, it seems, of how completely devastated she has been by her grown son’s return to the nightmare world of drug addiction.  That’s really what we needed to talk about, and I’m glad she happens to be my last appointment of the day.

Antoinette Rose is an internal medicine physician.

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