My position as a nurse practitioner at a free clinic is always rewarding, but sometimes it is especially so. Typically, we do not see patients with the chief complaint of back pain because we do not have orthopedic services and cannot prescribe narcotics. However, on a slow day I overheard our receptionist triaging a new patient calling with the complaint of back pain.

The receptionist was getting ready to tell him we don’t prescribe narcotics, and I suggested she ask if he had any other problems. He then mentioned a sore on his shoulder that wouldn’t heal. We worked to schedule him in later that day.

After some discussion of his back pain, my patient hesitantly expressed concern over a lesion on his shoulder. He recalled that it had been there for six or seven years; he first noticed it after a bike accident in which he had gotten asphalt in that shoulder.

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Over the last year, the area had increased in size. With his limited resources he had been keeping the wound clean and covered, yet it continued to drain clear, bloody fluid. While living in another state, he was treated with a broad-spectrum antibiotic but had only minimal improvement. The softball-sized, cavitating lesion concerned me. I expected a foul odor, but there was none. Because of its depth, I was concerned that there might be osteomyelitis.

I strongly encouraged the young man to have lab work performed, including a wound culture and x-ray of the shoulder, that evening. I began the process of referring him to outpatient wound care through a local hospital.

When I arrived the following morning, there was a message from one of our volunteer physicians. The x-ray report had been called to him. As I suspected, it was questionable for osteomyelitis. However, the patient refused treatment until he could talk to me. After I spoke with him he readily agreed to go to the hospital.

A thorough inpatient work-up with multiple specialist consults revealed that he did not have osteomyelitis, but squamous cell carcinoma with spinal metastasis. He was transferred to a leading tertiary care center for further treatment.

I later found out that this young man was one of my husband’s high school friends. It was astounding to think that he had cancer with metastasis.

Unfortunately, the diagnosis had been missed just six months before because a limited work-up had been performed due to the patient’s lack of insurance. This thirty-four year old is now in hospice care.

Prior to this encounter, I worked one day each week at the free clinic, spending the rest of my time treating coughs, colds and urinary tract infections at a family practice group. This was an awakening point in my career — I began devoting more of my time to the free clinic, where each patient needs my attention and care.

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