Monday
Eileen, a 37-year-old factory worker, is one of those rare people whom everyone likes the instant they meet her. She described having a wonderful life except for one large problem. Standing 63 inches tall and weighing 273 lb resulted in a body mass index of 48 for Eileen. Despite walking three miles a day and limiting her diet to 1,400 calories per day, Eileen’s weight barely budged. She had tried taking sibutramine (Meridia) but stopped it. Later, she took orlistat (Xenical) but discontinued it as well. Neither medication in conjunction with her exercise program and diet produced significant weight reduction. We discussed the risks and potential long-term complications of bariatric surgery. Screening for endocrine problems was negative, and she passed a psychologic evaluation. Eileen underwent Roux-en-Y gastric bypass surgery for morbid obesity. Six months later her weight is down to 167 lb. “Have you experienced any side effects from the operation or the 108-lb weight loss?” I asked her. “Only one,” Eileen replied with a big smile as she tugged on the elastic waistband of her slacks. “The need for a whole new wardrobe!” Eileen is little more than half the woman she once was, yet her loss of size is dwarfed by the health benefits she has gained and the joy she has realized.
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Tuesday
Hermann came to my office complaining of extreme weakness, a burning sensation in his chest, and abdominal pain. The middle-aged man looked almost as white as the paper covering the examination table. A stool sample tested positive for occult blood. An electrocardiogram and chest x-ray were normal. Hermann’s hemoglobin was 7.9 g per dL, and his red blood cell indices were consistent with iron deficiency anemia. An upper gastrointestinal x-ray revealed a duodenal ulcer. His anemia, and possibly his pain, might be attributed to that finding. Because of his age and symptoms, I recommended he have a colonoscopy to complete his evaluation. Hermann balked at that suggestion. He was more than satisfied that we had already established a good diagnosis. “Why do you have to look for something else wrong with me?” he wanted to know. It was a reasonable question. Was I merely “going by the book” and being thorough, or was it intuition that had me prodding and pleading with this patient to undergo one more test? Hermann grudgingly consented to having a colonoscopy. The test identified an early adenocarcinoma. His colon cancer was resected and his ulcer treated medically. There are times when it doesn’t pay to be satisfied with just one diagnosis, especially when your “gut” feeling tells you otherwise.
Anymore, it seems as if every patient I see has had sinusitis at one time or another. So, when Beverly showed up at my office with a headache, facial pressure, a fever as high as 101.2[degrees]F, and purulent nasal drainage streaked with blood, the diagnosis of acute sinusitis was as obvious to her as it was to me. “I feel awful,” she said. “I’d just as soon be sick with almost anything other than this.” Be careful what you wish for! I prescribed amoxicillin-clavulanate (Augmentin) for her infection. Beverly telephoned a few days later to report an upset stomach, so I had her switch to cefuroxime axetil (Ceftin). One week later she was back at my office, minus her sinus symptoms but now with lower abdominal cramping and profuse nonbloody diarrhea. A stool sample for Clostridium difficile toxin was positive. When I informed Beverly that the treatment of pseudomembranous colitis required stopping the cefuroxime and taking yet another antimicrobial agent, she looked at me as if I had lost my mind. “You’ve got to be kidding,” she retorted. “Isn’t it obvious by now that antibiotics don’t like me? I can’t say I care much for them either.” Nevertheless, she graciously accepted a prescription for metronidazole (Flagyl), trusting that her doctor finally got it right.
Wednesday
Alongside every great man is a great woman. Sam was in the office today, accompanied by his wife, and I hardly recognized either of them. A few months ago, this 38-year-old, overweight man with well-controlled hypertension on losartan (Cozaar) had screening laboratory work done. He was dismayed to learn that his fasting blood glucose level was 204 mg per dL and total cholesterol level was 255 mg per dL. “If I plan on sticking around awhile, I guess I’d better get serious,” Sam decided. And did he ever. He met with a dietitian who instructed him on a low-cholesterol, American Diabetes Association diet. He began exercising five days a week. To date, Sam has lost 39 lb, and his waist size has gone from 41 to 37 inches. His fasting glucose levels at home range from 75 to 103 mg per dL. He looks and feels like a new man–greater self-esteem, increased energy level, and more in control of his life. Sam’s most recent glycohemoglobin A1C level was 5.8 percent and total cholesterol level was 162 mg per dL. What I didn’t anticipate was the effect of Sam’s diabetes on his overweight wife. In an effort to encourage her husband, she followed the same diet and exercise regimen prescribed for Sam. Guess what? She lost 40 lb. There’s no limit to what people can accomplish once they decide to try.