MGordon_MD
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Jul 13, 2009, 8:56 AM
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By Dr. Michael Gordon
An excerpt from his autobiography -- Brooklyn Beginnings: A Geriatrician's Odyssey
Sometimes a patient’s illness may only become apparent after some critical event or after another physician sees the patient with “new eyes.” I often teach my residents that the reason consultations are often helpful is not just that the person you are referring to has special or unique knowledge—which, of course, is usually the case—but that a consulting physician is looking at the patient with new eyes and listening with new ears. One such case was remarkable in that the patient had a condition with a severity that I had not seen since medical school.
At the time I saw her, she was in her later seventies. Her younger sister worked as a volunteer in the out-patient clinic area where my geriatric clinic was situated. Through the family doctor, the sister had arranged for me to see her older sibling because the sister was always tired. “I know you can be tired when you get close to eighty years old,” she told me, “but this is just not like her—all she wants to do is sleep. She has also gained quite a lot of weight.” A few weeks later, the older sister walked into my office, and, as soon as she entered the examining room, I said to the resident who was with me, “What does she have?”
The resident looked at her and said, “I need to take a history—I am not sure.”
I greeted the patient, who replied with a rough raspy voice, “What’s the diagnosis?” I asked again. The resident asked if she could ask some questions. She ascertained that the patient was tired, always sleeping, and had gained a lot of weight. I then asked again, “Think—weight gain, fatigue, and—look at her face.” It was the height of summer. I asked the patient, “When you are at home these days, do you feel you need to wear a sweater?” The patient answered, “I am always cold; no matter what, I am always cold. I am always turning the air conditioner off and I walk around in a sweater.”
By this time, the resident had put the puzzle together. “She is hypothyroid. But how did you know before you asked her some questions?”
I explained, “When I was in medical school, we had a patient with similar symptoms, and the chief of medicine did pretty much what I have done here with you. When I asked how he knew the diagnosis, he said, “She looks just like Aunt Mary!” He went on to explain that he had an aunt who developed not just hypothyroidism, but a very severe case of myxedema, in which the characteristic look included a bloated, heavy, pasty, appearance to the face, and a deep hoarse voice. So the typical appearance led to the diagnosis even without taking a real history. Of course, with the history, the story fit even more into place—with the cold intolerance and weight gain. And, when the resident examined her, she found the other characteristic features, such as dry skin. What was interesting is that the patient had had a pacemaker put in not long before for a very slow heart rate, and I wondered if the doctor had considered the possibility of low thyroid levels when he did it.
We started the patient on the correct replacement thyroid hormone, sent a letter to the family doctor, with a copy to the cardiologist. Over the next few months, she improved dramatically, with her face returning to its previous thin appearance (the sister had brought in a picture that was a few years old so that I could evaluate the changes). Her voice improved, as did her skin texture, but, most importantly, the perpetual fatigue disappeared. A few weeks after I had seen her in this much improved condition and wrote a follow-up letter to both physicians, I received a phone call from the cardiologist admitting to me that he had missed the thyroid diagnosis altogether. To his credit, it sounded as if the condition had not been as obvious as it was when I saw her, but he felt that her very slow heart rate had very likely been due to her thyroid, and that he had not considered the possibility before he inserted the pacemaker. With treatment, her heart rate returned to normal, and the cardiogram showed that the pacemaker no longer activated because the heart’s speed was no longer slow.
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Dr. Michael Gordon is Medical Program Director, Palliative Care Baycrest Geriatric Health Care System in Toronto, Canada and Professor of Medicine, at the University of Toronto. He is co-author with Bart Mindszenthy of Parenting Your Parents.
Parenting Your Parents is available in bookstores and online at: Indigo-Chapters, Amazon and Barnes & Noble. It is available in a US edition: Parenting Your Parents: Support Strategies for Meeting the Challenge of Aging in America.
For bulk orders email info@dundurn.com. Call: 416-214-5544 or Fax: 416-214-5556
Dr. Gordon is the author of the engaging memoir Brooklyn Beginnings: A Geriatrician's Odyssey, published by I-Universe.
Brooklyn Beginnings is available in bookstores and online at: Indigo-Chapters, Amazon.ca, Amazon.com, Barnes and Noble and I-Universe
Visit Dr. Michael Gordon's website.
(This post was edited by MGordon_MD on Aug 14, 2009, 7:25 AM)
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