Feet First

“It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.” - Sir William Osler

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    Thursday, February 07, 2013
    State of January

    Dementia is like a sinkhole. It erodes from within. Particularly with Alzheimer's, the social graces are preserved until late in the disease. You see someone who is clean, properly dressed, gracious and smiling, able to carry on a conversation - although they might seem a bit vague. It isn't until you start asking detailed questions that you begin to see what's behind the facade. What's there is a vacuum.

    Patient Gracious Lady, GL for short, has been my patient for many years. She would sometimes be brought by a family member, but often came alone. I usually see her about twice a year, as she has been in pretty good physical health. During her appointments nothing about her demeanor said dementia or struck me as unusual. She was recently hospitalized for a fairly minor problem, but the admitting MD warned me that she had been quite confused and the family member who brought her to see me for a post-discharge visit confirmed it.

    "She'll ask me a question and I answer it. Then five minutes later, she asks the same question again."

    "Who's been paying her bills? Are they getting paid?" - if you suspect dementia, this is always a good question to ask as finances are one of the first things to go by the wayside. In this case though it didn't help.

    "I'm paying them." It turned out that family members had been helping her pay her bills for the past several years. During this discussion, GL sat quietly with a calm smile on her face, divorced from the entire conversation.

    "I'm going to do something called a mini mental state exam." This is a fairly quick test which covers vocabulary, short term memory, math and orientation to place and time. It isn't perfect as even someone with early dementia will likely get the questions right. But sometimes, as today, the results can be quite striking.

    I held up a pen and she named it immediately. But when I tapped the object on her wrist and asked her to name it, it took her 45 seconds to remember that it was called a wristwatch.

    Time to test location. "What state are we in?"


    Oh crap, I thought. Wait a minute.

    "Is it someplace like Wisconsin? Rhode Island?"

    "No, those aren't right." She pondered for a while. "It's January."

    I stole a look at the relative, who was looking pretty devastated. Every answer revealed another deficiency. To be brief, the maximal score on the MMSE is 30 points; she scored less than half that.

    There are tests that can and should be run if you suspect dementia, to rule out medical causes. You check thyroid, vitamin B12 and syphilis titers among other tests. I ordered them, but I am not really optimistic that her problem is treatable. Her MMSE score is probably too low for her to benefit from medication.

    The one blessing that I have seen in dementia is that the patients themselves don't seem to be aware that they have a problem - or if they are aware, it doesn't really bother them. When a patient comes in with a complaint of "I keep forgetting things and I'm really worried that I have a problem," you can almost guarantee that they are not dementing. It's when the family or friends bring the patient in that you have to be concerned. GL had that same calm, detached air. The good news is that she has caring family who will look after her, and I firmly believe that social interaction helps in this disease.  Still, it is not something that one would ever wish for a relative or loved one.


    Sunday, February 03, 2013

    I say, Your Majesty, you know how to handle a weapon. Rumor has it Jack Bauer took lessons from you.

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    Saturday, February 02, 2013
    On Children

    Sometimes patients will bring their children to their appointments - this usually means they are very young children and that the parents couldn't make arrangements for the kids. It doesn't bother me. In fact, on a tough day it invigorates me to have a baby in the room. My favorite trick for the young ones is to hand them a tongue depressor; it is wonderful to see them eyeing it, grasping it with both hands (what is this? I imagine them thinking) and then, of course, eventually gnawing on it.

    I also remember one energetic two-year-old who entertained himself by opening the bottom drawer of the exam table and taking out, one by one, the small plastic jars of  preservative fluid contained therein. The jars are for Pap smears. Don't worry, they were safely sealed and there was no way he could have opened them. The worried father asked if this was a problem. "As long as he's not screaming, I'm happy," I reassured him.

    The older ones find it interesting to look over my shoulder as I'm typing and especially to look at pictures of X rays. Or sometimes they will just stare at me, The Doctor, as I interview and examine their parent. Or they may even ask questions, which I love. Rarely a child will announce that he or she wants to be a doctor and I encourage them heartily.

    Pediatrics, though, I could not do. I realized that as a medical student the first night a neonate came in with a fever and we had to do a spinal tap on the infant. Now that my office is right next to the Pediatrics Department and I hear the wails of children echoing through the air vent on a regular basis, I am even more certain I made the right choice.