Zebras and Horses #2

02/26/2009 at 6:29 AM 1 comment

Today I had a perfect example of my last post.  A new patient came to my office, he is spanish speaking, uninsured and at the moment laid off. This will come to play in the presentation.

He did not look particularly sick, he did look thin but not remarkably so. He complained of being unable to eat, being nauseated, dizzy and losing a lot of weight. Some of this took some time to get out, not because of language but because of culture. I have found that when I see someone from south of the border, there is the language issue but there is also the culture issue, doctors are perceived differently and talking openly is not their norm. In addition another block is the much lower amount of education about health and the human body.

I tried to quantify how much weight he lost. Some people are nauseated, dont eat much lose 2 or 3 pounds and feel the world is coming to an end (mostly well insured patients) then there is this guy. He had lost 62 pounds! he was only 108 now. He had lost nearly 40% of his body weight! and he had not been fat. He had a picture of himself a year ago and the contrast was startling. There was clearly something very wrong and very serious.

My mind went through a list looking for things I could check without incurring much cost. Also a list of how bad this could be. For a while the list was bleak. Leukemia, other cancers, Severe ulcer disease could do this if untreated but he should have had a lot of stomach pain.  He was not jaundiced so I felt liver disease as unlikely. Could be some tropical disease, a parasite. It had been a year so some things that kill quickly were off the table.

First we had him pee. Then we would check for anemia ( both tests we could do right then, cost me little and him nothing). Amazingly  the answer was in the urine. He has diabetes. Severe ,untreated , ketotic diabetes for a year. remarkably his sugar was only 304. He then verified that he was constantly thirsty and peed all the time. His  ketotis is an indication of starvation in this case, verifying once again his story. 

This is an amazing presentation in this country. No one goes this long in ketosis, loses so much weight without being seen, is constantly nauseated and with diarrhea for a year. Plus he was working during most of this time. 

Remarkably this is probably the best diagnosis he could have hoped for that would explain all these severe symptoms. It is treatable, even cheaply.

I could not put him on the medicine I wanted to (Metformin) until I find out if his kidneys are functioning well. Who knows if a year of ketosis damages them? Once again cost becomes an issue. 

I put him on a cheap old medicine, restricted his carbs to nearly zero for two days, will see him again at that time to evaluate how he is doing and then proceed to find a treatment he can afford and live with. It will be interesting to see how fast his weight goes up once we get this corrected.

 In summary I had a very common disease present with very unusual symptoms because of a combination of social  issues, definitely not a zebra.

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Zebras and Horses Further ear problems

1 Comment Add your own

  • 1. Hannah  |  02/27/2009 at 5:35 PM

    Great blog and hope to have time soon to come back and read some more! xx

    Reply

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