Another man in trouble

03/16/2010 at 5:27 AM Leave a comment

The last patient on a slow monday night ( which by itself was notable, those night appointments go at a premium and three of the patients did not show! We undoubtedly turned away ten patients that wanted those appointments) was a middle aged man of my age but looking a good 15 years older than his stated age. Not only did he look shopworn he was clearly in a case of severe wasting. His complaint was primarily how tired he was after a full day at the job and his weight loss.

We could see from the chart that he had lost 30 pounds in the last year, unfortunately we could not tell when he lost it because his last visit had been a year ago. To top it off in 2003 he had a whipple procedure done. This is a radical surgery of the upper abdomen where the pancreas is removed along with many other pieces of organs. It is not done lightly or frequently and reserved for patients with Pancreatic cancer if caught early enough to give them just a glimmer of hope  of surviving the disease. (or so I thought)

I was enlightened that apparently the whipple is used for non cancer situations. He was having severe chronic pancreatitis, an extremely painful and debilitating inflammation of the pancreas from his alcoholism. He admitted to a case of beer a day at the time. It did seem to cure him and he proceeded with his life and a decreased intake of six to eight beers a day.

On exam he looked like a concentration camp survivor, he was emaciated, his face had that haunted look from the loss of fat pads around his temple and cheek ( this makes the zygomatic arch more prominent and the face more skull like in appearance). His legs and arms were girl like despite his work requiring heavy labor. He stated he could barely lift fifty pound boxes (BTW- I can barely lift fifty pound boxes but it has nothing to do with being ill).

Clearly this man was very sick, perhaps fatally so. That he had suffered for months, or perhaps a year with this kind of misery is a testament to something: denial, fear, stubbornness, who knows. My job was to determine what the appropriate course of treatment and diagnosis should be. It is the easiest thing in the world to just send him to the ER and have them do all the tests in the world in the first day and be done with it, but that is not necessary, nor appropriate.

The differential in my mind at the time were: untreated diabetes, cancer of the pancreas, liver, stomach, gall bladder, ducts, or liver failure secondary to alcohol. The best possible outcome would be diabetes.

Next post: answers


Entry filed under: true story. Tags: , , , .

Indigestible sugar? Why does it help? man in trouble (part 2)

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